rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
752,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2017-12-06,658,D,1,1,BDXJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > AMENDED: Correction made to date for F658. The dates were: 12/24/17, 12/25/17, and 12/26/17. The correct dates are: 12/24/16, 12/25/16, and 12/26/16. Based on facility policy review, medical record review, and interview, the facility failed to follow physician orders [REDACTED].#439) of 14 residents reviewed. The findings included: Review of facility policy, Drug Administration General Guidelines, dated 11/2016 revealed, .Medications are administrated (administered) as prescribed, in accordance with good nursing principles and practices .At the end of each medication pass, the person administering the medications reviews the MAR (Medication Administration Record) to ascertain that all necessary doses were administered and all administered doses were documented . Medical record review revealed Resident #439 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED]. Infuse 100 ml (900 mg) over 60 minutes at 100 ml/hr (per hour) every 24 hours times 2 weeks. Medical record review of the 12/2016 MAR indicated [REDACTED]. Medical record review of Physician's Telephone Orders dated 12/24/16 revealed, .[MEDICATION NAME] (antifungal medication) 150 mg po (by mouth) daily X (times) 3 days for yeast [MEDICAL CONDITION] . Medical record review of the 12/2016 MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 12/4/17 at 6:00 PM in the conference room confirmed the facility failed to administer [MEDICATION NAME] and [MEDICATION NAME] as prescribed by the Physician for Resident #439.",2020-09-01
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
5306,MAGNOLIA CREEK NURSING AND REHABILITATION,445461,1992 HWY 51 S,COVINGTON,TN,38019,2016-04-13,323,E,1,0,53WE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based of policy review, medical record review and interview, the facility failed to complete a fall risk assessment for 3 of 3 (Resident #1, 6 and 7) sampled residents reviewed for falls. The findings included: 1. The facility's Falls and Fall Risk, Managing policy documented, .When a resident falls, the following information should be recorded in the resident's medical record .Completion of a falls risk assessment . 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility incident investigation dated 2/16/16 revealed the resident was found by staff on the floor of his room next to the bed. Medical record review revealed no fall risk assessment was completed following the resident's fall. 3. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility incident investigation dated 3/17/16 revealed the resident was found by staff sitting on the floor in the resident's restroom. Medical record review revealed no fall risk assessment was completed following the resident's fall. 4. Medical record review revealed Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. Review of a facility fall investigation report dated 3/17/16 revealed Resident #7 was found in her room sitting on her knees on the floor. Medical record review revealed no fall risk assessment was completed following the resident's fall. 5. Interview with the Director of Nursing (DON) on 4/13/16 at 3:55 PM, in the Minimum Data Set office, when asked if a fall risk assessment should be completed following a resident fall, the DON stated, .When it's a fall, the nurse on the floor, is to do the fall risk assessment.",2019-04-01
2538,MILLINGTON HEALTHCARE CENTER,445425,5081 EASLEY AVENUE,MILLINGTON,TN,38053,2019-01-27,658,J,1,0,Q97T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Invacare Reliant 450 (mechanical) Lift (assistive transfer device) manufacturer recommendation review, Oxford University Hospitals Occupational Therapy manual review, Lippincott Manual of Nursing Practice 10th Edition review, Mobility Advisor Wheelchair Ramps review, policy review, medical record review, and interview, the facility failed to ensure staff provided care according to acceptable standards of clinical practice to prevent accidents for 2 of 7 (Resident #1 and #2) sampled residents reviewed for accidents. The facility failed to ensure safe transport was provided for Resident #1 who was transported without staff supervision by a transport company employee, fell out of the wheelchair, sustained facial injuries and a fractured nose which resulted in Immediate Jeopardy. The facility failed to ensure staff appropriately and safely transferred Resident #2 via mechanical lift . On 11/7/18 Resident #2 sustained cheek discoloration. On 12/12/18 after a staff member transferred Resident #2 using a mechanical lift without assistance of another staff member, Resident #2 sustained extensive facial bruising, swelling, swallowing difficulties and had a fractured mandible (jaw) which resulted in actual harm and Immediate Jeopardy. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 1/27/19 in the conference room. The facility was cited an Immediate Jeopardy at F658-[NAME] The Immediate Jeopardy is ongoing. An extended survey was conducted on 1/26/19 and 1/27/19. The findings include: 1. Review of the Oxford University Hospitals Occupational Therapy A Guide to Using Your Manual Wheelchair Safely manual dated (MONTH) (YEAR) documented, .Going down a steep slope .It is safer if the wheelchair can be guided down a steep slope backwards by a carer (caregiver) . Review of the Lippincott Manual of Nursing Practice 10th Edition documented, .Ensuring Safety .assess safety .Assess for the patient's personal safety issues-sensory deficits .The nursing process is a deliberate, problem-solving approach to meeting the health care and nursing needs of patients. It involves assessment (data collection), nursing diagnosis, planning, implementation, and evaluation, with subsequent modifications . Review of the Mobility-Advisor. com ADA (Americans with Disabilities Act) Wheelchair Ramps undated article documented, .When the front wheels hit the landing, the wheelchair can come to a sudden stop, causing the wheelchair user to fly forward . Review of the Coordination of Transportation policy dated (MONTH) (YEAR) documented, .The facility will assist in making appointments and safe transport arrangements for the resident .The facility will consider all clinical, physical, mental and financial conditions related to the transportation arrangements . Medical record review for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed a score of 10 out of 15 which indicated the resident had moderately impaired cognition. A Fall Risk assessment dated [DATE] and 12/19/18 revealed a score of 14 and was .at high risk for potential falls. Resident #1's Care Plan initiated on 11/19/18 documented, The resident has an ADL (activity of daily living) Self Care Performance Deficit .Interventions .The resident requires staff participation with transfers. Resident #1's Care Plan initiated on 11/28/18 documented, The resident has impaired cognitive function r/t (related to) Dementia .Interventions .supervise . Resident #1's Nurses note dated 12/19/18 at 2:45 PM documented Patient with dental apt (appointment) today .Patient noted to have left the front door for dentist apt with (Named Transport Company) transport x1 (1 transport employee). A few mins (minutes) later entered the facility with (Named Transport Company) transport .Patient was sitting up in WC (wheelchair) with blood noted on face . Review of a statement completed by Licensed Practical Nurse (LPN #1) on 12/19/18 documented, Transportation personnel stated .we were going down the ramp, he fell forward out of chair . Interview with the DON on 1/15/19 at 1:00 PM in the conference room, the DON was asked if anyone accompanied Resident #1 to the dental appointment. The DON stated, No staff accompanied (Named Resident #1) . The DON was asked the cognitive status of Resident #1 and she stated, .his cognition does come and go .he didn't remember anything after the fall .he has had previous falls . The DON was asked what was expected during transportation if a resident was cognitively impaired and she stated, If a resident is cognitively impaired then either a family member or a CNA (certified nursing assistant) goes with them .There were 2 van transport employees that day 1 stayed in the van . Review of a statement by Transportation Employee #1 and verified on 1/16/19 at 1:00 PM documented, .I went to the desk and got his (Resident #1) face sheet then we continue to leave we went down the ramp to get in the van as we started going toward the van he failed (fell ) forward out of the wheelchair .the driver got out the van help (helped) me pick him up. Interview with Transportation Employee #1 on 1/16/19 at 1:00 PM via telephone, Transportation Employee #1 was asked about the incident and he stated, I helped him (Resident #1) into the wheelchair .I backed him out the front door and down the ramp .turned him and started toward the van and he just fell forward out of the wheelchair like he couldn't hold himself up .we picked him up and got him inside. Interview with Transportation Employee #2 on 1/16/19 at 1:10 PM via telephone, Transportation Employee #2 stated, .I was in the van .I was looking down at phone dialing and then talking to dispatch. I didn't see them come out of the building, go down the ramp or fall. I just happened to look up and see him (Resident #1) on the ground . An Administrator's note dated 12/20/18 documented, .(Named Resident #1) .was asked if he could recall any events from the incident .He( Resident #1) did not know specifically if he was turned forward or not but recalled that the wheelchair stopped .He remembered the wheelchair stopping but he kept coming out of the wheelchair .Resident recalled hitting his face on the cement .he believes that his weight shifted . Interview with Resident #1 on 1/16/19 at 1:40 PM in his room, Resident #1 was asked to describe the events on the day he fell in the parking lot and he stated, .1 transport guy came to room .the transport guy took me out the front doors and down the ramp, at the bottom he stopped but I didn't, I slid out (of the wheelchair) in the driveway and landed on my knees, hands and hit my face .He took me out forward and took me down that ramp forward . Interview with Facility Staff #1 on 1/16/19 at 2:25 PM in the conference room, Facility Staff #1 stated, .I saw the transport guy push (Named Resident #1) forward through the front exit doors .he was not pulling him through the doors backwards, he pushed him forward out the front doors . The failure of the facility to ensure acceptable standards of practice were provided to Resident #1, a cognitively impaired resident with a history of falls and mobility deficits, resulted in actual harm and Immediate Jeopardy when Resident #1 was transported out of the facility by a transport company employee, was unaccompanied and unsupervised by facility staff. Resident #1 fell out of the wheelchair, sustained lacerations and a fractured nose. 2. Review of the Invacare Reliant 450 Lift manufacturer recommendation (undated) revealed, .Invacare recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures . Review of the facility Lift Management Program policy dated (MONTH) (YEAR) documented, .Our Lift Management Program is designed to meet the following goals: .To protect .residents from injury .Each co-worker is expected to support this program 100% (percent) .This procedure is always done with 2 people . Medical record review for Resident #2 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. An Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 was assessed with [REDACTED]. Resident #2's Care Plan initiated on 4/4/18 documented, The resident has an ADL (activities of daily living) Self Care Performance (deficit) .r/t (related to) stroke .dementia .[MEDICAL CONDITION] .Interventions .Hoyer (mechanical) lift with assist of 2 for transfers . Interview with the DON on 1/26/19 at 11:10 AM in the conference room, the DON was asked why Resident #2 was to have mechanical lift transfers by 2 people and the DON stated, We determined to use the lift and 2 people because of her size and debility. She was a large lady and completely out (paralyzed) except for a slight amount of movement in 1 arm and head. She'd had a stroke and was total care . Interview with the DON on 1/26/19 at 1:15 PM in the conference room, the DON was asked what was determined to be the cause of the discolored area (found on Resident #2's left cheek) and she stated, (Named Certified Nursing Assistant #1) had gotten her up via lift around 5:30 (AM) that morning .the sling brushing her face was the only thing we could come up with that caused the area (discoloration to cheek on 11/7/18) . An Incident Report dated 12/12/18 at 10:06 AM documented, .Witnesses Statement 12/12/18 Phone interview with (Named CNA #1) states she believes she did not have adequate assist with Hoyer lift . Interview with CNA #1 on 12/28/18 at 12:57 PM via telephone, CNA #1 was asked how she transferred Resident #2 and she stated, .I get her up in the morning, 1 person .since I've been there, I've always transferred by myself . Interview with the DON on 1/15/19 at 1:00 PM in the conference room, the DON was asked what she expected staff to do during lift transfers and the DON stated, .2 people are to transfer with lifts. The facility failed to ensure staff followed the facility policy and acceptable standards of practice for an appropriate and safe transfer of Resident #2 via mechanical lift. Resident #2 was assessed to require 2 people transfers via mechanical lift. Resident #2 was found on 11/7/18 with a discoloration on her left cheek determined to have been caused during lift transfer. During a second incident on 12/12/18 Resident #2 developed significant facial bruising, swelling, deterioration of swallowing status and was found to have a fractured right mandible (jaw) on 12/12/18 after being transferred by 1 staff member via mechanical lift. This resulted in actual harm and Immediate Jeopardy to Resident #2.",2020-09-01
2539,MILLINGTON HEALTHCARE CENTER,445425,5081 EASLEY AVENUE,MILLINGTON,TN,38053,2019-01-27,689,J,1,0,Q97T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Invacare Reliant 450 Lift (mechanical assistive transfer device) manufacturer recommendation review, policy review, hospital medical record review, medical record review, observation and interview, the facility failed to provide 2 of 7 (Resident #1 and #2) sampled residents appropriate and adequate supervision and assistance that ensured an environment free of accident hazards. The facility failed to provide adequate staff supervision for Resident #1 during transportation to an outside appointment. Resident #1 had been assessed at high risk for falls, had a history of [REDACTED]. Resident #1 was placed in a wheelchair, pushed out the doors of the facility and down a ramp by an outside transportation employee, unaccompanied, unsupervised by facility staff, and had not been assessed for safe independent transport. Resident #1 fell face forward out of the wheelchair onto the parking lot, sustained lacerations to his face and a fractured nose which resulted in actual harm and Immediate Jeopardy. The facility failed to ensure appropriate and safe lift transfers were provided to Resident #2 who was paralyzed on the left side from a [MEDICAL CONDITION] (stroke), was assessed as cognitively impaired and required total assistance of 2 staff with mechanical lift transfers. Resident #2 was transferred via lift by 1 staff member and was found with a discoloration on the left cheek on 11/7/18 and sustained a facial injury of extensive bruising and swelling, swallowing difficulties and was diagnosed with [REDACTED].#2. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 1/27/19 at 9:00 AM in the conference room. The facility was cited an Immediate Jeopardy at F689-J which is Substandard Quality of Care. The Immediate Jeopardy is ongoing. An extended survey was conducted on 1/26/19 and 1/27/19. The findings include: 1. Review of the Coordination of Transportation policy dated (MONTH) (YEAR) documented, .The facility will assist in making appointments and safe transport arrangements for the resident .The facility will consider all clinical, physical, mental and financial conditions related to the transportation arrangements . Review of the facility Care Plan policy revised on 12/12/17 documented, .Each resident will have a plan of care to identify problems, needs, and strengths that will identify how the facility staff will provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Review of the facility Fall Prevention Protocol policy dated 9/21/17 documented, .All residents/patients that had a score of > (greater than 10 was at high risk) 10 on a fall screen will have a care plan to minimize injury . Medical record review for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. An Admission Minimum Data Set ((MDS) dated [DATE] documented the resident required extensive assistance with transfers and locomotion on and off the unit. A Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed a score of 10 out of 15 which indicated the resident had moderately impaired cognition. A Fall Risk assessment dated [DATE] and 12/19/18 revealed a score of 14 and was .at high risk for potential falls. Resident #1's Care Plan initiated on 11/19/18 documented, .The resident has an ADL (activity of daily living) Self Care Performance Deficit .Interventions .The resident requires staff participation with transfers. A Care Plan initiated on 11/28/18 documented, The resident has impaired cognitive function r/t (related to) Dementia .Interventions .supervise . Resident #1's Care Plan initiated on 11/28/18 documented The resident has impaired cognitive function r/t (related to) dementia .Interventions .supervise . Resident #1's Nurses note dated 12/19/18 at 2:45 PM documented .Patient with dental apt (appointment) today .Patient noted to have left the front door for dentist apt with (Named Transport Company) transport x1 (1 transport employee). A few mins (minutes) later entered the facility with (Named Transport Company) transport .Patient was sitting up in WC (wheelchair) with blood noted on face .911 called for transport . Review of a statement completed by Licensed Practical Nurse (LPN) #1 dated 12/19/18 documented, .I observed (Named Resident #1) sitting upright in WC moderate bleeding to bridge of nose, brow ridge, and inside mouth, but unable to find cause of bleeding in mouth. Transportation personnel stated, .'we were going down the ramp, he fell forward out of chair .'I attempted to evaluate resident's cognition. 'Resident alert but unable to respond verbally, resident was able to follow my finger to the left but unable to follow to the right, resident did not respond verbally . Resident #1's Nurses note dated 12/21/18 at 9:49 AM documented, Fall on 12/19/18 in parking lot with escort services .Nasal FX. (fracture) and lacerations noted . Review of a statement completed by Registered Nurse (RN) #1 and verified on 12/27/18 at 10:50 AM documented, .I observed (Named Resident #1) sitting in a WC w/blood (with blood) on his face and hands .(Named Resident #1) had 2 gashes between his eyes, one gash mid nose, a large hematoma/clot in his bottom lip & (and) blood coming out of his mouth. He also had two bruises-one on each knee & one abrasion on each knee . Interview with LPN #1 on 1/15/19 at 10:25 AM in the conference room, LPN #1 stated, .I assisted .after his fall. He (Resident #1) was awake .but not responsive verbally . Interview with the DON on 1/15/19 at 1:00 PM in the conference room, the DON was asked if anyone accompanied Resident #1 to the dental appointment. The DON stated, No staff accompanied (Named Resident #1) . The DON was asked the cognitive status of Resident #1 and the DON stated, .his cognition does come and go .he didn't remember anything after the fall .he has had previous falls . The DON was asked what was expected during transportation if a resident was cognitively impaired and she stated, If a resident is cognitively impaired then either a family member or a CNA (Certified Nursing Assistant) goes with them .There were 2 van transport employees that day 1 stayed in the van . Interview with the Administrator on 1/15/19 at 10:20 AM in the conference room, the Administrator was asked for the transportation contract and policy and he stated, We do not have a transportation policy, staff just get them up and ready and the transport company picks them up .don't have a copy of the contract . Interview with the DON 1/15/19 at 1:10 PM in the conference room, the DON was asked how resident safety was ensured during transportation and she stated, We do not do a safety assessment for transportation. Review of a statement verified on 1/16/19 at 1:00 PM by Transportation Employee #1 documented, .I went to the desk and got his (Resident #1) face sheet then we continue (continued) to leave we went down the ramp to get in the van as we started going toward the van he failed (fell ) forward out of the wheelchair .the driver got out the van help me pick him up. Interview with Transportation Employee #1 on 1/16/19 at 1:00 PM via telephone, Transportation Employee #1 was asked about the incident and he stated, I helped him (Resident #1) into the wheelchair, went to the desk and got his face sheet and asked if anyone was going with him. I was told his daughter was going to meet us at the doctor's clinic . (Named Resident #1) never said anything to me just nodded .I backed him out the front door and down the ramp .turned him and started toward the van and he just fell forward out of the wheelchair like he couldn't hold himself up .we picked him up and got him inside. Interview with Transportation Employee #2 on 1/16/19 at 1:10 PM via telephone, Transportation Employee #2 stated, .I was in the van .I was looking down at phone dialing and then talking to dispatch. I didn't see them come out of the building, go down the ramp or fall. I just happened to look up and see him on the ground . An Administrator's note dated 12/20/18 documented, .(Named Resident #1) .was asked if he could recall any events from the incident .He ( Resident #1) did not know specifically if he was turned forward or not but recalled that the wheelchair stopped .He remembered the wheelchair stopping but he kept coming out of the wheelchair .Resident recalled hitting his face on the cement .he believes that his weight shifted . Interview with Resident #1 on 1/16/19 at 1:40 PM in his room, Resident #1 was asked to describe the events on the day he fell in the parking lot and he stated, .1 transport guy came to room .got in wheelchair .the transport guy took me out the front doors and down the ramp, at the bottom he stopped but I didn't, I slid out (of the wheelchair) in the driveway and landed on my knees, hands and hit my face .He took me out forward and took me down that ramp forward . Observations during this interview revealed Resident #1 had a healed scar across the bridge of his nose and healed scars on both knees. The resident's wheelchair was at the bedside and noted to have a pressure cushion with a slick covering on it. Interview with the Social Worker on 1/16/19 at 2:10 PM in the conference room, the Social Worker was asked how the facility assured the residents are transported safely and the Social Worker stated, .Not aware of any type of safety assessment for transports, I don't do one . Interview with Facility Staff #1 on 1/16/19 at 2:25 PM in the conference room, Facility Staff #1 stated, .I saw the transport guy push (Named Resident #1) forward through the front exit doors .he was not pulling him through the doors backwards, he pushed him forward out the front doors . Review of Resident #1's hospital computerized tomography (CT) Maxillofacial (forehead, face, and dental) area scan dated 12/19/18 revealed, .Pt (patient) came by EMS (emergency medical services) for AMS (altered mental status) after being pushed down ramp in wheelchair .and fell forward, Pt with LAC (laceration) to nose, 2 lacerations to forehead .There is left-sided nasal plates fracture (fractured nose) . The failure of the facility to adequately supervise Resident #1, a cognitively impaired resident with a history of falls and mobility deficits, resulted in actual harm and Immediate Jeopardy when Resident #1 was transported out of the facility by a transport company employee, unaccompanied, unsupervised by facility staff and not assessed by facility staff for safe transport independently. Resident #1 fell out of the wheelchair and sustained lacerations and a fractured nose. 2. Review of the Invacare Reliant 450 (mechanical) Lift manufacturer recommendation (undated) documented, .Invacare recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures . Review of the facility Lift Management Program policy dated (MONTH) (YEAR) documented, .Our Lift Management Program is designed to meet the following goals: .To protect .residents from injury .Each co-worker is expected to support this program 100% (percent) .This procedure is always done with 2 people . Medical record review for Resident #2 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. An Annual MDS dated [DATE] revealed Resident #2 was assessed with [REDACTED]. Resident #2's Care Plan initiated on 4/4/18 documented, .The resident has an ADL (activities of daily living) Self Care Performance .r/t (related to) stroke .dementia .[MEDICAL CONDITION] .Interventions .Hoyer (transfer assistive device) lift with assist of 2 (persons) for transfers . Interview with the DON on 1/26/19 at 11:10 AM in the conference room, the DON was asked why Resident #2 required mechanical lift transfers by 2 people and she stated, We determined to use the lift and 2 people because of her size and debility. She was a large lady and completely out (paralyzed) except for a slight amount of movement in 1 arm and her head. She'd had a stroke and was total care . An Incident Report dated 11/7/18 at 1:30 AM revealed Resident #2 was found with a discoloration on her left cheek. An Incident Report dated 12/12/18 at 10:06 AM documented, .Witnesses Statement 12/12/18 Phone interview with (named CNA #1) states she believes she did not have adequate assist with Hoyer (mechanical) lift. She said it was possible the lift arm tapped (named Resident #2) cheek . Resident #2's Nurses note dated 11/7/18 at 10:58 AM documented, .Discoloration the left cheek area that appears as fabric burn .Resident requires a mechanical lift and sling for all transfers. Investigation finds that lift pad grazed Left cheek during transfer . Interview with CNA #1 on 12/28/18 at 12:57 PM via telephone, CNA #1 was asked how she transferred Resident #2 and she stated, .I get her up in the morning, 1 person .since I've been there, I've always transferred by myself . Interview with the DON on 1/26/19 at 1:15 PM in the conference room, the DON was asked what caused this discolored area on Resident #2's cheek and she stated, (Named CNA #1) had gotten her up via lift around 5:30 (AM) that morning, .the sling brushing her face was the only thing we could come up with that caused the (discolored) area . An Incident Report dated 12/12/18 at 10:06 AM revealed Resident #2 was found with, .Green bruising/discoloration to L (left) cheek extending up to L eye, swelling, and redness noted. Half dollar sized dark green bruise to R (right) side of chin. Dried red blood observed to L nostril .Witnesses Statement 12/12/18 Phone interview with (named CNA #1) states she believes she did not have adequate assist with Hoyer (mechanical) lift. She said it was possible the lift arm tapped (named Resident #2) cheek . A situation, background, assessment, recommendation (SBAR) Communication Form dated 12/15/18 documented Resident #2 with deterioration, . Significant decline in food and fluid intake in resident with marginal hydration and nutritional status .Discoloration .L side of face starting at L eye extending down the face to the jaw line. Bruising is noted to bilateral (both) jaw lines. Resident having difficulty swallowing, liquids upgraded to nectar thick liquids, increase in drooling noted .Send to ER (emergency room ) for eval (evaluation) and treatment . Review of Resident #2's hospital medical record revealed a History and Physical (H&P) dated 12/15/18 that documented, .She (Resident #2) presented from a nursing home with worsening altered mental status and facial bruising .Significant bruising on the left side of her jaw .CT maxillofacial: Subtle (high energy trauma) nondisplaced [MEDICAL CONDITION] body of the right mandible (jaw) . Interview with CNA #1 on 12/28/18 at 12:57 PM via telephone, CNA #1 was asked how she transferred Resident #2 and she stated, .I get her up in the morning, 1 person ., since I've been there, I've always transferred by myself . Interview with LPN #2 on 1/22/19 at 5:42 AM via telephone, LPN #2 stated, .There for a little bit (Named CNA #1) didn't ask for help (when transferring residents with a mechanical lift) . Interview with the DON on 1/15/19 at 1:00 PM in the conference room, the DON was asked what she expected staff to do during lift transfers and she stated, .2 people are to transfer with lifts. The failure of the facility to ensure staff appropriately and safely transferred Resident #2 via mechanical lift resulted in actual harm and Immediate Jeopardy when Resident #2 was found with discoloration to the left cheek on 11/7/18. A second incident occurred on 12/12/18 and Resident #2 developed significant facial bruising, facial swelling, deterioration of swallowing status and had a fractured right mandible (jaw) after the resident had been transferred by 1 staff member via mechanical lift.",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
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
2020,GRACELAND REHABILITATION AND NURSING CARE CENTER,445331,1250 FARROW ROAD,MEMPHIS,TN,38116,2019-10-31,686,G,1,0,UHXG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on National Pressure Ulcer Advisory Panel (NPUAP) quick reference guide, policy review, closed medical record review, and interview, the facility failed to ensure identified changes in a resident's skin condition were assessed, reported, and a physician's orders [REDACTED].#1) sampled residents reviewed with in-house acquired pressure ulcers. This failure of the facility resulted in actual Harm for Resident #1. The findings include: The NPUAP quick reference guide, 2nd addition, published 2014, documented, .A pressure ulcer is 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 .Comprehensive assessment of the individual and his or her pressure ulcer informs development of the most appropriate management plan and ongoing monitoring of wound healing .Stage 3 pressure ulcer .Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough (moist devitalized tissue, can be cream, yellow, or tan in color) may be present but does not obscure the depth of tissue loss .Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar (non-viable black (dark) tissue) 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 . The facility's Pressure Ulcer Risk Assessment policy dated 2/20/19 documented, .If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected .Routinely assess and document the condition of the resident's skin .for signs and symptoms of irritation or breakdown .Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated . The facility's Pressure Ulcer/Skin Breakdown - Clinical Protocol policy dated (MONTH) (YEAR) documented, .The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings .and applications of topical agents . Closed medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the nursing admission assessment and interim care plan dated 7/26/19 revealed Resident #1 was at risk for pressure ulcer development due to immobility and incontinence. Medical record review of the comprehensive care plan dated 7/29/19 revealed the Resident #1 was at risk for pressure ulcer development due to immobility and incontinence. Medical record review of the 60 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact, required extensive assistance for bed mobility, transfer, ambulation, dressing, eating, toileting, and personal hygiene, and was at risk for pressure ulcer development. Medical record review of a Shower Sheet dated 9/26/19 revealed Resident #1 had a dark area to her left hip. The form was signed by Certified Nursing Assistant (CNA) #1 and Licensed Practical Nurse (LPN) #1 indicating the newly identified skin condition had been reported to the nurse by CNA #1. Medical record review of the nursing progress notes and assessments dated 9/26/19 revealed no documented assessment of Resident #1's left hip by LPN #1. Medical record review of a Shower Sheet dated 9/28/19 revealed Resident #1 had an open area on her sacral region. The form was signed by CNA #2 and LPN #1 indicating the newly identified skin condition had been reported to the nurse by CNA #2. Medical record review of the nursing progress notes and assessments dated 9/28/19 revealed no documented assessment of Resident #1's sacrum by LPN #1. Medical record review of a Pressure Ulcer Evaluation dated 10/1/19 revealed a facility acquired Unstageable pressure ulcer to Resident #1's left hip was first observed by the Treatment Nurse on 9/30/19, slough was present, and the wound bed was 100 percent (%) necrotic (dead or devitalized) tissue. The pressure ulcer measured 1.8 centimeters (cm) in length, 1.4 cm in width, and without measurable depth. Medical record review of a Pressure Ulcer Evaluation dated 10/1/19 revealed a Stage 3 pressure ulcer present on Resident #1's sacrum was first observed by the Treatment Nurse on 9/30/19, the wound bed was 50% pink tissue and 50% yellow slough. The pressure ulcer measured 1 cm in length, 1 cm in width, and 0.1 cm in depth. Interview with the Treatment Nurse on 10/31/19 at 11:34 AM, the Treatment Nurse was asked about Resident #1's pressure ulcers to her left hip and sacrum. The Treatment Nurse revealed she had worked 11:00 PM - 7:00 AM on 9/30/19 on Resident #1's hall and the resident's CNA had called her into Resident #1's room to look at her skin due to the skin breakdown. The Treatment Nurse confirmed that 9/30/19 was the first time either pressure ulcer had been assessed. The Treatment Nurse also confirmed the left hip pressure ulcer was 100% necrotic and the sacral pressure ulcer was 50% slough when identified on 9/30/19. The Treatment Nurse was asked if the pressure ulcers should have been identified and treated before they had become necrotic. The Treatment Nurse stated, Yes. Interview with CNA #1 on 10/31/19 at 11:55 AM, in the Conference Room, CNA #1 was asked about the dark area on Resident #1's left hip she had identified on 9/26/19. CNA #1 revealed the area was in the crease between the resident's left lower hip and upper thigh, the area was not open, and confirmed she had reported it to LPN #1 both verbally and had documented it on the shower form. Interview with LPN #1 on 10/31/19 at 12:20 PM, in the Conference Room, LPN #1 was asked if she had assessed Resident #1's changes in skin condition reported to her by CNA #1 on 9/26/19 and CNA #2 on 9/28/19. LPN #1 confirmed she had not assessed or reported the newly identified skin condition changes to the oncoming shift or the physician for treatment orders. Interview with the Nurse Practitioner (NP) on 10/31/19 at 3:40 PM, in the Conference Room, the NP was asked if LPN #1 should have assessed the pressure ulcers when they were first identified. The NP stated, .I would expect the nurse to look at it (pressure ulcer) and report it . The NP confirmed she had not been informed of the pressure ulcers until 10/1/19. Telephone interview with CNA #2 on 10/31/19 at 3:52 PM, CNA #2 was asked about the open area on Resident #1's sacrum she had identified on 9/28/19. CNA #2 revealed the area was not dark, had not looked necrotic, there was no odor or drainage and she had reported the area to LPN #1. The facility's failure to assess, report and provide treatment before the newly identified pressure ulcers deteriorated and progressed to a Stage 3 pressure ulcer and an Unstageable pressure ulcer resulted in actual Harm for Resident #1.",2020-09-01
2019,GRACELAND REHABILITATION AND NURSING CARE CENTER,445331,1250 FARROW ROAD,MEMPHIS,TN,38116,2019-10-31,580,G,1,0,UHXG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on National Pressure Ulcer Advisory Panel (NPUAP) quick reference guide, policy review, closed medical record review, and interview, the facility failed to ensure identified changes in a resident's skin condition were reported to the physician and a physician's orders [REDACTED].#1) sampled residents reviewed with in-house acquired pressure ulcers. The failure of the facility to report identified skin condition changes to the physician and obtain treatment orders before deterioration to a Stage 3 pressure ulcer and an Unstageable pressure ulcer resulted in actual Harm for Resident #1. The findings include: The NPUAP quick reference guide, 2nd addition, published 2014, documented, .A pressure ulcer is 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 .Comprehensive assessment of the individual and his or her pressure ulcer informs development of the most appropriate management plan and ongoing monitoring of wound healing .Stage 3 pressure ulcer .Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough (moist devitalized tissue, can be cream, yellow, or tan in color) may be present but does not obscure the depth of tissue loss .Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar (non-viable black (dark) tissue) 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 . The facility's Changes in a Resident's Condition or Status policy documented, .Our facility shall notify the resident, his or her Attending Physician, and representative sponsor of changes in the resident's medical condition and/or status .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been .A significant change in the resident's physical/emotional/mental condition . The facility's Pressure Ulcer Risk Assessment policy dated 2/20/19 documented, .If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected . The facility's Pressure Ulcer/Skin Breakdown - Clinical Protocol policy dated (MONTH) (YEAR) documented, Assessment and Recognition .4. The physician will assist the staff to identify the type .and characteristics (presence of necrotic (dead or devitalized) tissue, status of wound bed .) of an ulcer .Treatment/Management .1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings .and applications of topical agents. 2. The physician will help identify medical interventions related to wound management .3. The physician will help staff characterize the likelihood of wound healing . Closed medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was discharged to the hospital on [DATE] due to gastrointestinal symptoms. Medical record review of the nursing admission assessment and the interim care plan dated 7/26/19 revealed Resident #1 was at risk for pressure ulcer development due to immobility and incontinence. Medical record review of the 60 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was at risk for pressure ulcer development. Medical record review of a Shower Sheet dated 9/26/19 revealed Resident #1 had a dark area to her left hip. The form was signed by Certified Nursing Assistant (CNA) #1 and Licensed Practical Nurse (LPN) #1 indicating the newly identified skin condition had been reported to the nurse by the CN[NAME] Medical record review of the nursing progress notes dated 9/26/19 revealed there was no documentation the physician was notified of the darkened area on the resident's left hip. Medical record review of a Shower Sheet dated 9/28/19 revealed Resident #1 had an open area on her sacral region (bottom of the spine and lies between the lumbar spine and the coccyx (tailbone)). The form was signed by CNA #2 and LPN #1 indicating the newly identified skin condition had been reported to the nurse by the CN[NAME] Medical record review of the nursing progress notes dated 9/28/19 revealed there was no documentation the physician was notified of the open area to the sacral region. Medical record review of a Pressure Ulcer Evaluation dated 10/1/19 revealed a facility acquired Unstageable pressure ulcer to Resident #1's left hip was first observed by the Treatment Nurse on 9/30/19, slough was present, and the wound bed was 100 percent (%) necrotic tissue. The pressure ulcer measured 1.8 centimeters (cm) in length, 1.4 cm in width, and without measurable depth. Medical record review of a Pressure Ulcer Evaluation dated 10/1/19 revealed a Stage 3 pressure ulcer present on Resident #1's sacrum was first observed by the Treatment Nurse on 9/30/19, the wound bed was 50% pink tissue and 50% yellow slough. The pressure ulcer measured 1 cm in length, 1 cm in width, and 0.1 cm in depth. The Physician was notified on 10/1/19 of the pressure ulcers and the following physician's orders [REDACTED].> .Cleanse Sacrum with wound cleanser, pat dry, apply [MEDICATION NAME] dressing qod (every other day)/prn (as needed) every day shift .Santyl Ointment 250 UNIT/GM (Grams) ([MEDICATION NAME]) Apply to Left hip topically every day shift . Interview with the Treatment Nurse on 10/31/19 at 11:34 AM, the Treatment Nurse was asked about Resident #1's pressure ulcers to her left hip and sacrum. The Treatment Nurse confirmed that 10/1/19 was the first time the physician had been notified of the pressure ulcers. The Treatment Nurse also confirmed the left hip pressure ulcer was 100 % necrotic and the sacral pressure ulcer was 50% slough when identified on 9/30/19. Interview with LPN #1 on 10/31/19 at 12:20 PM, in the Conference Room, LPN #1 was asked about Resident #1's changes in skin condition reported to her by CNA #1 on 9/26/19 and CNA #2 on 9/28/19. LPN #1 confirmed she had not reported the newly identified areas to the physician for treatment orders. Interview with the Nurse Practitioner (NP) on 10/31/19 at 3:40 PM, in the Conference Room, the NP stated, .I would expect the nurse look at it (pressure ulcer) and report it (to the physician) . The NP confirmed she had not been informed of the pressure ulcers until 10/1/19. The facility's failure to report and obtain a physician's orders [REDACTED].#1.",2020-09-01
4271,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2016-10-13,314,G,1,1,LFXZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on National Pressure Ulcer Advisory Panel (NPUAP) reference guide, policy review, medical record review, and interview, the facility failed to timely identify, accurately assess and/or treat pressure ulcers for 2 of 7 (Residents #2 and 53) sampled residents with pressure ulcers. The facility's failure to timely identify, accurately assess and/or treat pressure ulcers resulted in actual harm to Resident #2, and #53 when the pressure ulcers deteriorated. The findings included: 1. Review of the NPUAP quick reference guide defined a Stage II (2) pressure ulcer as, .Partial thickness loss of dermis, presenting as a shallow open ulcer with a red pink bed, without slough. (MONTH) also present as an intact or open/ruptured serum filled blister . Review of the NPUAP quick reference guide defined a Stage III (3) pressure ulcer as, .Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling . Review of the NPUAP quick reference guide defined a Stage IV (4) pressure ulcer as, .Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleous do not have (adipose) subcutaneous tissue and these ulcers can be shallow . Stage IV ulcers can extend into muscle and/or supporting structures . making osteo[DIAGNOSES REDACTED] (bone infection) or osteitis (bone inflammation) likely to occur. Exposed bone/muscle is visible or directly palpable . Review of the NPUAP quick reference guide defines an Unstageable wound as, .full thickness tissue loss in which actual depth of the ulcer is completely obscured 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 are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Stage III (3) or IV (4) . 2. The facility's Pressure Ulcer Risk Assessment policy documented, .The purpose of this procedure is to provide guidelines for assessment and identification of residents at risk of developing pressure ulcers .Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area, which destroys the tissues .Pressure ulcers are a serious skin condition for the resident .Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated .Staff will perform routine skin inspections (with daily care) .Nurses will conduct skin assessments at least weekly to identify changes .Document the procedure .The type of assessment conducted .the name and title (or initials) of the individual who conducted the assessment .If the resident refused the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. Document family and physician notification of refusal . 3. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A skin assessment dated [DATE] documented, .RESIDENT SKIN ASSESSED PER TREATMENT NURSE .READMISSION .SCAR TISSUE NOTED TO SACRAL AREA . Review of a quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #2 was severely cognitively impaired, was totally dependent on staff for all activities of daily living (ADLs) and did not have any pressure ulcers. The Braden Risk Assessment Reports (indicating risk for developing pressure ulcers) dated 6/15/16 documented a Braden score of 12 indicating the resident was at high risk for developing pressure ulcers. Review of an annual MDS dated [DATE] documented Resident #2 was severely impaired cognitively, was totally dependent on staff for all ADLs and did not have any pressure ulcers. A care plan dated 9/6/16 documented, .Problem .Resident has Pressure Ulcer (s) .SACRUM ONSET 09/06/2016 .STAGEII .Approach .9/20/16 wound treatment as ordered . The weekly skin report dated 9/6/16 documented, Wound Location: .Sacrum .Wound Type .Open Area .Status: Ulcer .L (length) 0.8 x W (width) 0.9 x D (depth) 0.1 .Present On Admission: False . A Wound Physician (WP) note dated 9/7/16 documented, Was asked to see this resident yesterday by 3rd floor staff nurse with concerns of open area noted to sacrum with pink tissue with no drainage or odor . Review of the physician's wound care order dated 9/14/16 revealed .Cleanse sacral wound c (with) wound cleanse (WC). Pat dry. Apply a [MEDICATION NAME] dressing QOD (every other day) for 14 days . An Interdisciplinary Team (IDT) Note dated 9/16/16 documented, .At risk review per IDT r/t (related to) Stg (Stage) II IHPU (in house acquired pressure ulcer) on Sacrum . The Braden Risk Assessment Reports (indicating risk for developing pressure ulcers) dated 9/22/16 documented a Braden score of 12 indicating the resident was at high risk for developing pressure ulcers. The Weekly Wound report dated 9/22/16 documented, .Wound Location: .Sacrum .Wound Type: .Pressure Ulcer .Wound Measurements (LxW) 0.2000 x 0.2000cm (centimeters) .Depth: 0.1000cm . Stage 3 . The report revealed the pressure ulcer had deteriorated from a stage 2 to a Stage 3. A Weekly Wound assessment dated [DATE] and 9/28/16 documented, .Wound Location .Sacrum .Wound Measurements 0.2000 (L) centimeters (cm) x 0.2000 (W) cm .Depth (D) 0.1000cm Present On Admission: False Wound Stage .3 . The WP evaluation dated 9/27/16 documented, .She presents with a stage 2 wound sacrum of at least 21 days duration. There is light serous exudate . with measurements of 0.3 (L) x 0.3 (W) x 0.1 (D) cm. and no change in progress . The WP note revealed the wound had increased in size by 0.1 cm. Review of the physician's wound care order dated 9/28/19 revealed .Continue with Calcium Alginate and [MEDICATION NAME] to sacral wound until resolved . Review of the Weekly Condition Report (WCR) dated 9/28/16 revealed Resident #2 had a sacral wound with a date identified of 9/6/16 with an initial stage of UN (unstageable) of the sacrum. There was a line drawn through the UN and stage 3 was written in. The WCR revealed the pressure ulcer was initially identified on 9/6/16 as unstagable and then changed to a Stage 3. The care plan with the same date of 9/6/16 documented the initial pressure ulcer was a Stage 2. The Weekly Wound report dated 9/28/16 documented, .Wound Location: .Sacrum .Wound Type: .Pressure Ulcer .Wound Measurements 0.3000 (L) x 0.3000 (W) cm .0.1000 (D) cm .Wound Stage: stage 3 . An IDT Note dated 9/30/16 documented, .IDT/PAR (Patient At Risk) review r/t FAPU (facility acquired pressure ulcer), Stage III (3) to Sacrum . Review of the physician's wound care order dated 10/3/16 revealed, .Continue Calcium Alginate c [MEDICATION NAME] QOD until resolved . There was not an order to discontinue the wound treatment and the wound was still present on 10/4/16. Review of the Weekly Pressure Wound Tracking report dated 10/4/16 - 10/10/16 revealed Resident #2 had a stage 3 pressure ulcer to her sacrum. A WP progress note dated 10/4/16 documented, .PLEASE NOTE TYPOGRAPHICAL ERROR, THE WOUND STAGE CHANGED FROM STAGE 2 STAGE 3 . Review of a treatment administration record (TAR) dated 9/1/16 through 9/30/16 revealed there was no documentation the treatments were administered as prescribed on 9/17, 9/18, 9/19, 9/20, 9/21, and 9/22/16. D/C (discontinue) was written on each date from 9/22/16 through 9/30/16. There was no physician's order to discontinue the wound treatment and the wound was still present on 10/4/16. Review of a TAR dated 10/1/16 through 10/31/16 revealed that treatments were not documented as performed on 10/1/16, 10/2/16 or 10/3/16. Observations in Resident #2's room on 10/4/16 at 1:15 PM, revealed Licensed Practical Nurse (LPN) #1 preparing to perform wound care. The dressing dated 10/4/16 was removed by LPN #1. The sacral wound was dry with pink tissue approximately 0.1cm x 0.1 cm x 0.1 cm. There was no odor noted. Interview with LPN #1 on 10/4/16 at 12:50 PM, in the Chapel, LPN #1 was asked about the missed treatments and documentation. LPN #1 stated, .I did assess it on 9/7/16 I think that I am the one that found it and I did not know how to do Wound Sense at that time .it was pink tissue Stage 2, I guess. 9/7/ (16) is the first day I rounded with (Named wound Doctor) .when the wound went from stage 2 to 3, I gave her that, it developed a little bit of slough so we had to call it a 3 .I was new to EMAR (electronic documentation system), I wasn't clear about click on the box and not just mark it . LPN #1 was asked how she documented treatments on the 8th, 10th, 12th, 14th, and 16th and nothing else until 9/22 when the TAR documentation showed the treatments were discontinued. LPN #1 was asked if she was unsure of how to document, how she documented on those dates? LPN #1 stated, .I just got lucky .we rewrite the order every 14 days if it is not changed . LPN #1 was asked why the TAR had discontinue if the order was still current. LPN #1 stated, .I don't know, I don't dc (discontinue) them . Interview with LPN #1 on 10/4/16 at 1:00 PM, in the elevator, LPN #1 stated, .when I came here around 9/6 (16) I was used to the paper TAR. I was unsure about the computer system .I had to learn it on my own. The SDC (Staffing Development Coordinator) didn't even know how to use it . Interview with the Director of Nursing (DON) on 10/4/16 at 2:35 PM, in the Chapel, the DON was shown the IDT notes from 9/16/16 documenting a stage 2 IHPU on the sacrum, the IDT note dated 9/30 documented a stage 3 to the resident's sacrum and the WP's note on 9/6/16 that documented a stage 2 wound on the resident's sacrum. The DON was asked why the wound deteriorated between 9/16 and 9/30. The DON stated, Let me look at my notes before I answer that . At 2:55 PM, the DON stated, .It started out as 2 but we had to say a 3 because of slough. It was superficial. It was a small open area. It wasn't large enough to warrant a catheter, it is in the crack .it could be my mistake with the computer . Telephone interview with the WP on 10/4/16 at 3:40 PM, the WP was asked if the wound deteriorated from a stage 2 to a stage 3 due to the discrepancy in documentation. The WP stated, .Let me look at my notes .it was as stage 2 on both of my notes I have a stage 2 .I think it was my error . The WP was asked if treatments not being done as ordered could cause a wound to deteriorate. The WP stated, .If missed treatment, it could .they had a gap with the weekend, the nurses, some worked over .I don't know if they had a dedicated weekend nurse (for treatments) or not .that computer system I'm not sure about it, but it seems a bit much . Interview with the DON on 10/4/16 at 4:00 PM, in the Administration office, the DON was asked who does treatments on the weekend when LPN #2 is off, since she works Monday through Friday. The DON stated, .(LPN #1) has worked last 2 Saturdays and (LPN #4) will do treatments when (LPN #1) is off. (LPN #3) used to do treatments; I am looking for a weekend treatment nurse . Interview with the DON on 10/4/16 at 5:45 PM, in the Chapel, the DON was asked about the omitted treatments on the TAR. The DON stated, .We had some issues with EMAR and (Named Electronic Wound Program). We noticed in (MONTH) documented treatments were missing and people that did not have wounds were where it was showing up. We could pull it up electronically and see the treatments were done, but would not show up on print out. We also had that issue in (MONTH) . The DON was asked if she could pull it up electronically now and see that. The DON stated, .No . The DON was then asked if there was any back up documentation to show that treatments had been done. The DON stated, No . The DON was asked if there was a work order or something that would show the concern with the documentation in the electronic system. The DON stated, No .we QA'ed it in (MONTH) . There was no documentation provided from April. The facility's failure to timely identify, accurately assess and/or treat the pressure ulcer resulted in actual harm when Resident #2 developed an unstageable pressure ulcer to her sacrum. 4. Medical record review revealed Resident #53 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the WOUND CARE SPECIALIST EVALUATION of the stage 3 coccyx wound revealed the wound on 5/3/16 to measure 0.4 L x 0.2 W x 0.3 D in cm. Review of the (MONTH) (YEAR) Weekly Wound of the Stage 3 coccyx wound revealed the following wound measurements: a. 5/11/16 0.1 L x 0.3 W x 0.6 D b. 5/18/16 0.2 L x 0.1 W x 0.4 D There were no weekly wound assessments provided for the stage 3 coccyx wound for the week of 5/25/16. Review of the (MONTH) (YEAR) Weekly Wound revealed on 6/1/16 the Stage 3 coccyx wound measured 0.5 L x 0.2 W x 0.4 D. The annual Minimum Data Set ((MDS) dated [DATE] documented Resident #53 had a Brief Interview for Mental Status (BIMS) score of 13 indicating Resident #53 is cognitively intact per staff assessment and had one stage three pressure ulcer with length (L) 1.7 centimeters (cm) width (W) 0.7 cm depth (D) 0.3 cm. A physician order dated 9/8/16 documented, .APPLY HYDRAGUARD BARRIER CREAM WITH EACH INCONTINENT EPISODE .SACRAL WOUND . The care plan dated 7/17/15 and revised on 9/14/16 documented, .Problem .at risk for developing skin breakdown due to needs assist with bed mobility .history of pressure ulcers, left above knee amputation .poor appetite . Approach .Provide treatments as ordered . There was no documentaion that wound care was administered as ordered from 9/7/16 through 9/29/16. Review of the (MONTH) (YEAR) Weekly Wound of the Stage 3 coccyx wound revealed the following measurements: a. 9/6/16 2.1 L x 1.0 W x 0.6 D b. 9/14/16 1.5 L x 0.5 W x 0.5 D c. 9/21/16 2.0 L x 2.0 W x 0.1 D A physician order dated 10/4/16 documented, .[MEDICATION NAME] packing to undermining area q (every) day x 14 days Start 10-5-16 . The pressure ulcer had become larger in size and developed undermining. Observations in Resident #53's room, on 10/12/16 at 10:03 AM, revealed LPN #1 preparing to perform wound care. Upon entering the room LPN #1 stated, .I've already measured the wound it's .2.2 (L) lx1.2 (D) x 0.5 (D) .only difference is undermining 3x5 .treatment everyday I think the problem is she doesn't eat . Interview with LPN #1 on 10/4/16 at 5:24PM, in the Chapel. LPN #1 was asked about Resident #53's pressure wound. LPN #1 stated, I got here .around the 6th of (MONTH) .it has progressed .not bad .it's a stage 4 now .that's what I've known it as .it has undermining .the surface area is smaller .I think its deteriorated because of nutrition status and her comorbities .she is heavy . LPN #1 was asked where she documented the wound treatments. LPN #1 stated, .should have a zero on it .this is all new to me. LPN #1 confirmed that treatments were not performed. Interview with the DON on 10/4/16 at 5:57 PM, in the Chapel, the DON was asked about Resident #53's pressure ulcer. The DON stated, .I don't think she had wounds when she came in. The DON was asked if she knew the stage of Resident #53's pressure ulcer. The DON stated, .I think it's a three . The DON was asked if empty spaces on the TAR mean that no wound care was provided. The DON stated, .means no documentation . Interview with LPN #1 on 10/4/16 beginning at 6:20 PM, in the Chapel, LPN #1 was shown Resident #53's weekly assessment where she had staged Resident #53's pressure wound as a stage 3. LPN #1 was asked if Resident #53 had a stage 3 or a stage 4 pressure ulcer. LPN #1 stated, .it's a stage 3 or a stage 4 .it's a stage 4 because it's on her coccyx . At 6:38 PM, LPN #1 returned to the Chapel and stated, .it is a stage 4 .the doctor did an addendum that it wasn't a stage 4 because can't see bone . Interview with LPN #1 on 10/12/16 at 3:43 PM, in the Chapel, LPN #1 was asked if Resident #53 should be receiving weekly wound assessments. LPN #1 stated, .yes . LPN #1 was asked about the empty spaces on the TAR for the month of (MONTH) for wound care. LPN #1 was unable to provide documentation that wound care had been provided from 9/7/16 through 9/29/16. Interview with LPN #3 on 10/13/16 at 9:38 AM in the Chapel, LPN #3 was asked if she used to be the facility's wound nurse. LPN #3 stated, Yes . LPN #3 unit was asked if she had provided wound care treatments for Resident #53 . LPN #3 stated, Yes . LPN #3 was shown the (MONTH) (YEAR) TAR where no treatments had been documented from 9/7 to 9/29 and was asked if she could provide documentation for wound care for those dates. LPN #3 stated, No . The facility was unable to provide documentation the resident's wound care was performed as ordered, the wound became larger in size and developed undermining, resulting in in actual harm to Resident #53.",2019-10-01
2183,HILLVIEW COMMUNITY LIVING CENTER,445367,"897 EVERGREEN STREET, PO BOX 769",DRESDEN,TN,38225,2019-06-05,686,D,1,0,9LDZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on National Pressure Ulcer Advisory Panel guidelines, policy review, medical record review, observations and interview the facility failed to provide care and services to promote healing of pressure ulcers for 1 of 2 (Resident #3) sampled residents reviewed for pressure ulcers. The findings include: 1. The NATIONAL PRESSURE ULCER ADVISORY PANEL dated (MONTH) (YEAR) documented partial-thickness loss of skin with exposed dermis .should not be used to describe moisture associated skin damage (MASD) .MASD basic guidelines: No slough or eschar . 2. The facility's SKIN CARE PR[NAME]ESS policy dated 1/17/18 documented, .It is the policy of this facility to provide care and services with the goal of maintaining the resident's skin integrity and to provide care and services that meet professional standards to treat the loss of skin integrity should it occur .Process Guidelines .4. If a wound is not showing signs of improvement within 2 weeks of treatment, a re-evaluation of the wound and change in treatment should be considered . 3. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician order [REDACTED].cleanse stage 3 pressure injury to right buttock with wound cleanser or NS (normal saline), pat dry with gauze, apply collagen powder to wound bed, cover with foam dressing and secure with transparent dressing every day shift for pressure injury . The Physician Telephone Order dated 5/16/19 documented, .clean MASD to right buttock with wound cleanser and dry, apply skin prep around edges and allow to dry, apply [MEDICATION NAME] dressing q (every) 3 days and prn (as needed) soilage, every 24 hours as needed for skin care . The Physician Telephone Order dated 6/5/19 documented, .Santyl Ointment 250 unit/GM (gram) ([MEDICATION NAME]) Apply to right buttock topically one time a day . Review of the Pressure Injury Report dated 5/13/19 documented, .right buttock Stage 3 wound with 75% (percent) slough-white . Review of the Wound Care Skin Integrity Evaluation completed by the Wound Care Consultant dated 5/16/19 documented, . RIGHT BUTT[NAME]K .MASD .Wound Bed .yellow 75%, Adherent Fibrous Slough . Review of the Non-Pressure Skin Report dated 5/21/19 documented, .right buttock wound as MASD with UTD (unable to determine) . Review of the Non-Pressure Skin Report dated 5/29/19 documented, .right buttock wound as MASD . Review of the Pressure Injury Report dated 6/5/19 documented, .right buttock wound as Unstageable Pressure Injury with 25% slough, 75% gran (granulation) . Medical record review revealed Resident #3 received [MEDICAL TREATMENT] 3 days a week on Tuesday, Thursday, and Saturday and a hospitalization for a [MEDICAL CONDITION] from 5/13/19 through 5/15/19. 4. Observations of Resident #3 in room [ROOM NUMBER] B on 6/4/19 at 2:10 PM revealed right buttock wound with an open circular wound with 25% white to pale yellow slough in the center of the wound with a slight amount of serosanguinous drainage. Interview with the Director of Nursing (DON) in room [ROOM NUMBER] B on 6/4/19 at 2:10 PM, the DON was asked if the wound to the right buttock was a pressure injury. The DON stated .I thought it was pressure when it was first identified, we called (Named Wound Consultant) and she thought it was MASD and we changed it (wound description). Interview with the DON in the Conference Room on 6/5/19 at 4:17 PM, the DON was asked would MASD have slough. The DON stated, No, never had experience with MASD, should have researched it . The DON was asked if she consulted with the physician after the consultant changed the treatment. The DON stated, Probably should have . Telephone interview with the Medical Director on 6/5/19 at 6:50 PM, the Medical Director was asked if MASD would have slough and the Medical Director stated, No. It would be superficial, possibly a scattered area .",2020-09-01
1247,SIGNATURE HEALTHCARE OF MEMPHIS,445241,1150 DOVECREST RD,MEMPHIS,TN,38134,2018-02-23,690,D,1,0,5S2X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a Certified Nursing Assistant (CNA) job description, medical record review, observation, and interview, the facility failed to ensure 1 of 3 (Resident #3) sampled residents who were incontinent of bladder received appropriate treatment and services to achieve or maintain as much normal bladder function as possible. The findings included: 1. A CNA JOB DESCRIPTION dated and signed by CNA #2 on 3/14/16 documented, .Essential Duties & Responsibilities .Provide personal care (I.e., grooming, bathing, dressing, oral care, etc.) of residents daily and as needed . 2. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Resident #3 was always incontinent of bowel and bladder and required extensive assistance with personal hygiene. A care plan dated 9/28/17 and reviewed 12/20/17 revealed, .Problem .Resident has ADL (Activities of Daily Living) Self Care Deficit .Approaches .Staff to provide only the amount of assistance/supervision to meet the Resident's needs for all ADLs .Refer to Therapy as needed to evaluate and treat as indicated . The personnel file for CNA #2 hired on 3/14/16 was reviewed and revealed 1 of 14 COACHING & COUNSELING SESSION forms dated 11/23/17 which documented, . (X) WRITTEN .(Named Random Resident's) call light was on. I answered it and she motioned that she needed to be changed. (Named CNA #2) was making her rounds and (Named Random Resident's) room was next. I left the light on and continued to pass my meds (medications). The light had being (been) sounding for a while. When I looked up or noted (Named CNA #2) had gone home leaving (Named Random Resident) in bed on urine saturated sheet and diaper and pad .Earlier .asked (Named CNA #2) to (Delta symbol meaning check) her. However, after noting (Named Random Resident) in bed with urine saturated diaper, sheet and pad it did not look as though she had been changed at all .Stakeholder (CNA #2) failed to provide proper care to a [MEDICAL CONDITION] Resident, failed to provide proper ADL's. She completely ignored the pt's (patient's) needs . There was no documented follow-up for CNA #2's counseling session dated 11/23/17. A grievance form dated 2/12/18 revealed Resident #3's sister (Power of Attorney) had a concern. The grievance form documented, .Describe concern in detail: Visited after lunch while she was still in d.r. (dining room). Says there was a puddle under her chair. (Named Sister) took her to room & helped change the resident. She says the urine poured out Concerned w (with)/timeliness of incontinence care .Plan to resolve complaint/grievance: Staff to rendered (render) incontinence care q (every) 2 (hours) per assist resident to BR (bath room) as needed. Ensure resident receives assistance c (with) toileting needs. Results of actions taken: Staff assisting resident to BR as needed. Supervisor & staff assisting w/ ensuring incontinence care under Q (every) 2 (hours) & (and) as needed . Interview with Resident #3 on 2/21/18 beginning at 1:40 PM, in Resident #3's room, She was asked if she is checked and changed timely. Resident #3 stated, .The person that gets me up in the morning time, they change me, clean me up and I get dressed, I like to be out (in the facility) and they won't come and find me and they don't change me .I have not been changed at all today . Resident #3 was asked if she has told the CNA she needs changing. She stated, I see them but they say they ain't got me .I can get in and out (bed to wheelchair) myself, but I need a little assistance sometimes and when I ask for a little, they don't give me no assistance .They say I have an attitude . Observations in Resident #3's room on 2/21/18 from 1:40 PM until 2:30 PM, revealed Resident #3 had an odor of urine. Resident was not checked by staff during this time. At 2:30 PM, the Activity Assistant came in and wheeled her to activities. Observations continued in the dining room from 2:30 PM until 3:30 PM. Resident #3 was not checked by staff during the time she was in the dining room. Observations on 2/21/18 at 4:20 PM, Resident #3 was observed in the hallway self ambulating toward the dining room. She was asked if she had been changed. She stated, Yes, they just changed me. (Named Activity Director) took me to my room because my urine was on the floor in the dining room and it was coming out of my wheelchair. She had the same color pants on and was asked if those were the same pair of pants she had on earlier. Resident #3 stated, She put a clean dry pair of pants on me. Resident #3 had no odor of urine at this time and was wearing a clean dry pair of pants. Interview with the Activity Director on 2/21/18 at 4:30 PM, in the Activity Office, she was asked about what she saw and did concerning Resident #3. She stated, She (Resident #3) had urinated all over the floor, she had wheeled herself up to the table (in the dining room) with urine still dripping from her chair .I took her to her room and turned on the call light, then I told the nurse and told the CNA (CNA #1). Interview with CNA #1 on 2/21/18 at 4:41 PM, in the Dining Room, she was asked if she had just changed and cleaned Resident #3. She confirmed that she did. CNA #1 was asked if it looked like she had been changed at all today. CNA #1 stated, No, she was very soiled .her outside pants were wet too . CNA #1 was asked if she came in to work and found (Named Resident #3) wet very often. CNA #1 stated, Yeah. She was asked if she had told anyone about how she found her. CNA #1 stated, I did a month or so ago, that nurse is no longer here though. She was asked if she had told anyone else. CNA #1 stated, No . Interview with CNA #2 on 2/22/18 at 1:39 PM, in the Conference Room, she was asked if she was assigned to (Named Resident #3) yesterday (2/21/18). CNA #2 stated, Yes, I was assigned to her. She was asked when she changed her. CNA #2 stated, I believe I changed her around 10 o'clock (AM). CNA #2 was asked how often Resident #3 should be checked and changed if needed. CNA #2 stated, Every 2 hours. CNA #2 was asked if she checked her every 2 hours yesterday. CNA #2 stated, No, that was the only time . CNA #2 was asked why she did not check on her every 2 hours. CNA #2 stated, Well, sometimes she gets in her moods, sometimes we ask her and she says she is not wet .She was in a mood yesterday. There are certain people she lets change her, but if you go back and ask her later, she will let you change her. Interview with the Assistant Director of Nursing (ADON) on 2/22/18 at 4:26 PM in the Conference Room, she was asked about Resident #3's incontinence care needs. The ADON stated, .I followed up with the sister (POA) again yesterday (2/21/18), I was still thinking what else can I do, so I thought about a referral to therapy for a toileting plan .and I put a monitoring log with the CNAs. I will do this monitoring log for about a week for each shift. It started today on the day shift, it is an incontinence check . The facility was unable to provide any documentation of interventions for Resident #3 after the grievance was addressed on 2/12/18.",2020-09-01
3182,"COLLIERVILLE NURSING AND REHABILITATION, LLC",445495,490 WEST POPLAR AVENUE,COLLIERVILLE,TN,38017,2019-07-11,677,E,1,0,3FM311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a complaint allegation review, shower schedule review, medical record review, observation, and interview, the facility failed to ensure scheduled bathing and/or showers for 3 of 3 (Resident #1, #2 and #3) were provided. The findings include: 1. Complaint intake information dated 7/2/19 documented, .The complainant alleges the resident (Resident #1) is not getting his showers as scheduled . 2. Review of the facility's Shower Schedule revealed all residents were scheduled to receive a shower or full bed bath three times a week on Monday, Wednesday and Friday or Tuesday, Thursday and Saturday. 3. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set Assessment ((MDS) dated [DATE] revealed the resident had unclear speech, had severe cognitive impairment, was non-ambulatory and dependent on staff for all activities of daily living (ADL). Review of the comprehensive care plan dated 9/30/18 revealed Resident #1 was dependent on staff for bathing/showers. Review of Resident #1's ADL documentation revealed no bath/shower was given between 5/2/19 to 5/7/19 (4 days) and 5/30/19 to 6/3/19 (5 days). Observations in Resident #1's room on 7/8/19 at 1:15 PM, and on 7/9/19 at 10:35 AM and 12:20 PM, revealed the resident spoke no discernable words, had severe cognitive impairment without the ability to express his needs. He received a continuous feeding via Gastrostomy tube and was dependent on staff for all of his needs. 4. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] the resident was severely cognitively impaired, non-ambulatory and dependent on staff for all ADLs. Review of the comprehensive care plan dated 4/19/18 revealed the resident was dependent on staff for bathing/showers. Review of Resident #2's ADL documentation revealed a bath/shower was not given from 5/3/19 to 5/6/19 (4 days) and 6/23/19 to 6/26/19 (4 days). Observations in Resident #2's room on 7/8/19 at 1:25 PM, 3:35 PM, and on 7/9/19 at 10:50 AM and 12:30 PM, revealed the resident had no speech, had severe cognitive impairment, could not make his needs known, received a continuous feeding via Gastrostomy tube and was dependent on staff for all of his needs. 5. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS dated [DATE] revealed the resident had severe cognitive impairment, was non-ambulatory and dependent on staff for all of his ADLs. Review of the comprehensive care plan dated 6/3/19 revealed Resident #3 was dependent on staff for bathing. Observations in Resident #3's room on 7/8/19 at 1:15 PM and 3:30 PM, and on 7/9/19 at 10:37 AM and 12:21 PM, revealed the resident had no speech, had severe cognitive impairment, could not make his needs known, received a continuous feeding via Gastrostomy tube and was dependent on staff for all of his needs. 6. Interview with the Director of Nursing (DON) on 7/9/19 at 4:10 PM, in the Admission Office, the DON was asked if residents should be receiving a full bed bath or shower 3 times a week. The DON stated, Yes. Telephone interview with the complainant on 7/11/19 at 2:30 PM, the complainant was asked about Resident #1's hygiene and bathing, the complainant confirmed the complaint allegation information and stated, .I just want his body clean, his mouth clean and for them to get him up .",2020-09-01
5116,WYNDRIDGE HEALTH AND REHAB CTR,445304,456 WAYNE AVENUE,CROSSVILLE,TN,38555,2016-05-25,309,D,1,0,G07I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a facility Admission Agreement, record review, observation, and interview, the facility failed to ensure incontinent briefs were reordered for 1 resident (#3) of 3 sampled residents. Resident #3 was without a reorder of incontinent supplies for approximately 11 months. The findings included: Review of facility, Admission Agreement, signed [DATE] by Resident #3's responsible party revealed the resident agrees to: Pay all of the fees and charges described in this contract upon the terms agreed to unless third party payor arrangements have been made. Provide proof of such third party payor arrangements. Provide or be responsible for personal items of clothing, toiletries, ect. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an Incontinence Care Plan onset date [DATE] revealed the resident had a slight decline in bowel continence and was frequently incontinent of bladder. The updated care plan goal dated [DATE] revealed the resident would remain clean and dry. The approach included check for incontinence at regular intervals, use incontinent pads/brief as needed, change promptly when soiled. Review of the Interdisciplinary Care Plan dated [DATE] revealed the family was present and voiced concerns regarding the resident's incontinent briefs. Continued review of the Interdisciplinary Care Plan revealed the 200 Unit Manager (UM) ensured the family the incontinent supplies were ordered. Review of the facility's most recent insurance information dated [DATE] was the last yearly authorization (which expired in a year ,[DATE]) revealed the resident received briefs for a [DIAGNOSES REDACTED]. Observation of Resident #3 on [DATE] at 10:35 AM revealed the resident sitting in a wheelchair (w/c) wearing a geri-sleeve on the right lower arm, a Sensor tab alarm clipped to the back of the resident's clothing. Observation of the resident's shelf revealed four incontinent briefs. Observation of Resident #3 on [DATE] at 11:45 AM revealed the resident was assisted to the bathroom for toileting. Observation of the resident's brief revealed slight dampness and no odor of urine noted. Continued observation of the resident's peri area revealed skin intact and no signs of skin breakdown. Interview with Certified Nursing Assistant (CNA) #1 on [DATE] at 11:50 AM revealed incontinent residents are checked every two (2) hours (on the even hours). CNA #1 stated incontinent supplies are either furnished by the family or the facility reorder (unsure of how the reorder process implemented). Continued interview revealed the CNA stated .donated incontinent brief supplies are provided to residents who are in need .was unsure of how the residnet obtained incontinent supplies . Interview with the 200 UM on [DATE] on 3:15 PM revealed the facility did not provide incontinent briefs and stated incontinent briefs are order through the family or the facility assumes the responsibility for reorder. Continued interview revealed the UM was unaware of Resident #3's need for incontinent briefs and confirmed the facility failed to supply the resident with incontinent briefs.",2019-05-01
1246,SIGNATURE HEALTHCARE OF MEMPHIS,445241,1150 DOVECREST RD,MEMPHIS,TN,38134,2018-02-23,550,D,1,0,5S2X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a medical record review, observation, and interview, the facility failed to preserve the dignity for 1 of 3 (Resident #3) sampled residents observed for incontinence care. The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Resident #3 was always incontinent of bowel and bladder and required extensive assistance with personal hygiene. A care plan dated 9/28/17 and reviewed 12/20/17 revealed, .Problem .Resident has a potential for complications associated with incontinence of bowel and/or bladder .Goal .Resident's dignity will be maintained without embarrassment or fear through next review date . Interview with Resident #3 on 2/21/18 beginning at 1:40 PM, in Resident #3's room, She was asked if she was checked and changed timely. Resident #3 stated, . I like to be out (in the facility) and they won't come and find me and they don't change me .I have not been changed at all today . Resident #3 was asked if she has told the Certified Nursing Assistant (CNA) she needs changing. She stated, I see them but they say they ain't got me .I can get in and out (bed to wheelchair) myself, but I need a little assistance sometimes and when I ask for a little, they don't give me no assistance .They say I have an attitude .I tell them in meetings that they leave me soaking . Observations in Resident #3's room on 2/21/18 from 1:40 PM until 2:30 PM, revealed Resident #3 had an odor of urine. At 2:30 PM, the Activity Assistant came in and wheeled her to activities. Observations continued in the dining room from 2:30 PM until 3:30 PM. Resident #3 was not checked by staff during the time she was in the dining room. Interview with the Activity Director on 2/21/18 at 4:30 PM, in the Activity Office, she was asked about what she saw and did concerning Resident #3. She stated, She had urinated all over the floor (in the dining room), she had wheeled herself up to the table with urine still dripping from her chair .I took her to her room and turned on the call light, then I told the nurse and told the CNA (CNA #1). Interview with CNA #1 on 2/21/18 at 4:41 PM, in the Dining Room, she was asked if she just changed and cleaned Resident #3. She confirmed she did. CNA #1 was asked if it looked like she had been changed at all today. CNA #1 stated, No, she was very soiled .her outside pants were wet too .it was still dripping on the floor in her room . Interview with Resident #3 on 2/22/18 at 8:45 AM in Resident #3's room, Resident #3 was sitting on the side of the bed. She was asked about the day before when she was in the dining room after the activity program and how did she feel after she wet on the floor. Resident #3 stated, .It upset me and embarrassed me, I don't like to do that . Interview with CNA #2 on 2/22/18 at 1:39 PM, in the Conference Room, she was asked if she was assigned to (Named Resident #3) yesterday (2/21/18). CNA #2 stated, Yes, I was assigned to her. CNA #2 was asked how often Resident #3 should be checked and changed if needed. CNA #2 stated, Every 2 hours. CNA #2 was asked if she checked her every 2 hours yesterday. CNA #2 stated, No . CNA #2 was asked why she did not check on her every 2 hours. CNA #2 stated, Well, sometimes she gets in her moods, sometimes we ask her and she says she is not wet .She was in a mood yesterday . Interview with the Administrator on 2/22/18 at 5:05 PM in the conference room, she was asked about Resident #3 and what are some things that should be done so her incontinence all over the floor won't continue and she won't be upset and embarrassed about it. The Administrator stated, .She should be gently encouraged to let them take her to her room and just check her. They don't need to just say ok and walk away because she might not realize she is wet and she is a heavy wetter so it could happen if they don't encourage her to let them check her. We will do additional education on this .",2020-09-01
2730,AHC DYERSBURG,445446,1900 PARR AVENUE,DYERSBURG,TN,38024,2017-10-06,501,K,1,1,DRLB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on contract review, policy review, review of The Lippincott Manual of Nursing Practice, 10th Edition, review of job descriptions, [MEDICAL TREATMENT] contract review, medical record review, and interview, the facility failed to ensure the Medical Director assisted the facility with identifying, evaluating and addressing clinical concerns, coordinating the medical care and providing clinical guidance and oversight regarding the implementation of resident care policies and procedures that reflect the current standards of practice for the residents residing in the facility. The facility failed to ensure the Medical Director assisted with addressing clinical concerns and provided guidance regarding resident care of the residents residing in the facility by failing to ensure there was an effective process that monitored and addressed the potential for adverse consequences related accidents/falls during transportation for medical care outside the facility, and failed to ensure the facility investigated and implemented appropriate interventions after falls during transport, resulting in Immediate Jeopardy (IJ) for 1 of 4 (Resident #58) sampled residents, when Resident #58, who was blind in both eyes and a bilateral lower extremity [MEDICAL CONDITION] (surgical removal of both legs) sustained a fall with a serious injury, a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) during transport on [DATE]. The resident was hospitalized as a result of the fall, declined during hospitalization , and expired in the hospital on [DATE] with [DIAGNOSES REDACTED]. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment or death for resident. The Administrator, the Regional Nurse Consultant (NC), and the Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 4:48 PM, in the conference room. The facility was cited an Immediate Jeopardy at F501-K. An extended survey was completed on [DATE]. An acceptable allegation of compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on [DATE] at 6:57 PM. Corrective actions were validated onsite by the surveyors on [DATE] and [DATE]. The Immediate Jeopardy was effective [DATE]. The immediacy was removed [DATE]. The noncompliance continues at F501-E for monitoring of effectiveness of the corrective actions to ensure sustained compliance. The findings included: The Medical Director Agreement documented, .The Medical Director shall be responsible for the implementation of resident care policies and coordination of medical care in the nursing home in compliance with all Medicaid, Medicare, and other applicable state and federal regulations. The Medical Director shall .Review reports of all incidents or unusual incidents occurring on the premises, identifying hazards to health and safety and recommending corrective action to the administrator .Advise and provide consultation on matters regarding medical care, standards of care, surveillance and infection control . The facility's Fall Risk/Fall Prevention Guidelines policy dated (MONTH) 2014, documented, .An assessment is the initial step in preventing avoidable falls. The completing of a fall risk assessment can be useful in identifying and managing risk factors. A Fall Risk Assessment .will be completed by a licensed nurse indicating the patient's risk factors .Upon admission/readmission to the facility .After a fall .Significant change in medical status .Quarterly .The licensed nurse completing the assessment will address the identified risk category, developing a plan of care, and the implementation of appropriate interventions to assist with fall prevention .Review of medications; eliminate unnecessary medications to reduce the risk of falls; patients receiving high risk medications .will be observed during routine care for possible adverse side effects .Post Fall Management is an opportunity to conduct a root cause analysis of a patients (patient's) fall, identifying specific factors that contributed to the fall. The fall determination will assist care givers in implementing interventions that are cause specific, possibly reducing future falls .Licensed Staff .Will complete the Nurse Event Note, detailing with as much information as possible, how/why the occurrence occurred .Attempt to determine the cause of the event, update the Fall Risk Assessment Tool, gather statements from staff members, resident, family and/or other witnesses; implement/modify the patient's current plan of care with intervention(s) associated with the cause of the fall .Nursing Administration .Will review all occurrences during the morning QA (Quality Assurance) meeting .The Interdisciplinary Team .will initiate a thorough investigation of the incident and discuss findings and potential interventions during the morning QA meeting .Finalize the Occurrence Investigation report, ensuring that all contributing factors have been identified, and the appropriate intervention has been implemented .Modify the patient's plan of care as needed .The DON (Director of Nursing) or designee will input all fall data into the Facility's Monthly Fall Tracking Report .Fall Analysis .The Interdisciplinary Team will discuss falls in their morning QA meeting and perform a root cause analysis for each fall in order to identify why the fall occurred. The purpose of this process is to assist the clinician in implementing appropriate interventions that will reduce the occurrence of falls for the patient .The facility will share fall reporting data with the Medical Director, discussing any identified trends that may require further investigation and/or revision of the facility's procedures .Develop Corrective Action Plans as needed for identified trend(s) that may require further monitoring to achieve the optimum goal for fall reductions within the facility . The Lippincott Manual of Nursing Practice, 10th Edition documented, .Nursing Practice And The Nursing Process .Ensuring Safety .Continually assess safety .particularly if the patient is very ill and the care plan is complex .Assess for the patient's personal safety issues-sensory deficits . Review of the [MEDICAL TREATMENT] Services Agreement documented, .Operator (Long Term Care Facility) shall be responsible for making arrangements to transport the patient to Provider's ([MEDICAL TREATMENT]) Clinic .If the patient needs to be accompanied .Operator shall be responsible for making such arrangements. Operator shall also be responsible for ensuring that the patient is medically stable to be transported . The Medical Director failed to ensure implementation of basic care policies and coordination of medical care related to care plan revision to reflect falls with implementation of interventions for fall prevention, resulting in I[NAME] Refer to F280. The Medical Director failed to advise and consult with facility Administration on matters regarding medical care, surveillance, and professional standards of practice related to resident assessments, resulting in I[NAME] Refer to F281. The Medical Director failed to ensure policies and procedures for safety assessments were in place and completed prior to transportation without an escort outside the facility for medical services related to [MEDICAL TREATMENT]. The failure of the facility to provide the appropriate safety assessment/reassessment resulted in I[NAME] Refer to F309. The Medical Director failed to ensure services were provided to ensure identification of potential hazards to the health and safety, and failed to recommend appropriate corrective actions to facility Administration related to conducting safety assessments for transporting residents in a wheelchair van unattended, resulting in I[NAME] Refer to F323. The Medical Director failed to ensure the facility followed their policies and procedures regarding an effective Administration. Refer to F490 The Medical Director failed to ensure the Governing Body provided effective surveillance and oversight to ensure policies and procedures were initiated and implemented related to concerns of hazards to health and safety, resulting in I[NAME] Refer to F493 The Medical Director failed to ensure an effective Quality Assurance Committee recognized concerns with hazards to health and safety and failed to implement effective interventions and monitoring to resolve concerns of hazards to health and safety, resulting in I[NAME] Refer to F520. An extended survey was completed on [DATE]. An acceptable allegation of compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on [DATE] at 6:57 PM. Corrective actions were validated onsite by the surveyors on [DATE] and [DATE]. Validation of the credible A[NAME] was accomplished onsite [DATE] and [DATE], through review of facility documents, review of in-service records, observations, and interviews with nursing staff. The surveyors validated the corrective actions stated in the A[NAME] were implemented which removed the immediate jeopardy. The facility provided evidence of in-service training with sign-in sheets for all charge nurses on completion of the Transfer Form to include the Safety Risk Assessment, including report to the transport driver, and signature of nurse, patient (if able), and driver, for every resident upon transfer off the facility premise; and to include an escort to accompany the resident in the event the driver refused to sign the Transfer Form. Interviews with the charge nurses conducted in the facility confirmed the nurses understood the transfer process was always to include the safety assessment with documentation. The noncompliance continues at F501-E for monitoring of the corrective actions to ensure sustained compliance. The facility is required to submit a plan of correction.",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
2108,LAUDERDALE COMMUNITY LIVING CENTER,445354,215 LACKEY LANE,RIPLEY,TN,38063,2017-05-05,224,K,1,0,QMFO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility documents, grievance complaint, Investigation report, policy review, medical record review, observation and interview, the facility failed to ensure residents were free from abuse, neglect and mistreatment by facility staff for 5 of 13 (Residents #16, 45, 55, 57 and 61) residents reviewed in the stage 2 sample review. The failure of the facility to ensure residents were free from mistreatment and neglect resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all residents and resulted in IMMEDIATE JEOPARDY (IJ) to Residents #16, 45, 57 and 61 and psychological harm to Resident #55 as evidenced by a tearful, emotional response during interview. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Director of Nursing and Region One Nurse Consultant #1 were informed of the Immediate Jeopardy on [DATE] at 1:09 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F224-K, which is Substandard Quality of Care. An extended survey was completed on [DATE]. The Immediate Jeopardy was effective [DATE], and is ongoing The findings included: 1. The facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Prevention policy documented, The resident has the right to be free from abuse, neglect .Resident must not be subjected to abuse by anyone .Abuse-The willful infliction of injury .intimidation or punishment with resulting physical harm, pain or mental anguish .Verbal abuse-The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents .Mental abuse-Includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .Psychosocial harm-Include but not limited to extreme embarrassment, ongoing humiliation, degradation as a human being .Neglect-Failure of the facility, it's employees or service providers to provide goods and services to a resident . 2. Review of the Dignity and Respect policy documented, .It is the policy of this facility to treat each resident with respect . the staff shall display respect for residents when speaking with, caring for, or talking about them . 3. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nurse's note dated [DATE] at 8:00 PM, was errored out with a line through the documentation indicating it as incorrect. Review of the [DATE] at 8:00 PM, nurse's note written by Licensed Practical Nurse (LPN) #7 revealed, incorrect documentation (error) . Called to resident's room by CNA (Certified Nursing Assistant). Assigned CNA was standing in the doorway of resident's room waiting for assistance. When I entered the room, the resident's head was turned towards the headboard and her neck was between the mattress and the siderail on the right side of the bed. Her body was off the bed, her bottom on the floor with her legs stretched out in front of her. Her right arm was up on the bed close to her head. With the assitance (assistance) .of the CNAs, we laid the resident in the floor. This nurse felt for a pulse, listened for breathing and heartbeat. At this time, another nurse called the DON (Director of Nursing) while this nurse and CNAs transferred resident to the bed. DON was called at 8:10 PM. MD (Medical Doctor) notified at 8:28 pm. Resident was bathed and dressed by CNAs. The DON's note dated [DATE] at 8:15 PM, was errored out as incorrect documentation. Review of the [DATE] DON's note for 8:15 PM, revealed incorrect documentation (errored out with a line through the documentation indicating it as incorrect) revealed, .observed resident lying in bed upon assessment no pulse, no respirations noted, time of death pronounced at 8:11 PM, spoke to RP (Responsible Party) request that (named funeral home) be called to transport body to funeral home Review of LPN #7's revised documentation revealed [DATE] at 9:00 PM, .Called to resident's room by CN[NAME] Assigned CNA was standing in the doorway of resident's room waiting for assistance. When I entered the room, the resident's head was turned toward the headboard with the left side of her face pressed against the side rail. Her body was off the bed, her bottom was on the floor and her legs were stretched out in front of her. The right arm and shoulder were on the bed pointing towards the headboard. With the assistance of CNAs, we laid the resident in the floor. This nurse assessed for pulse, breathing and heartbeat. None was found. As this time, another nurse called the DON while the resident was transferred to bed. DON called at 8:10 pm. MD notified at 8:28 pm. Resident was bathed and dressed by CNAs. On [DATE] at 1:25 PM, the Administrator was asked for all facility investigations conducted from (MONTH) (YEAR) to the present date. The Administrator was unable to provide documentation of any incidents from (MONTH) (YEAR) to present. Interview with Confidential Interviewee (CI) #7 on [DATE] at 8:01 AM, by telephone, CI #7 was asked what she knew of Resident #16's death. CI #7 stated, I was not a part of that scenario, I came in to work the following day and I heard about the situation, and when I went to the morning meeting I said to (named DON) State will be in because this is reportable. Is there anything you want me to be checking on, since we have to do a reportable and we're in our window. They will probably come on in. She said 'What do you mean state will be here?' And I said, with that reportable. And she said, 'That's not a reportable. She said after their investigation (she and the Administrator) they determined it was not reportable .Well, they came in that night after the incident happened and started their investigation .I don't know what their investigation involved but I felt like after reading that note that it was a reportable . Interview with CI #8 on [DATE] at 5:32 PM, in the conference room, CI #8 was asked if she knew of any accidental deaths in this facility. CI #8 stated, Yes, (Resident #16). CI #8 was asked what happened. CI #8 stated, She was in the bed and fell out of the bed and got hung in the railing. She got caught up in the railing in the bed .her legs were on the floor and the neck was caught between the railings. CI #8 was asked if she meant the side rails. CI #8 stated, Yes. She has an alarm but it didn't go off. CI #8 was asked if she meant a bed pressure alarm did not go off. CI #8 stated, Yes. CI #8 was asked how often they check the alarms. CI #8 stated, It was working if you pressed real hard. When she came out of the bed it didn't make any noise. CI #8 was asked if the DON came in that night. CI #8 stated, Yes, and the Administrator. CI #8 began to cry. CI #8 was asked if Resident #16 had a history of [REDACTED].#8 stated, People on the other shifts said she tried to get up but I have never seen her try to get up. CI #8 was asked about the maintenance supervisor. CI #8 stated, That was his mom. CI #8 was asked what happened when the resident was found. CI #8 stated, .(Named nurse) was here, and she came around there and checked her. We put her on the bed .I'm trying to think who all was here, we put her on the bed .before the DON arrived. CI #8 was asked if she told the Administrator and DON what happened. CI #8 stated, I told them what had happened. CI #8 was asked if she told them that Resident #16's head was caught in the side rail. CI #8 stated, Yes, and that her legs were on the floor. CI #8 was asked if the resident was in the bed when the DON came. CI #8 stated, Yes. CI #8 was asked if she told both the Administrator and the DON. CI #8 stated, They questioned me. CI #8 was asked if she had been told to not tell anyone. CI #8 stated, I wrote a statement. CI #8 was asked if she wrote what she saw. CI #8 stated, Yes. CI #8 was asked to whom was the statement given. CI #8 stated, (named DON). CI #8 was asked if Resident #16's head was in her normal position (since the resident had kyphosis (rounded upper back)). CI #8 stated, When we got her off the floor it was in normal position. CI #8 was asked if Resident #16 was breathing. CI #8 stated, No and she wasn't moving. CI #8 was asked how long had it been since staff had seen her last. CI #8 stated, It had been 2 hours .I was going, into her room. CI #8 was asked what time this occurred. CI #8 stated, (she was) put .to bed after supper. It was between 8 and 8:30, I think. CI #8 was asked if the resident was on the bed when the DON got there. CI #8 stated, Um hum (yes). CI #8 was asked how Resident #16 was lying. CI #8 got on the floor to try to demonstrate and stated, Her head was facing the wall, her face was to the railing and was caught up .the geri chair was on the side of the bed that she was. CI #8 was asked if both the top rails were up. CI #8 stated, Yes. She was on the door side of the bed away from the (other) resident .she was between the rail and the mattress. CI #8 was asked who were the other staff there that night but she could only remember CNA #5. Interview with CI #12 on [DATE] at 8:55 PM, by telephone, CI #12 was asked what she knew about the death of Resident #16. CI #12 was asked how Resident #16 was found. CI #12 stated, Whenever I walked in the room the right arm and her head was right there-the side rail things-her head and arm were pinned in the side rail. Her feet were almost at the wall. Her bottom was not touching the ground. CI #12 was asked if she had said her bottom was not touching the floor. CI #12 stated, Right. CI #12 was asked what was caught in the side rail. CI #12 stated, It seemed like more her jaw. CI #12 was asked about the position of her neck. CI #12 stated, .the way it was turned looked unusual. It was turned sideways and up, making her look toward the ceiling. The previous statements were re-read to CI #12, and she was asked if that was what she had said. CI #12 stated, Yes .the side rail had her jaw and her arm pinned up. I could not tell if her feet were touching the wall or not. It could have been her feet, she had long legs so it might have been that it wouldn't let her come down. CI #12 was asked if she had been told not to tell anyone about the incident. CI #12 stated, Um, in all honesty, until we talked to the Administrator and DON we were told not to talk to anyone about this . CI #12 was asked if she had given a written statement. CI #12 stated, Yes. Interview with CI #10 on [DATE] at 8:00 AM, in the conference room, CI #10 was asked what she knew of Resident #16's death. CI #10 stated, .When I walked in the room she was sitting in the floor by the bed and her head was turned toward the headboard so that made the left side of her face up against the side rail. CI #10 was asked what happened next. CI #10 stated, we got her to the floor. CI #10 was asked if there was a pulse. CI #10 stated, No .she was a DNR (do not resuscitate) .I had the nurse check for me. CI #10 was asked if Resident #16 was breathing. CI #10 stated, No. CI #10 was asked what happened then. CI #10 stated, While the nurse was gone I checked for vital signs. Myself and a couple of aides transferred her back to the bed. Then the other nurse called (named DON) because we have to have a RN (registered nurse) to pronounce .(LPN #1) also notified the family .I notified the doctor . CI #10 was asked what she had told the doctor, if she had told him how she was found lying. CI #10 stated, Just that she had passed. CI #10 was asked if anyone called the Administrator. CI #10 stated, I did not but I believe (named DON) did. CI #10 stated, She had to have rolled out of the bed. She did not walk. She sat in a geri chair. CI #10 was asked if she filled out a written statement. CI #10 stated, Yes ma'am. CI #10 was asked if there were any marks on Resident #16 after the incident. CI #10 stated she had a spot on her jaw .left .a little discoloration there. CI #10 was asked if she knew if the son was aware of the incident. CI #10 stated, No ma'am .I was told (named Administrator) told him. CI #10 was asked if the Administrator and DON came into the facility that night. CI #10 stated, Yes ma'am. CI #10 was asked how Resident #16's face was turned when she was off the bed. CI #10 stated, It was turned to the right toward the headboard. CI #10 was asked if the resident's bottom was touching the floor. CI #10 stated, Yes ma'am. CI #10 was asked to describe how her legs were positioned. CI #10 stated, They were stretched out in front of her .her geri chair was between her chest of drawers and the bed .her legs were under the geri chair .the aides picked up the geri chair .her legs were straight. CI #10 was asked if Resident #16's neck was in a normal position for her. CI #10 stated, It was down and turned . CI #10 was asked if Resident #16 had contractures. CI #10 stated, She did, most of the time she was a wiggle worm. CI #10 was asked if Resident #16 had fallen before. CI #10 stated, Not since I've been here, but before. CI #10 was asked if Resident #16 had a pressure alarm on her bed. CI #10 stated, She did but it did not go off. But, it was on. That was my big thing because it did not go off. The DON interrupted the interview (by walking into the room) with CI #10 at this point. CI #10 continued, It did not go off. (Named Administrator) asked when I check my alarms. I check them at my 8:00 med (medication) pass and that is what I was doing when that happened. Interview with the DON on [DATE] at 10:01 AM, in the conference room, the DON was informed that the survey team had asked for all investigations. The facility was unable to provide an investigation of the circumstances of the death of Resident #16. The DON was asked if an unexplained death is to be reported to the State. The DON stated, Yes. The DON was asked if they had any unexplained deaths in the facility. The DON stated, No. The DON was asked if she was present the night of (Resident #16's) death. The DON stated, I was, after she passed away. The nurse called and said (Resident #16) doesn't have any respirations and I can't find a pulse. I said is she a DNR. She said yes and I told her I was on my way. The DON was asked if she always comes in if a resident expires. The DON stated, Since my other RN resigned, I have to come in. The DON was asked what happened after she arrived. The DON stated, I checked her. She had expired. I didn't call the doctor or the family. I don't remember if I called or if other staff called. I asked what happened. Course it was her birthday. It looked like she had slid out of the bed after she expired. The DON was asked how it was determined that she slid out of the bed after she expired. There was a long pause. The DON stated, That's what we assumed. Cause she had definitely slid out of the bed. Her body was still warm. The CNA said she was part way on the floor. She had no bruising or anything so she couldn't have been there long. The DON was asked if Resident #16 had any marks on her. The DON stated, Yeah, she had a light red, it was pink in color, where her face had been touching the side rail. The DON pointed to her right face and stated, I'm not sure if it was right or left. The DON was asked if there was an investigation. The DON stated, No, I just asked them what was going on and what happened. The DON was asked if she had any witnesses write a statement. The DON stated, (named assigned nurse) put her statement in .the computer. Two other ladies made statements. The DON was asked if there were just 2 statements made. The DON stated, Yes, (named assigned nurse) put hers in the computer. The DON was asked if there was any further investigation. The DON stated, No. The DON was asked if the Administrator came to the facility that night. The DON stated, Yes, he came to talk to (named Resident's son). The DON was asked if it was normal for the Administrator (that lives 70 miles away) to come to the facility when there is a death. The DON stated, No, but him and (named son) are pretty close so he wanted to make sure (named son) was ok. The DON was asked if Resident's son was aware that she was found on the floor. The DON stated, Yes. The DON was asked what time she arrived. The DON stated, I have no idea. I'm sorry. The DON was asked what time the Administrator arrived. The DON stated, It wasn't too long after I did. The DON was asked who called the Administrator. The DON stated, I did. The DON was asked what she told the Administrator. The DON stated, That (named son's) mom had passed away. The DON was asked why she thought the nurse's note that was marked out was incorrect documentation. The DON stated, Because the way she had explained .was not correct. When I looked at the bed. She had quarter side rails and she had the mattress overlay, so there was no way that was possible. The DON stated, There is only this much space between (holding fingers up to show the amount of space) . To clarify what the DON had said, the surveyor asked, do you mean LPN #7 could not demonstrate the position Resident #16 was found without placing her head between the side rails. The DON shook her head and stated, Exactly, because it was impossible .I looked at the mattress and the rail. Nothing could fit between the mattress and the rail. You can't squeeze it .They would have to forcefully remove her and that is not what the nurse said. It was impossible. The facility's failure to identify and investigate the circumstances of Resident #16's unexpected death resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all residents in the facility. 4. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], Anxiety Disorder, Kyphosis (outward curvature of the spine), Major [MEDICAL CONDITION], Contracture of the Knee and Hip, and Dementia with Behavioral Disturbances. Record review revealed the resident had a fall from the bed on [DATE]. The resident scooted too close to edge of bed and rolled off. Interview with CI #4 on [DATE] at 9:53 AM, in the conference room, was asked about problems with Resident #45's care. CI #4 stated, .I told them (staff) you can't jerk (her clothes off) cause you will break her legs .she is so little. CI #4 was asked who she had said this to. CI #4 stated, (Named CNA #1) .the DON said 'she (Named CNA #1) hires and she fires them.' .She (Named CNA #1) came in there and got ready to lay her down. She didn't lay her down, she throwed her down. She (Named CNA #1) was mad cause she (Resident #45) had .her clothes on. They didn't want her to have clothes on .They (staff) stand right outside the room pointing to the door and listen .(Named nurse) told her that she ( Resident #45) was not supposed to have clothes on. She (Named CNA #1) got so mad and threw the chair around so fast. (Named CNA #1 said) 'There is no problem with that woman anyway' .She took her (Resident #45) out of the chair and threw her in the bed .There are about 3 of them that don't care about these people .If they were a little more caring they might be alright but right now, no ma'am .I don't want her (Named CNA #1) in there . Interview with CI #1 on [DATE] at 1:45 PM, in the conference room, CI #1 stated, The DON and Social Worker (SW) are very close and they cover for each other .(CNA #1) jerked (the resident's) chair .was rough. CI #1 was asked if she was rough handling or talking to Resident #45. CI #1 stated, Both .this is about the 4th incident that I have had with her .on [DATE] (resident) had a scratch on her leg. (Named family member) talked to the DON about it .CNA #1 was the CNA (assigned to her at the time of the scratch). CI #1 stated, .was told (the resident) fell out of the bed during the night. (Resident #45) is immobile .hasn't walked for a year and a half .my fear is that they know I am in here talking to yall (survey team). I have found CNA #1 openly hostile .CNA #1 carries a lot of power and she can be vindictive . Interview with CI #3 on [DATE] at 5:55 PM, in the conference room, CI #3 was asked about the care for Resident #45. CI #3 was asked if she had seen anyone be rough with the residents. CI #3 stated, Oh yes, turning them and pulling their clothes off .I know (CNA #2), I have seen her .(Resident #45) had a big scratch on her leg and we asked how she got the scratch on her leg. (CNA #1) had the 2 of them (Resident #45 and Resident #61- roommates) that day . CI #3 was asked what she has seen that she considers rough. CI #3 stated, They just take her back and push her over and she hollers, 'Oh! Oh!' They be trying to turn her and clean her. You can hear the bed go boom, boom (bed hitting against the wall) . Interview with CNA #1 on [DATE] at 1:04 PM, in the conference room, CNA #1 was asked regarding complaints against her care of Resident #45. CNA #1 stated, She said we didn't take care of her. And I said 'Yes we do.' The DON told me not to take care of Resident #45 anymore, to keep the chaos down . CNA #1 was asked how many people it takes to put (Resident #45) in the bed. CNA #1 stated, One .I set her chair up and grab her under the arms and transfer her over to the bed. CNA #1 was asked if Resident #45's feet touch the floor. CNA #1 stated, No ma'am . CNA #1 was asked if Resident #45 moans when she puts her in the bed. CNA #1 stated, Sometimes. Interview with CI #1 on [DATE] at 3:42 PM, by telephone, CI #1 was asked to whom she reported her concerns. CI #1 stated, Which time .I talked to the SW. CI #1 was asked if she ever reported that some one was rough with Resident #45. CI #1 stated, Yes. (CNA #1) was rough . CI #1 was asked who she reported the rough treatment to. CI #1 stated, (Named DON) because that is why I did not want (CNA #1) back in the room. CI #1 was asked exactly what the rough treatment was. CI #1 stated, Jerking on her clothes . CI #1 stated, I told her CNA #1 was very rough .Her attitude was very short with her and this was not the first time she was uncooperative . CI #1 was asked if she had ever witnessed them in the room, talk over the residents. CI #1 stated, I have heard her say, 'I don't have time for that.' 'That's not my job' .She is very short with people . CI #1 was asked if they had a concern, did she feel like it would be addressed. CI #1 stated, .DON or Administrator- No I do not. I believe they will tell me that it has been. CI #1 stated, .There have been 3 occasions since Christmas. (The resident) had a large scratch on .face, and then .fell out of the bed, and then there was (the skin tear on her leg) .But no one knows how they happened. I don't know nothing has been done. No one has gotten back to me. They didn't say, oh, (the resident) must have slipped .It is very frustrating that (the resident) keeps having accidents and no one knows anything about it . Review of the nurses notes for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) revealed there was no documentation of these injuries. Interview with the DON on [DATE] at 10:12 AM, in the conference room, the DON was asked for the investigations for the 3 incidents related to #45's related to the fall, the skin tear and the scratch the resident sustained [REDACTED].There was no investigation or documentation of a scratch . Interview with the Administrator on [DATE] at 7:30 PM, in the conference room, the Administrator had been asked for an incident report and investigation for a scratch to Resident #45's face some time after Christmas. The Administrator stated, There were no incidents on a scratch on Resident #45's face since Christmas. Interview with CI #16 on [DATE] at 10:54 AM, in the DON office, CI #16 was asked if Resident #45 had more incidents since the surveyors were in the facility. CI #16 stated, .She has had on ,[DATE] a bruise on her left forearm and an abrasion on left shin. An abrasion on right forearm on ,[DATE] from the body audit we did that day. CI #16 was asked about something on her thigh. CI #16 stated, Skin tear to the left thigh on ,[DATE] .her frail skin it would be torn easily. The facility failed to ensure Resident #45 was free from mistreatment when staff were allowed to handle her roughly and not meet her needs. 5. Medical record review revealed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an admission MDS dated [DATE] and quarterly MDS dated [DATE] revealed Resident #55 was cognitively intact. Observations in Resident #55's room on [DATE] at 4:42 PM, revealed Resident #55 lying in bed. Resident #55 stated, I stay in bed, I can't walk . Interview with Resident #55 on [DATE] at 4:42 PM, in the resident's room, the resident was asked if she could tell the surveyor about a time when she was mistreated or someone spoke harshly to her while in the facility. The resident stated, .I've been treated okay since y'all came .it's just the ones before y'all came they used to hurt my feelings and make me cry and say hateful things to me . The resident was asked who said those things to her. The resident stated, DON. The resident was asked what the DON said. The resident stated, One time .She said is there any way you can call your boyfriend, I need to talk to him. I called and said the DON wants to speak to you. She said, Hi, Mr. (Named Boyfriend), I just want to make sure we're on the same page, (Named Resident) she's getting too big and you need to stop bringing her pizza .I don't hate this place just the people that were here . The resident was asked if anyone here now mistreats you. The resident stated, No ma'am, I've not seen those people since y'all been here so whatever y'all are doing, you're doing a good job . The resident became visibly upset, tearful and agitated during the interview and apologized for becoming so upset. Interview with CI #5 on [DATE] at 9:04 AM, CI #5 was asked if Resident #55 had ever expressed to her that staff had hurt her feelings and made her cry. CI #5 stated, Sometimes when I go in the room .she's crying and I ask her to talk to me. She says .her feelings have been hurt and I say tell me (Named Resident 55) but she won't . CI #5 was asked if she had reported that to anyone. CI#5 summarized that she had heard it discussed in shift report and when staff went in the room they could tell the resident was upset. CI #5 stated, .Since I've been working with her I've seen her crying several times . Interview with CI #16 on [DATE] at 2:59 PM, in the DON office, CI #16 was asked what were her expectations when a resident is tearful. CI #16 stated, I would expect that they would address and identify what was causing her to be tearful, notify Social Services, notify the doctor, but first and foremost find out why they're tearful. There was no documentation the facility provided appropriate care and services to prevent verbal abuse of Resident #55. The failure to provide an environment free from retaliation and mistreatment resulted in Psychological Harm to Resident #55 when she was belittled and treated rudely by the DON. 6. Medical record review revealed Resident #57 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] and the annual MDS dated [DATE] revealed Resident #57 had a Brief Interview for Mental Status (BIMS) of 4 indicating the resident had severe cognitive impairment. The care plan revised on [DATE] documented, Focus .COMMUNICATION problem r/t (related to) [MEDICAL CONDITIONS]([MEDICAL CONDITION]) .Intervention .Allow adequate time to respond .Do not rush .Resident is able to answer simple yes and no questions. Does well when given word/answer options . Interview with CNA #2 on [DATE] at 7:32 AM, in the Conference Room, CNA #2 was asked if there are residents that certain CNAs are not to assist with. CNA #2 stated, Named (Resident #57) I was told to not go back into that room . left her wet . A phone interview with CI #15 on [DATE] at 2:11 PM, was asked if they were having problems with the staff. CI #15 stated, (Resident #57) doesn't want her (CNA #2) in the room, she will say no, no, no she's mean .I was the one to go ask for her (referring to CNA #2) not to go in her (Resident #57) room . CI #15 when you asked for CNA #2 not to go back into her room did they do anything. CI #15 stated, Not to my knowledge . CI#15 stated, I know something happened . A phone interview with CI #17 on [DATE] at 2:45 PM, CI #17 was asked have you voiced your concerns about staff to anybody. CI #17 stated, Nurses .got no reaction .right after Memorial Day (YEAR) I called Corporate office .the lady on the phone asked why I didn't take the complaint to the nurse and I said the complaint is about the nurse and she said oh . CI #17 was asked do you feel like anybody here in management address or listens to your concerns. CI #17 stated, (management) just rolls their eyes . Interview with the Administrator on [DATE] at 10:00 AM, in the Administrator's office, the Administrator was asked have there been any complaints about handling residents' rough. The Administrator stated, Not directly to me . Review of Grievance/Complaint Investigation Report revealed there were no grievances reported in the month of (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) regarding Resident #57. Interview with the Social Worker (SW) on [DATE] at 10:33 AM, in the conference room, the SW was asked if there were any complaints or grievances for the month of (MONTH) and December. The SW stated, No. The SW was asked if there were only five complaints and grievances for the month of January, only one complaint and grievances for the month of February, only one complaint and grievance for the month of (MONTH) and only four complaints and grievances for the month of April. The SW stated, Yes. The SW was asked what type of complaint would be put on the complaint log. The SW stated, .call lights, food issues, staff members . The SW was asked would any complaint big or little go on the complaint log. The SW stated, Yes, if I know about it . The facility failed to ensure Resident #57 was free from mistreatment when the staff were allowed to handle her roughly and not meet her needs. 7. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] documented Resident #61 was severely impaired cognitively and required extensive assistance for all ADLs. Interview with CI #4 on [DATE] at 9:53 AM, in the conference room, CI #4 was asked about Resident #61. CI #4 stated, .There are",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
2109,LAUDERDALE COMMUNITY LIVING CENTER,445354,215 LACKEY LANE,RIPLEY,TN,38063,2017-05-05,225,K,1,0,QMFO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility documents, policy review, medical record review, observation, and interview, the facility failed to ensure all allegations involving death, abuse, neglect, mistreatment and injuries of unknown origin were thoroughly investigated; and the facility failed to prevent further potential abuse, neglect and mistreatment for 5 (Resident #s 16, 45, 55, 57, and 61) residents of the 13 residents reviewed for abuse or neglect. The facility failed to thoroughly investigate the incident of a resident found dead between the bed side rail and the mattress; and take immediate actions that would prevent potential entrapment deaths of other residents; and report the death to the State Survey Agency. The failure of the facility to investigate a death, prevent abuse and mistreatment, investigate all allegations of abuse and mistreatment, investigate injuries of unknown origin, and report appropriate investigations to the State Agency resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all residents and resulted in IMMEDIATE JEOPARDY (IJ) to Residents #16, 45, 61, and 57 and psychological harm to Resident #55. Immediate Jeopardy is a situation is 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, the Director of Nursing and Region One Nurse Consultant were informed of the Immediate Jeopardy on [DATE] at 1:09 PM, in the Conference Room. The facility was cited an IMMEDIATE JEOPARDY at F 225-K, which is Substandard Quality of Care. An extended survey was completed on [DATE]. The Immediate Jeopardy is effective [DATE], and is ongoing. The findings included: 1. The facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Prevention policy documented, The resident has the right to be free from abuse, neglect .Resident must not be subjected to abuse by anyone .Abuse-The willful infliction of injury .intimidation or punishment with resulting physical harm, pain or mental anguish .Verbal abuse-The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents .Mental abuse-Includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .Psychosocial harm-Include but not limited to extreme embarrassment, ongoing humiliation, degradation as a human being .Neglect-Failure of the facility, it's employees or service providers to provide goods and services to a resident .All injuries or bruises that are suspicious in any way or injuries of an unknown origin must be investigated. An injury is classified as an injury of unknown origin when both of the following conditions are met. 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 or the number of injuries observed at one particular point in time or the incidence of injuries over time. The Administrator and / or the Director of Nursing is responsible for initial reporting, investigation of alleged violations, and reporting of results to the proper authorities .An interview with and statement from staff members (on all shifts) having contact with the resident during the period of the alleged incident .Interviews with and statement from the resident's roommate, family members, and visitors as needed. The facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan .REPORTING/RESPONSE policy documented, .It is the policy of this facility that persons employed by this facility with knowledge or reasonable cause to believe that any resident has been the victim of abuse, exploitation, neglect, or mistreatment must report or cause a report to be made to the appropriate state agencies as prescribed by the laws of that state. Failure by staff (including management and supervisory staff) to report possible/alleged incidents of abuse/neglect to Administration per policy, will result in disciplinary action up to and including immediate termination. The facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan policy documented, The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .Neglect-Failure of the facility, it's employees or service providers to provide goods and services to a resident necessary to avoid physical harm, mental anguish, or emotional distress .The prohibition plan includes the following components: 5. Investigation of allegations .7. Reporting and responding .The facility will report alleged violations, conduct investigations of alleged violations, report the results to proper authorities, and take necessary corrective actions . The facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Staff training policy documented, .how and when to report allegations without fear of reprisal .Training will also include accession resources that are available to staff and family members who may benefit from counseling through chaplain services and social services .The facility management staff will receive training needed to provide good leadership, encourage teamwork, and promote a pleasant, safe environment . The facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Prevention policy documented, .Staff supervision for inappropriate behaviors during interaction with or care of residents .The facility will continue to make efforts to decrease staff turnover and provide training and assistance to staff to ensure that the best care possible will be provided in a caring manner .The facility will listen to staff and continue to make improvements .The facility will continue to make the work environment a pleasant and safe one for all employees so they may provide a pleasant and safe environment for the residents. Staff will be supervised to identify behaviors such as derogatory language: rough handling; ignoring residents while giving care .The facility administrator and or the Director of Nursing should review risk management reports at each administrative meeting to identify possible situations of abuse. This may include but is not limited to incident reports, including injuries of unknown origin and grievance reports. Ongoing efforts to minimize abuse, neglect, misappropriation of property, and exploitation will be accomplished through the facility's QAPI (Quality Assurance Performance Improvement) program . The facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan INVESTIGATION policy documented, .All injuries or bruises that are suspicious in any way or injuries of unknown origin must be investigated .The administrator and/or the Director of Nursing is responsible for initial reporting, investigation of alleged violations, and reporting of result to the proper authorities. The facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan PROTECTION policy documented, .Residents will be protected during an investigation whether it is abuse, neglect, exploitation, or mistreatment . The facility's Investigating Grievances and Concerns policy documented, It is the policy of this facility and its facilities to investigate all grievance and complaints filed with this facility .The investigation and report will include, as each may apply .a. The date and time the incident took place; b. The circumstances surrounding the incident; c. Where the incident took place; d, The names of any witnesses and their account of the incident; e. The resident's account of the incident; f. The employee's account of the incident; g. Accounts of any other individuals involved .'h. Recommendations of the corrective action. Upon receipt of a grievance and/or concern, the Grievance Official will coordinate the investigation of the allegation and file a written report with Facility Administrator of such findings with five (5) working days of receiving the grievance and /or complaint .The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be to correct any identified problems. Such report will be made by the Administrator or Grievance Official within ten (10) working days of the filing on the grievance or complaint with this facility .All reports of abuse, neglect, mistreatment, or misappropriation of property must be reported to the administrator within twenty-four (24) hours of their occurrence. An immediate investigation must be made, and the findings of such investigation must be made, and findings of such reported to the administrator within three (3) working days of the occurrence of such incidents. 2. Review of the manufacturer's recommendations for the Panacea Bed Manual, used by the facility, revealed, .An optimal bed system assessment should be conducted on each resident by a qualified clinician or medical provider to ensure maximum safety of the resident. The assessment should be .related to the use of restraints and bed system entrapment guidance .Powered air mattress surfaces may pose a risk of entrapment. Prior to use, ensure the therapeutic benefit outweigh the risk of entrapment . Review of the manufacturer's guidelines for the Panacea Air Overlay, used by the facility, revealed, .Failure to comply with all directions and warnings may result in injury or death .Due to the alternating pressure feature .some devices and products may not be appropriate for the use with this device. Do not use pressure pad alarm or alert systems in conjunction with the overlay .This device is not designed to replace good care giving practices, including, but not limited to .Adequate care plans and training for staff personnel for entrapment and fall prevent . The facility's Bed Rail Guideline policy documented, .It is the policy of this center to limit the use of bed rails and similar devices unless the benefit outweighs the risks .A physician order [REDACTED]. The facility's Mechanical Lift Evaluation policy documented, .In order to facilitate a safe lifting environment for staff and resident. Mechanical lifts are to be utilized for lifting and transferring residents whenever possible . 3. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was unable to participate in the Brief Interview for Mental Status (BIMS) assessment, had moderately impaired cognitive skills, required extensive assist of two (2) plus persons for bed mobility and transfers between surfaces such as from bed to chair. The MDS revealed the resident had bilateral range of motion impairments of upper and lower extremities. Review of the annual MDS dated [DATE] revealed the resident was unable to participate in the BIMS assessment and had severely impaired cognitive skills and required extensive assist of two (2) plus persons for bed mobility and transfers between surfaces such as from bed to chair. Review of the undated care plan documented, .Resident is dependent of staff for .Physical mobility issue which caused pain r/t (related to) weakness and contractures, and dx (diagnosis) of kyphosis/Scoliosis .pain is aggravated by movement .has LIMITED PHYSICAL MOBILITY .contracture(s) (of the) extremities . On [DATE] at 1:25 PM, the Administrator was asked for all investigations conducted since (MONTH) (YEAR). The Administrator was unable to provide evidence the incidents involving Resident #16 were thoroughly investigated. a. Review of the care plan revealed Resident #16 had a skin tear to the left elbow that was resolved on [DATE]. There was no incident report or investigation provided by the facility regarding this skin tear. b. Record review revealed the resident had a fall from the bed on [DATE]. There was no incident report or investigation provided by the facility regarding this fall on [DATE]. Neuro checks were not completed per facility policy. Neuro checks (vital signs, pupils for reactions equal and reactive to light) were not done for [DATE] at 9:30 AM or 5:30 PM. The undated care plan revealed the resident fell from the bed [DATE] and sustained a scratch injury to the cheek. The facility intervention was to remove the air mattress and replaced the mattress with an air overlay. Interview with the Region Nurse Consultant (RNC) #1 on [DATE] at 3:25 PM, in the conference room, the RNC #1 confirmed all neuro checks were not completed in accordance with the facility policy. c. Review of the nurse's note dated [DATE] at 8:00 PM (20:00) was errored out as incorrect documentation. Review of the [DATE] nurse's note by LPN #7 for 8:00 PM, revealed, incorrect documentation (error). The documentation error revealed, .Called to resident's room by CN[NAME] Assigned CNA was standing in the doorway of resident's room waiting for assistance. When I entered the room, the resident's head was turned towards the headboard and her neck was between the mattress and the siderail on the right side of the bed. Her body was off the bed, her bottom on the floor with her legs stretched out in front of her. Her right arm was up on the bed close to her head. With the assistance .of the CNAs, we laid the resident in the floor. This nurse felt for a pulse, listened for breathing and heartbeat. At this time, another nurse called the DON (Director of Nursing) while this nurse and CNAs transferred resident to the bed. DON was called at 8:10 pm. MD (Medical Doctor) notified at 8:28 pm. Resident was bathed and dressed by CNAs. Review of the [DATE] DON's note for 8:15 PM, documented incorrect documentation errored out with a line through the documentation indicating it as incorrect revealed, .observed resident lying in bed upon assessment no pulse, no respirations noted, time of death pronounced at 8:11 PM, spoke to RP (Responsible Party) request that (named funeral home) be called to transport body to funeral home Review of LPN #7's additional documentation after the incorrect documentation for [DATE] at 9:00 PM, revealed, .Called to resident's room by CN[NAME] Assigned CNA was standing in the doorway of resident's room waiting for assistance. When I entered the room, the resident's head was turned toward the headboard with the left side of her face pressed against the side rail. Her body was off the bed, her bottom was on the floor and her legs were stretched out in front of her. The right arm and shoulder were on the bed pointing towards the headboard. With the assistance of CNAs, we laid the resident in the floor. This nurse assessed for pulse, breathing and heartbeat. None was found. As this time, Another nurse called the DON while the resident was transferred to bed. DON called at 8:10 pm. MD notified at 8:28 pm. Resident was bathed and dressed by CNAs. Review of the (MONTH) (YEAR) physician orders [REDACTED]. There was no documentation for the justification of the facility's use of side rails for Resident #16. Review of the facility's Record of Death dated [DATE] documented, .resident noted with (signed for no) pulse, (sign for no) respirations . There was no other documentation on the form related to the resident's death. Review of the death certificate revealed Resident #16's death occurred on [DATE] at 8:00 PM, the cause was cardiac failure and was signed by the resident's physician. Interview with Confidential Interview (CI) #1 on [DATE] at 1:45 PM, in the conference room, CI #1 was asked about concerns. CI #1 stated, .(named Resident #16) was in the floor when the CNA (Certified Nursing Assistant) (did not give the name) found her the night of .([DATE]). (Named DON) called all the CNAs into this room (Conference Room) and told them that they could not discuss this with any one at any time .thought her neck was broken. They were told to straighten up the body before medical personnel were called in . Interview with Confidential Interviewee (CI) #7 on [DATE] at 8:01 AM, by telephone, CI #7 was asked what she knew of Resident #16's death. CI #7 stated, I was not a part of that scenario, I came in to work the following day and I heard about the situation, and when I went to the morning meeting I said to (named DON) State will be in because this is reportable. Is there anything you want me to be checking on, since we have to do a reportable and we're in our window. They will probably come on in. She said 'What do you mean state will be here?' And I said, with that reportable. And she said, 'That's not a reportable. She said after their investigation (she and the Administrator) they determined it was not reportable .Well, they came in that night after the incident happened and started their investigation .I don't know what their investigation involved but I felt like after reading that note that it was a reportable . Interview with the Corporate Vice President (VP) of Legal on [DATE] at 4:50 PM, per telephone, the VP of Legal was asked if the DON and Administrator were educated on what incidents are reportable to the State. The VP of Legal stated, Oh yeah, and there are policies they have access to ,[DATE] .kiosks in the hallways to access those policies. Interview with CI #8 on [DATE] at 5:32 PM, in the Conference Room, CI #8 was asked if they were aware of any accidental deaths in this facility. CI #8 stated, Yes, (Resident #16). CI #8 was asked what happened. CI #8 stated, She was in the bed and fell out of the bed and got hung in the railing. She got caught up in the railing in the bed .her legs were on the floor and the neck was caught between the railings. CI #8 was asked if she meant the side rails. CI #8 stated, Yes. She has an alarm but it didn't go off. CI #8 was asked if she meant a bed pressure alarm did not go off. CI #8 stated, Yes. CI #8 was asked how often they check the alarms. CI #8 stated, It was working if you pressed real hard. When she came out of the bed it didn't make any noise. CI #8 was asked if the DON came in that night. CI #8 stated, Yes, and the Administrator. CI #8 began to cry. CI #8 was asked if she had a history of [REDACTED].#8 stated, People on the other shifts said she tried to get up but I have never seen her try to get up. CI #8 was asked about the maintenance supervisor. CI #8 stated, That was his mom. CI #8 was asked what happened when the resident was found. CI #8 stated, .(Named nurse) was here, and she came around there and checked her. CI #8 was asked if the nurse found a pulse. CI #8 stated, She said it was very, very light. We put her on the bed .I'm trying to think who all was here, we put her on the bed .before the DON arrived. CI #8 was asked if she told the Administrator and DON what happened. CI #8 stated, I told them what had happened. CI #8 was asked if she told them that Resident #16's head was caught in the side rail. CI #8 stated, Yes, and that her legs were on the floor. CI #8 was asked if the resident was in the bed when the DON came. CI #8 stated, Yes. CI #8 was asked if she told both the Administrator and the DON. CI #8 stated, They questioned me. CI #8 stated, I wrote a statement. CI #8 was asked if she wrote what she saw. CI #8 stated, Yes. CI #8 was asked to whom was the statement given. CI #8 stated, (named DON). CI #8 was asked if Resident #16's head was in her normal position (since the resident had kyphosis.) CI #8 stated, When we got her off the floor it was in normal position. CI #8 was asked if there was a pulse. CI #8 stated, One said she had a light pulse, it was real faint and the other said she didn't hear anything. CI #8 was asked if Resident #16 was breathing. CI #8 stated, No and she wasn't moving. CI #8 was asked if the resident was a Do Not Resuscitate (DNR.) CI #8 stated, I don't know. CI #8 was asked how long had it been since staff had seen her last. CI #8 stated, It had been 2 hours .I was going, into her room. CI #8 was asked what time this occurred. CI #8 stated, (she was) put .to bed after supper. It was between 8 and 8:30, I think. CI #8 was asked if the resident was on the bed when the DON got there. CI #8 stated, Um hum. (yes) CI #8 was asked how Resident #16 was lying. CI #8 got on the floor to try to demonstrate and stated, Her head was facing the wall, her face was to the railing and was caught up .the geri chair was on the side that she was. CI #8 was asked if both the top rails were up. CI #8 stated, Yes. She was on the door side of the bed away from the (other) resident .she was between the rail and the mattress. CI #8 explained that the resident was between the bed and the geri chair. CI #8 was asked who the other staff there that night but she could only remember CNA #5. CI #8 was asked if the same bed was in the room. CI #8 stated, I think it is. CI #8 was asked if the resident had a special mattress. CI #8 stated, She had the bubbles, the thing on the foot of the bed. CI #8 was asked if it was an air overlay. CI #8 stated, Yes. Interview with CI #12 on [DATE] at 8:55 PM, by telephone, CI #12 was asked what she knew about the death of Resident #16. CI #12 stated, .The CNA yelled .We ran to the room. I didn't know if I should go in .She was trying to figure out if she had a pulse but the girl there didn't know .No one knew if she was a CPR (cardio-pulmonary resuscitation) so I ran to see if she was a CPR. CI #12 was asked if she was a CPR. CI #12 stated, No ma'am, she was a DNR (Do Not Resuscitate). CI #12 was asked how was Resident #16 was found. CI #12 stated, Whenever I walked in the room the right arm and her head was right there. The side rail things-her head and arm were pinned in the side rail. Her feet were almost at the wall. Her bottom was not touching the ground. CI #12 was asked if she had said her bottom was not touching the ground. CI #12 stated, Right. CI #12 was asked what was caught in the side rail. CI #12 stated, It seemed like more her jaw. CI #12 was asked about the position of her neck. CI #12 stated, .the way it was turned looked unusual. It was turned sideways and up. The jaw line under the mandible was up making her look toward the ceiling. The previous statements were re-read to CI #12, and she was asked if that was what she had said. CI #12 stated, Yes .the side rail had her jaw and her arm pinned up. I could not tell if her feet were touching the wall or not. It could have been her feet, she had long legs so it might have been that it wouldn't let her come down. CI #12 was asked if she had been told not to tell anyone about the incident. CI #12 stated, Um, in all honesty, until we talked to the Administrator and DON we were told not to talk to anyone about this, but nothing was said afterwards. No one said anything after that. I don't know if it was accidental or some other medical reason, I am not sure. They had told me not to say anything until it had been investigated more. CI #12 was asked if she had given a written statement. CI #12 stated, Yes. CI #12 was asked if Resident #16 was on the bed when the DON there. CI #12 stated, Yes. CI #12 was asked if there were any marks on Resident #16. CI #12 stated, If I remember correctly, there was one on the jaw line. I'm not 100% (percent) but I think there was. CI #12 was asked on which side. CI #12 stated, On the left side of her face. CI #12 stated, .I would like to know more about it. Was an autopsy done? I don't know. No one ever said anything else about it. I don't know. Interview with CI #10 on [DATE] at 8:00 AM, in the conference room, CI #10 was asked what she knew of Resident #16's death. CI #10 stated, .When I walked in the room she was sitting in the floor by the bed and her head was turned toward the headboard so that made the left side of her face up against the side rail. CI #10 was asked what happened next. CI #10 stated, we got her to the floor. CI #10 was asked if there was a pulse. CI #10 stated, No .she was a DNR .I had the nurse check for me. CI #10 was asked if Resident #16 was breathing. CI #10 stated, No. CI #10 was asked if there was a pulse. No. CI #10 was asked what happened then. CI #10 stated, While the nurse was gone I checked for vital signs. Myself and a couple of aides transferred her back to the bed. Then the other nurse called (named DON) because we have to have a RN (registered nurse) to pronounce .(LPN #1) also notified the family .I notified the doctor .we cleaned her up. CI #10 was asked what she had told the doctor, if she had told him how the resident was found. CI #10 stated, Just that she had passed. CI #10 was asked if anyone called the Administrator. CI #10 stated, I did not but I believe (named DON) did. CI #10 was asked if Resident #16 had fallen. CI #10 stated, She had to have rolled out of the bed. She did not walk. She sat in a geri chair. CI #10 was asked if there were any marks on Resident #16 after the incident. CI #10 stated she had a spot on her jaw .left .a little discoloration there. CI #10 was asked if she told the son that she fell out of the bed. CI #10 stated, I was in another room when the son arrived .I did go in the room with him and his wife and told him I was sorry. That was all I said. CI #10 was asked if she knew if the son was aware of the incident. CI #10 stated, No ma'am .I was told (named Administrator) told him. CI #10 was asked if the Administrator and DON came into the facility that night. CI #10 stated, Yes ma'am. CI #10 was asked if the resident's bottom was touching the floor. CI #10 stated, Yes ma'am. CI #10 was asked to describe how her legs were positioned. CI #10 stated, They were stretched out in front of her .her geri chair was between her chest of drawers and the bed .her legs were under the geri chair .the aides picked up the geri chair .her legs were straight. CI #10 was asked if her neck was in a normal position for her. CI #10 stated, It was down and turned . CI #10 was asked if Resident #16 had contractures. CI #10 stated, She did, most of the time she was a wiggle worm. CI #10 was asked what type of mattress Resident #16 had. CI #10 stated, an air mattress. CI #10 was asked if Resident #16 had fallen before. CI #10 stated, Not since I've been here, but before. CI #10 was asked if Resident #16 had a pressure alarm on her bed. CI #10 stated, She did but it did not go off. But, it was on. That was my big thing because it did not go off. The DON interrupted the surveyor's interview with CI #10 at this point. CI #10 continued, It did not go off. (Named Administrator) asked when I check my alarms. I check them at my 8:00 med (medication) pass and that is what I was doing when that happened. Interview with the DON on [DATE] at 10:01 AM, in the conference room, the DON was informed that we have asked for all investigations. An investigation of this incident was not provided by the facility. The DON was asked if an accidental death is to be reported to the State (Tennessee Department of Health). The DON stated, Yes. The DON was asked if they had any accidental deaths in the facility. The DON stated, No. The DON was asked if she was present the night of Resident #16's death. The DON stated, I was, after she passed away. The nurse called and said (Resident #16) doesn't have any respirations and I can't find a pulse. I said is she a DNR. She said yes and I told her I was on my way. The DON was asked if she always comes in if a resident expires. The DON stated, Since my other RN resigned, I have to come in. The DON was asked what happened after she arrived. The DON stated, I checked her. She had expired. I didn't call the doctor or the family. I don't remember if I called or if other staff called .it was her birthday. It looked like she had slid out of the bed after she expired. The DON was asked how it was determined that she slid out of the bed after she expired. There was a long pause. The DON stated, That's what we assumed. Cause she had definitely slid out of the bed. Her body was still warm. The CNA said she was part way on the floor. She had no bruising or anything so she couldn't have been there long. The DON was asked if she had any marks on her. The DON stated, Yeah, she had a light red, it was pink in color, where her face had been touching the side rail. The DON pointed to her right face and stated, I'm not sure if it was right or left. The DON was asked if there was an investigation. The DON stated, No, I just asked them what was going on and what happened. The DON was asked if she had any witnesses write a statement. The DON stated, (named assigned nurse) put her statement in .the computer. Two other ladies made statements. The DON was asked if there were just 2 statements made. The DON stated, Yes, (named assigned nurse put hers in the computer. The DON was asked if there was any further investigation. The DON stated, No. The DON was asked if the Administrator came to the facility that night. The DON stated, Yes, he came to talk to (named Resident's son.) The DON was asked if it was normal for the Administrator (that lives 70 miles away) to come to the facility when there is a death. The DON stated, No, but him and (named son, who is the facility's maintenance supervisor) are pretty close so he wanted to make sure (named son) was ok. The DON was asked if Resident's son was aware that she was found on the floor. The DON stated, Yes. The DON was asked what time she arrived. The DON stated, I have no idea. I'm sorry. The DON was asked what time the Administrator arrived. The DON stated, It wasn't too long after I did. The DON was asked who called the Administrator. The DON stated, I did. The DON was asked what she told the Administrator. The DON stated, That (named son's) mom had passed away. The DON was asked about the nurse's progress note that was marked out. The DON stated, I told her to show me how (Resident #16) was in the bed. That is not what is in your note. The DON was asked how she knew the note was incorrect. The DON demonstrated how the resident was found. Then I read her note I had her show me exactly. What she had on her note was not what she demonstrated to me. The DON was asked what was incorrect. The DON stated, I think she said something about being strangled or choked, I am not sure now. The DON was asked why she thought that was incorrect. The DON stated, Because the way she had explained her earlier that was not correct. When I looked at the bed. She had quarter side rails and she had the mattress overlay, so there was no way that was possible. The DON was asked if the resident was sent for an autopsy. The DON stated, No, I don't know. The DON was asked who picked her up. The DON stated, The funeral home. The family wanted to wait awhile before calling the funeral home. The DON was asked if she would have had to do something if there was an autopsy. The DON stated, I'm not sure. The DON was asked if this was reported to the State (Tennessee Department of Health). The DON stated, No. The DON was asked if there was an investigation done. The DON stated, There was nothing formal. I just asked them what happened .before I left I told them to write when the body was transported . The DON was asked what the doctor was told. The DON stated, That she had expired, that she has passed away. I'm not sure if they told him she was on the floo",2020-09-01
4527,MANCHESTER HEALTH CARE CENTER,445391,395 INTERSTATE DRIVE,MANCHESTER,TN,37355,2016-09-15,223,D,1,0,M0NV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility investigation review, medical record review, and interviews, the facility failed to ensure residents were free from abuse and mistreatment for 1 Resident (#6) of 6 residents reviewed for abuse. The findings included: Review of facility policy entitled Abuse Prevention Standard, revised 9/15, revealed .The purpose of this written Resident Abuse, Neglect, and Misappropriation Prevention Program is to outline the preventative steps taken by this facility to reduce the potential for the mistreatment, neglect, and abuse of residents and the misappropriation of resident property, and to review those practices and omissions, which if allowed to go unchecked could lead to abuse .This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical, and/or mental abuse, corporal punishment, involuntary seclusion, or misappropriation of resident property by any facility staff member, other residents, consultants, volunteers, staff of other agency service the resident, facility members, legal guardians, friends, or other individuals .Abuse is defined as the harmful treatment of [REDACTED]. Review of the policy entitled Resident Rights and Dignity Management dated 4/16, in the section on Accommodation of Needs, revealed .In order to accommodate individual resident needs and preferences, staff attitudes and behaviors must be directed toward assisting the residents in maintaining independence, dignity, and well-being to the extent possible and in accordance with the resident's wishes . Continued review of the section on Dignity revealed .Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed . Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #6 scored 12/15 on the Brief Interview for Mental Status indicating he was able to make his needs known and communicate effectively. Continued review of the MDS revealed Resident #6 required extensive assist of 2 people with transfers; extensive assist of 1 person for dressing, toileting, eating, and grooming; was dependent on 1 person for bathing; and was occasionally incontinent of bowel and bladder. Review of the facility investigation revealed Resident #6 .reported to the Administrator on 9/1/16 that at 4:15 this morning, 2 techs got him up and he did not want to get up. He reported he told the techs he did not want to get up and they still got him up. He reported he tried to hold the lift sheet and one of the techs swatted at his hand. Resident reported they kind of giggled at him and also smirked at him. Resident reported he felt man-handled and was in fear for his life. Resident reported they did not hook his lift sheet correctly to the lift but that was no big catastrophe. Administrator asked if he felt safe and resident replied not with both of them here. Administrator asked if he would feel safe if they were not allowed to care for him again and resident reported he would feel safe without them here. The resident could not describe the staff members other than .one was white and one was black . Review of the Director of Nursing (DON) interview of Resident #6 on 9/2/16 revealed Resident #6 stated .Two black girls wouldn't help me to bed so I got the lift and they told me I couldn't do that. They put me to bed and I didn't sleep well. They couldn't get me comfortable in bed and I flipped and flopped all night. I think they got upset cuz I kept calling. This morning a black lady with scarf on her head and white lady, slender, close to 40, I have never seen them before. I told the black girl and white girl I wanted to stay in bed but they put the sling under me and hooked it wrong so I told them to stop but they got me up anyway and put me in my chair. They thought this was funny. When I was in my wheelchair they hooked my seatbelt but I never use it. They kept telling me I was going to get up and I didn't want to. I have been getting up so I can go to fine dining but wanted to sleep in today. I like the same people to take care of me every day . Review of the Administrator's interview of Certified Nursing Aide (CNA) #1 dated 9/25/16, revealed .Throughout the night he kept asking me things and everything was fine. I went in around 5 AM to get him up. I walked in and said good morning, are you ready to get up? He said yes. I started getting his clothes and pulled a brief out and got really upset. He said he doesn't wear brief. I asked him didn't he wear one in the bed but up in a chair and he said you stupid [***] . He kept fussing and (CNA #2) said you don't have to wear a brief, were put it up. He said you f .ing [***] , don't f .ing touch me I asked him to roll over towards me so I could straighten the pad and pull his pants up. He allowed me to do that. We went to hook lift pad up on hoyer. He kept telling (CNA #2) the pad was hooked up wrong but it was hooked up right. We lifted him and put him in the chair. He was wiggling in the chair; he grabbed the lift sheet and started saying let me down. I was trying to get hoyer out and he was trying to run over my toes. Once he was almost in the chair he said I don't want to get up now, we continued to put him in the chair . Review of the Administrator's interview with CNA #2 dated 9/2/16, revealed we went to get him up about 4:30 AM. I asked him myself are you ready to get up and he nodded his head yes. He had been on the light several times prior to that. I told him we were gonna get him up. We thought he needed a brief and that ignited him. I wasn't sure if he needed one so I had to ask him if he needed one and he was kind of agitated we asked him if he needed one. He was already on a sling in the bed. We slid him over and put his pants on. We hooked him to the lift. He said it was wrong. We unhooked it once and we hooked it back and told him it was right. He continued to say it was wrong but it wasn't. He started shaking the lift because he was upset it was wrong. He was still shaking the lift in the air. We sat him down in the chair. He started going off on us but I don't recall all he said. He said he didn't want me in his room again. He went and got (Supervisor) and told her they were shaking me in the lift and laughing at me. (Supervisor) said he's done that to me before and said he wanted to get people fired . Review of the Administrator's interview of the Registered Nurse Supervisor dated 9/2/16, revealed I never considered what he said to be abuse. I was making rounds and walked back there about 4:40 and he was shouting They made me get up. They laughed at me. I want them fired. He wouldn't calm down. He left the room to the hallway and I followed him. He looked at the 2 techs and said Look at them; they're laughing at me. The tech said he wanted to get up . Review of the DON's interview of Licensed Practical Nurse (LPN) #1 dated 9/1/16 revealed .(Resident #6) came to me on 9/1/16 at around 5 AM saying he wanted to report the techs but didn't say who. He said he wanted them fired because they got him up too early. I told him I would tell the charge nurse; she's tied up right now. When I seen (Supervisor) I told her and she rolled her eyes at me, like she knew what I was talking about. It made me wonder if she knew what I was talking about but I didn't ask her. He was angry but not yelling. He didn't say he was hurt or c/o (complaint of) pain. He said they were rough with him . Review of the Administrator's summary of the investigation dated 9/6/16, revealed .The interviews with the resident provided 3 staff members believed to be directly involved in the allegation, 2 agency techs and 1 staff RN Supervisor. The employee and agency personnel interviews produced concern regarding the actions of each individual. The agency tech, (CNA #1)'s account of what occurred was inconsistent with the resident's statement which was given on 3 separate accounts to 3 separate facility employees. Her statement was also inconsistent with the security camera footage of the allegation date/time. The second agency tech (CNA #2)'s account of what occurred was not quite as inconsistent as (CNA #1)'s statement but did conclude they both got the resident up against his wishes. The RN Supervisor was informed by the 2 agency techs after the alleged incident had occurred. The RN Supervisor's statement concluded she did not report the allegation to anyone further and did not address the resident's allegation of not wanting to get up but rather the resident was gotten up against his preference. Although the resident did not sustain any physical injuries based upon resident interview and physical assessment of the resident, the resident was visually upset when reporting the allegation. The 2 agency techs were reported to the agency and are not allowed to work in the facility. The RN Supervisor was terminated for not reporting the allegation and not addressing the resident's preference of not wanting to get up . Interview with the Administrator on 9/14/16 at 3:00 PM in the conference room revealed Resident #6 came to her to discuss the situation. Continued interview revealed she spoke with staff that worked the 11:00 PM - 7:00 AM shift and interviewed the agency staff involved as well as the RN Supervisor. Further interview revealed none of the three were allowed back into the facility until the investigation was completed. Continued interview revealed she watched the video for timing which did not match the CNAs' stories. Further interview revealed she checked on Resident #6 every other day to ensure everything was alright with him and to ask if the event was handled to his satisfaction. Continued interview revealed the RN Supervisor was terminated for failure to report abuse, but the RN Supervisor did not feel it was abuse. Further interview revealed the agency was notified the CNAs were not allowed back in the facility. Continued interview revealed the staff was in serviced on abuse.",2019-09-01
2644,MT JULIET HEALTH CARE CENTER,445439,2650 NORTH MT JULIET ROAD,MOUNT JULIET,TN,37122,2019-03-13,656,D,1,1,O5E111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility investigation, medical record review and interview, the facility failed to follow a care plan for 1 of 8 residents (#68) reviewed for falls. The findings include: Medical record review revealed Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] and the Quarterly MDS dated [DATE] revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. Continued interview revealed Resident #68 required total dependence with 2 people for transfers. Medical record review of the care plan dated 11/27/18 revealed Resident #68 required 2 people lift for transfers. Record review of the facility investigation dated 2/6/19 revealed Certified Nurse Aid tried to transferred Resident #68 to the wheelchair by herself which resulted in the CNA #4 sliding the resident to the floor. Interview with the Director of Nursing (DON) on 3/13/19 at 8:03 PM in the Administrators office confirmed the care plan was not followed which resulted in a fall.",2020-09-01
5036,CREEKSIDE CENTER FOR REHABILITATION AND HEALING,445516,306 W DUE WEST AVENUE,MADISON,TN,37115,2016-06-16,314,G,1,0,GZPX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy and protocol review, medical record review, interview, and hospital medical record review, the facility failed to timely identify, provide treatment and prevent deterioration of a pressure ulcer for 1 (Resident #1) resident of 12 residents reviewed for pressure ulcers. The facility's failure to timely identify, provide treatment and prevent deterioration of a pressure ulcer resulted in Actual Harm to Resident #1. The findings included: Review of the facility policy titled Skin Program Policy, undated, revealed, Skin problems are minimized to the greatest extent possible through an aggressive approach consisting of four components. They are: 1. Prevention, evaluation and screening 2. Ongoing surveillance 3. Treatment orders 4. Treatment protocol .Each resident is evaluated for .skin care at the time of admission .all residents receive a weekly skin integrity check performed by licensed personnel .all disciplines are alerted immediately if the resident .is at risk for the development of skin breakdown. The nursing department coordinates the response to the resident needs (in the area of skin integrity) by the following means .With an array of preventative measures practiced on the resident's behalf when the resident has been identified as being at risk .The admitting nurse completes a Braden skin and Pressure risk assessment .shows the resident to be 'at risk' or prone to skin breakdown .the Pressure Ulcer Prevention Checklist is implemented. Protocols for prevention of skin breakdowns are included on the Pressure Ulcer Prevention Checklist that should be completed .With each dressing change or at least on a weekly assessment will be made addressing at least the following per policy and procedure. 1. Site 2. Stage I, II, III, IV, Deep Tissue Injury, Unstageable 3. Size, diameter, depth and edges 4. Presence or absence of drainage, undermining 5. Presence or absence of odor, {necrotic} tissue type or amount 6. Skin color surrounding wound 7. {Peripheral} Tissue [MEDICAL CONDITION] 8. {Peripheral} Tissue Induration 9. Granulation Tissue 10. [MEDICATION NAME] 11. Response to treatment or progress 12. Dietary and physician notified 13. Responsible Party Notified . Review of the facility protocol titled Pressure Ulcer Protocol, undated, revealed, Prevention Protocol: Pressure relief; Skin care .Assessment; Incontinence Status; Resident Mobility; Resident and Family Education .Intervention .Repositioning in bed every 1-2 hours and in chair every 30 minutes; Wrinkle and debris free linen .Bowel and bladder management regimen .Educate resident .weight shifting in bed and chair, teach to turn if possible .Chart initial assessment of pressure ulcer noting: location, stage, size, depth, absence or presence of pain, absence or presence of pressure, exudate (if present), wound bed, description of wound edges. Daily monitoring includes .Evaluation of dressing if present .The presence of complications such as signs of increasing areas of ulcerations or infections or leaking around the wound . Review of the Hartmann Wound Care Protocol attached to the Pressure Ulcer Protocol provided by the facility revealed, Category/Stage I: Non-blanchable [DIAGNOSES REDACTED] Epidermis is intact .Treatment objective: Prevent any further damage to the resident's skin .Treatment Option 1 .*Appropriate support service for Stage 1 *Moisturizing cream or ointment .Treatment Option 2 *Appropriate support surface .Thin [MEDICATION NAME] dressing, a gel sheet dressing or a transparent film dressing .Category/Stage II: Partial thickness ulcer penetrating the epidermis and possibly into, but not through the dermis .*Sacral wounds* Use PermaFoam DO NOT use [MEDICATION NAME] .Treatment Objective: Prevent furter damage and create an environment conducive to re-[MEDICATION NAME] .Treatment Option 2 Stage II- Abrasion or shallow crater wound producing a minimal to moderate amount of drainage .*[MEDICATION NAME] dressing, gel sheet dressing or foam dressing .Gently cleanse the wound with normal saline or wound cleanser .Place the dressing over the center of the wound .Change the dressing every 3-4 days or if the dressing begins to leak .Turn the resident every 2 hours . Review of the facility prevention policy attached to the Pressure Ulcer Protocol and the Hartmann Wound Care protocol provided by the facility titled Protecting Against the Adverse Effects of External Mechanical Forces, Pressure, Friction and Shear is another goal in the prevention of pressure ulcers .Any individual in bed who is assessed to be at risk for developing pressure ulcers should be REPOSITIONED at least every 2 hours .A written plan for systematically turning and repositioning .should be used .Using LIFTING DEVICES such as a trapeze or bed linen to move (rather than drag) individuals in bed who cannot assist during transfers and position changes .A written plan for the use of positioning devices is helpful for chair-bound individuals. Medical record review revealed Resident #1 was admitted to the facility on [DATE], discharged on [DATE], readmitted on [DATE] and discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Medical record review the Post hospitalization Transition Discharge Instructions from the discharging hospital dated 3/16/16 revealed documentation of a Sacrum Stage one pressure ulcer, treated with repositioning and a [MEDICATION NAME] (foam dressing). Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 15/15 indicating the resident was cognitively intact. Continued review revealed the resident required extensive assistance for bed mobility and transfers, had no pressure ulcers and was always incontinent of urine and bowel. Medical record review of the comprehensive care plan dated 2/16/16 revealed the resident was at risk for skin breakdown. Continued review of the comprehensive care plan revealed no care plan for the care and treatment of [REDACTED]. Medical record review of the Nursing Admission assessment dated [DATE] at 4:27 AM by Licensed Practical Nurse (LPN) #1 revealed documentation of the presence of a Pressure Ulcer for Resident #1. Medical record review of the Nursing Risk assessment dated [DATE] at 9:51 AM revealed it was completed by Registered Nurse (RN) #1. Continued review of the Nursing Risk Assessment revealed a Visual Body Map that documented Resident #1 had an abrasion to the left gluteal coccyx area (low buttock/back area). Medical record review of the Departmental Notes dated 3/17/16 at 10:39 AM revealed LPN #2 documented .late entry for 3/16/16: resident also has noted open area on coccyx . Medical record review of the Skin Concerns Roster dated 3/17/16 at 5:27 PM by RN #1 revealed Yes skin concern-nurse notified. Medical record review of the Skin Inspection Report for Resident #1 revealed the following: 3/17/16 Skin Not Intact-Existing by LPN #3 4/22/16 Skin Not Intact-New by RN #2 4/27/16 Skin Not Intact-Existing by LPN #4 5/4/16 Skin Not Intact-Existing by LPN #4 Continued medical record review revealed no physician's order to treat the open area on the coccyx until 4/19/16. Medical record review of the Wound Assessment Report by LPN #5 dated 4/19/16 revealed Resident #1 had an abrasion to the coccyx that was identified on 4/19/16. There was no drainage; the wound measured 1.50 cm (centimeters) in length, 2.70 cm in width, and had a depth of 0.10 cm. Interview with LPN #5 on 5/18/16 at 8:40 AM in the day room on Unit 5 revealed the LPN stated she was notified by a Certified Nurse Aide (CNA) about the wound to Resident #1's coccyx area on 4/19/16. Medical record review of the Physician's Telephone Order dated 4/19/16 revealed clean coccyx buttocks (with) wc (wound cleanser), pat dry & apply [MEDICATION NAME] q (every) 3 days. Medical record review of the Wound Assessment Report completed by the Wound Nurse dated 5/4/16 revealed the wound type was an abrasion; wound location was coccyx; wound status was deteriorated; a small amount of serosanguinous (yellowish with small amounts of blood) drainage was present; the wound measured 4.00 cm in length, 4.50 cm in width and 0.10 cm in depth; description of the skin irritation/excoriation was documented as Red or darker pink, moderate irritation. Medical record review of the Wound Assessment Report completed by the Wound Nurse dated 5/9/16 revealed the wound status was unchanged; the wound type was an abrasion; wound location was the coccyx; a small amount of serosanguinous drainage and was documented as to have no infection, or pain. The measurements remained unchanged from the previous assessment on 5/4/16. Interview with the Wound Nurse on 5/18/16 at 8:00 AM in the Day room on Unit 5 confirmed the wound got bigger by a couple of centimeters. Continued interview revealed the Wound Nurse stated I did include (named Resident #1) on the list to round on for Tuesday 5/10/16 because I was concerned the wound grew bigger, and had drainage, and was not responding to treatment. Further interview revealed the Wound Nurse stated, I should have changed it to a Stage II on 5/4, but I was waiting to round with the NP on 5/10 to make sure what it was. Interview with CNA #1 on 5/18/16 at 10:40 AM in the Conference Room revealed the CNA stated, She did have a pink spot on her bottom, then an abrasion with a layer of skin gone. I'm not sure how it happened. Continued interview revealed the wound did open up some. She did have a wound on her coccyx and it got worse . Telephone interview with the Medical Director, (MD) on 5/19/16 at 7:54 AM revealed the MD was unaware of any type of wound for Resident #1. The MD was asked if the Wound Nurse had contacted him on 4/19/16, 4/27/16, 5/4/16 and 5/9/16 as documented on the Wound Assessment Reports for those dates. The MD stated, No, I definitely was not called 4 times. I was not aware of any problems until the Director of Nursing (DON) called me yesterday to ask me if I knew anything about a shearing problem for (named Resident #1). I told her no, this is the first I've heard of it. Interview with NP #2 on 5/19/16 at 9:45 AM in the Physician's Office at the facility revealed the NP was present in the facility 5 days a week. The NP stated, I never knew of any wound to (named Resident #1), and I work very closely with (named MD), and I can attest that he never knew anything either. (Named MD) and I rounded on Sunday 5/8/16 and (named Resident #1) was somnolent but arousable over 5/7/16 and 5/8/16. She had a gradual decline over the last week. I absolutely did not know about this. Interview with NP #3 on 5/19/16 at 10:00 AM in the Physician's Office at the facility stated she had no knowledge of any abrasion, wound or pressure ulcer to Resident #1. Medical record review revealed no documentation in the physician progress notes [REDACTED].#1 by the physician or nurse practitioner. Interview with the DON on 5/19/16 at 10:18 AM in the Conference room revealed the DON was shown the documentation from the transferring hospital on the Post hospitalization Transition Discharge Instructions for Resident #1 dated 3/16/16 that documented under Skin and/or Wound care, Sacrum; Stage one pressure ulcer, treated with repositioning and a [MEDICATION NAME]. Further interview revealed the DON was asked about the nursing documentation by 4 different nurses that had documented on 3/17/16 the resident had a pressure ulcer, open area on the coccyx, skin not intact-existing, and skin concern nurse notified. The DON did not respond. Telephone interview with NP #1 on 5/19/16 at 11:40 AM revealed the NP was nationally certified as a Wound Care and Ostomy Specialist. The NP denied having any knowledge of an abrasion, wound or pressure ulcer to the coccyx of Resident #1. The NP referred to her notes and stated she had treated the resident for leg pain but no other problems were brought to her attention. The NP was asked if she was notified on 5/4/16 by the Wound Nurse regarding the increase in size and drainage to the wound on the resident, the NP stated, No, I knew nothing about it. I received a list on 5/6/16 with (named resident) name on it to round on for Tuesday 5/10/16 but it is circled because I never saw her, and I thought she was at [MEDICAL TREATMENT]. The NP continued to state she was in the facility on Monday 5/2/16, Friday 5/6/16, and on Monday 5/9/16, and nothing was ever communicated to her about a wound or any other concern with the resident. The NP stated, I only know if the staff communicate to me or another NP, but I had no knowledge of this. Review of the hospital Emergency Provider Report dated 5/9/16 revealed the resident arrived at the emergency room at 11:33 AM for complaint of decreased alertness. The resident was admitted to the hospital at 2:25 PM. Review of the hospital Consultation Report from an Infectious Disease Physician dated 5/10/16 revealed the reason for the consultation [MEDICAL CONDITION] with infected decubitus ulcer. Continued review revealed .She has now been found also to have a very necrotic foul-smelling decubitus in the sacral gluteal area and wound care and infectious consultation has been requested .Examination of the sacral coccygeal gluteal area shows necrotic skin with mushy fluctuant tissues under the skin and an open hanging out fatty tissue in the coccygeal area with various foul malodorous drainage, obtained cultures .This will need to be surgically debrided for source control . Continued review revealed an Assessment/Plan by the infectious disease physician dated 5/11/16 which stated, .Septic shock/[MEDICAL CONDITION] .Decubitus ulcer of coccygeal region, unstageable, likely stage 4 infected .Continued review of the hospital medical record revealed a Hospitalist Progress Note dated 5/13/16 which documented, Decubitus Ulcer of coccygeal region unstageable .PRESENT ON ADMISSION .5/10 WOUND (Culture) (E-COLI, ESBL) (bacteria that normally lives in the intestines of people; resistant bacteria) . Telephone Interview with NP #1 on 5/24/16 at 7:37 AM revealed NP #1 when asked about the abrasion to the coccyx area, the NP stated, An abrasion is a Stage II pressure ulcer in that location. The NP was asked if a Stage II pressure ulcer can develop into a Stage IV pressure ulcer with foul, odorous smelling drainage with tissue hanging out in an 8-10 hour time frame. The NP stated, No. I think the ulcer was already there when the resident was at the facility and had been there. When explored you will find a Stage III or Stage IV. I suspect this was the scenario for (named resident). It looked like an abrasion, but obscured by the skin color. It doesn't happen quick. The wound nurses didn't recognize what they were seeing, it was a knowledge deficit. They thought it was simple but it was not. The NP was asked if she was aware of a skin problem for Resident #1 and she stated, I was not. No one notified me. I depend on the nurses to let me know there is a problem. There is a Communication Book for the NP's that the nurses can write their problems or concerns, but (name resident) wasn't listed and I never got anything on her. Review of the Hermitage Nurse Station Communication Book dated 3/16/16-5/9/16 revealed no skin concerns were documented for Resident #1. Telephone interview with the Infectious Disease Physician on 6/16/16 at 1:00 PM revealed the physician had consulted on Resident #1 on 5/10/16 at the hospital the facility discharged the resident to on 5/9/16. Continued interview revealed the Physician stated the pressure ulcer to the coccyx had to be a pre-existing condition for sure with necrotic tissue underneath. It can be stable to a point, but it doesn't happen from an abrasion. It must have been from a deep tissue injury, but not from an abrasion. The facility's failure to timely identify, provide treatment and prevent deterioration of a pressure ulcer resulted in Actual Harm to Resident #1.",2019-06-01
959,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2019-12-11,609,D,1,1,JMLT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review and interview the facility failed to report an allegation of abuse timely for Resident #3. The findings include: Facility policy review Abuse, Neglect, Misappropriation of Funds, revised 9/28/19 revealed, .to establish a policy and procedure designed to prohibit abuse, neglect, exploitation, involuntary seclusion of residents and/or misappropriation of resident property .the facility has a zero tolerance policy for abuse, involuntary seclusion, neglect, exploitation and misappropriation of resident property .any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator or Director of Nursing .allegation of Abuse and/or Serious Bodily Injury-2 Hour Limit: if the events that cause the reasonable suspicion of abuse immediately, but not later than 2 hours after forming the suspicion . Review of the facility investigation dated 11/4/19 revealed a witnessed altercation between Resident #3 and Resident #56. Continued review revealed on 11/3/19 Resident #56 slapped Resident #3. Further review revealed the Director of Nursing (DON) was notified of the incident on 11/4/19. Continued review revealed the DON reported the incident to the state agency on 11/4/19. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #3's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. Medical record review revealed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #56's MDS dated [DATE] revealed the resident had a BIMS score of 99, indicating the resident was unable to complete the interview. Continued review revealed the resident exhibited verbal behaviors. Interview with Licensed Practical Nurse (LPN) #2 on 12/11/19 at 10:40 AM on the third floor hallway revealed he didn't witness the altercation between Resident #3 and #56. Continued interview revealed he was unaware of the incident until he was going to clock out and an unnamed tech informed him of a physical altercation between Resident #3 and Resident #56. Continued interview revealed he reported the incident to his supervisor. Interview with Certified Nursing Technician (CNT) #3 on 12/11/19 at 12:50 PM in the Atrium Dining room revealed Resident #3 and Resident #56 had a physical altercation. Further interview revealed Resident #56 smacked Resident #3. Continued interview revealed CNT #3 reported the incident to her supervisor. Interview with the Director Of Nursing on 12/11/19 at 3:18 PM in her office revealed the staff informed her on 11/4/19 of an altercation between Resident #3 and Resident #56 that occurred on 11/3/19. Continued interview when asked to look at the incident date and the reporting date confirmed It was turned in late because I wasn't aware of the possible hitting until the next day after the incident.",2020-09-01
1469,AHC CUMBERLAND,445262,4343 ASHLAND CITY HIGHWAY,NASHVILLE,TN,37218,2017-09-13,225,D,1,0,F0U711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review and interview, the facility failed to properly complete an investigation for 1 resident (#9) of 17 residents reviewed. The findings included: Review of facility policy, Investigation dated (MONTH) 2014 revealed .Request written statements from persons who may have knowledge of the incident . Medical record review revealed Resident #9 admitted to facility on 5/13/16 with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #9 had a Brief Interview of Mental Status of 15, indicating she was cognitively intact. Review of a facility completed abuse investigation revealed a list of staff interviewed on 9/6/17 by the Assistant Director of Nursing/Registered Nurse (RN) #2 and the Risk Manager/Licensed Practical Nurse (LPN) #4. There was a hand written list with staff names and short statements beside each name (8 total) all in the same handwriting. There were 8 individually hand written statements dated 9/6/17, all in the same handwriting but a different handwriting from the list. Interview with RN #2 on 9/12/17 at 3:15 PM in her office revealed she wrote the list of the staff names and what that staff told her located in the facility completed investigation. RN #2 confirmed she failed to obtain written statements from the staff for the investigation of abuse to Resident #9. Interview with LPN #4 on 9/12/17 at 3:43 PM in her office revealed she wrote the 8 hand written individual statements located the facility completed investigation. LPN #4 confirmed she failed to obtain written statements for the investigation of abuse to Resident #9. Interview with the Administrator on 9/12/17 at 3:50 PM in her office confirmed the facility failed to obtain written statements from the staff that were interviewed and Resident #9 in the investigation of abuse to Resident #9.",2020-09-01
4044,AHC WEST TENNESSEE TRANSITIONAL CARE,445187,597 WEST FOREST AVENUE,JACKSON,TN,38301,2016-11-22,514,D,1,0,IQ3911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, closed medical record review and interview, the facility failed to document a change in a resident's condition and failed to document the administration of as needed (prn) medications or follow-up on effectiveness of the medication for 1 of 3 (Resident #1) sampled residents reviewed. The findings included: 1. The facility's Documentation policy documented, .Accurate and complete documentation is a critical aspect of every operation within a long term care nursing facility. This facility's policy is to document information timely and consistent with all applicable professional, legal and established standards and guidelines .Problems or a change in condition that develops must have nursing documentation on every shift for 3 days/72 hours or until the problem is resolved. Examples of new problems which would require every shift documentation are .Nausea and vomiting . 2. The facility's PHYSICIAN ORDER [REDACTED].Physician standing orders or protocol-based orders are pre-authorized orders conditioned upon the occurrence of certain clinical events .After determining the medication is appropriate, the nurse must document the medication on the eMAR. Effectiveness of the medication should also be documented on the eMAR . 3. Closed medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the emergency medical services (EMS) Patient Care Report dated 8/7/16, revealed EMS received the call from the facility for transfer of Resident #1 to the hospital at 2:12 PM, EMS arrived at the bedside at 2:17 PM and reached the hospital at 2:39 PM. Review of the hospital emergency room (ER) records dated 8/7/16, revealed the resident arrived in the ER with decreased responsiveness, skin cool and pale. She had agonal respirations and runs of ventricular fibrillation (fast irregular heart rhythm), and quickly declined into an asystole (no heart beat). The resident was pronounced dead on 8/7/16 at 2:50 PM due to cardiopulmonary arrest. Resident #1's (MONTH) (YEAR) Physician order [REDACTED].Start/Continue Standing Orders . The PHYSICIAN BASED-ORDERS documented, .VOMITING: .[MEDICATION NAME] ([MEDICATION NAME]) 12.5 mg (milligram) PO (by mouth)/PR (per rectum) every 4 hours PRN . The 24-HOUR REPORT OF PATIENT'S CONDITION AND NURSING UNIT ACTIVITY dated 8/6/16, which is not part of the residents' medical record but a nursing report for change of shift, documented, .(Named Resident #1) .PATIENT'S CONDITION - EVENING .NIGHT .pp (pain pill) given for chest soreness, 2 episodes of vomiting, [MEDICATION NAME] given (symbol for with) positive effect @ (at) 0430 (4:30 AM) . There was no documentation in Resident #1's Clinical Notes Report or in a DAILY SKILLED NURSE'S NOTE of the resident's nausea and vomiting, the administration of the [MEDICATION NAME], or if the medication was effective. Review of the (MONTH) (YEAR) eMAR revealed there was no documentation of the pain pill having been administered, or the effectiveness of the pain pill, and no documentation of the [MEDICATION NAME] or the effectiveness of the [MEDICATION NAME]. Telephone interview with the responsible nurse, Licensed Practical Nurse (LPN #1), on 11/17/16 at 3:56 PM, when asked if she had administered a pain pill and/or [MEDICATION NAME] to Resident #1, stated, .She (Resident #1) said she didn't feel good, she was dry heaving, her mouth was dry. We offered her po liquids. I gave her a pain pill because her chest was sore, then gave her [MEDICATION NAME] ([MEDICATION NAME]) . When asked if the medications should have been signed out on the eMAR, LPN #1 stated, Yes. When asked if the effectiveness of the medications should have been addressed, LPN #1 stated, Yes. The Clinical Notes Report dated 8/7/16 at 9:29 AM documented, .Spoke with family member concerning patient nausea and vomiting last night .explained to family about medicine to treat nausea and vomiting and standing order for prn [MEDICATION NAME] . Review of the (MONTH) (YEAR) eMAR revealed no documentation of the [MEDICATION NAME] being administered. There was no further documentation regarding Resident #1's condition related to the effectiveness of the [MEDICATION NAME] given for nausea and vomiting. Telephone interview with the responsible nurse, LPN #2, on 10/18/16 at 9:45 AM, when asked if Resident #1 had been given [MEDICATION NAME] during the day shift, LPN #2 stated, .One of the family members asked for nausea medication. I gave [MEDICATION NAME] per standing order .",2019-11-01
641,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2020-02-26,600,D,1,1,T07H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, facility documentation review, medical record review, and interview, the facility failed to prevent abuse for 1 of 2 residents (Resident #42) involved in a resident to resident altercation. The findings include: Review of the facility policy, Abuse, dated June 2018, showed, .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident/patient property and to ensure that all alleged violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown origin and misappropriation of resident/patient property are reported immediately to the Administrator/Director of Nursing of the center. Review of the medical record, showed Resident #4 was admitted to the facility on [DATE], with readmission on 6/7/2019 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #4 had a Brief Interview for Mental Status (BI[CONDITION]) score of 11 indicating moderate cognitive impairment. Further review showed Resident #4 had verbal behavior symptoms directed toward others. Review of the medical record, showed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], showed Resident #42 was rarely/never understood. Further review showed the resident had no mood or behavioral symptoms. Review of the facility investigation dated 2/18/2020, showed a witnessed physical altercation between Resident #4 and Resident #42 in the Activity room while waiting for the activity to begin. Further review showed Resident #4 grabbed Resident #42's wrist, slapped and kicked her. During an interview conducted on 2/25/2020 at 7:30 AM, the Activity Director confirmed Resident #4 and Resident #42 had a physical altercation. Further interview she stated, When I walked into the Activity room I saw (named Resident #4) holding (named Resident #42's) wrist. I asked (named Resident #4) to let go of (named Resident #42) and before I could separate them (named Resident #4) slapped and kicked (named Resident #42). During an interview conducted on 2/26/2020 at 2:10 PM, the Administrator confirmed Resident #4 and Resident #42 had a physical altercation on 2/18/2020.",2020-09-01
746,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2019-11-06,689,J,1,1,TEZO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, facility documentation review, medical record review, observation and interview the facility failed to provide adequate supervision to prevent elopement for 1 resident (#68) of 5 residents reviewed who were wander/elopement (Residents who have a history of leaving or trying to leave the facility, or have wandered or have the potential to wander into unsafe areas) risks resulting in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was informed of the Immediate Jeopardy (IJ) on 11/5/19 at 6:50 PM in his office. An extended survey was conducted from 11/5/19 to 11/6/19. F-689 was cited at a scope and severity of [NAME] F-689 J is Substandard Quality of Care. The Immediate Jeopardy was effective from 7/27/19 through 8/20/19. The facilities corrective action plan, which removed the IJ, was received and the corrective actions were validated onsite on 11/6/19 F-689 was cited at a scope and severity of J as past noncompliance. The facility is not required to submit a plan of correction for F-689 [NAME] The findings include: Review of the facility policy, Missing Residents and Elopement, dated 8/1/16 revealed .It is the policy of this facility that all residents are provided adequate supervision to meet each resident's personal care needs .All residents will be assessed for behaviors or conditions that put them at risk of elopement .All resident's assessed to be at risk of elopement will have this issue addressed in their plan of care .Residents that are at risk of elopement will be provided at least one of the following safety precautions: staff supervision of facility exits either directly or by video camera .door alarms on facility exits .a personal safety device that notifies facility staff when the resident has left the facility without supervision .all personal safety devices, door alarms and video cameras will be tested and document weekly .at no time will any door alarm or personal safety device be deactivated without direct supervision of the exit .Potential safety hazards on the exterior of the facility shall be identified such as wooded areas, water hazards, and busy roads .Should an alarm on one of the exits to the outside of the facility sound, staff will immediately respond to determine the cause of the alarm . Medical record review revealed Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #68's hospital records dated 7/15/19 revealed approximately 1 week prior to the hospitalization , and susequent admission into the facility the resident had wandered from his home, became lost in the woods and sustained rib fractures. Medical record review of Resident #68's 5 day Minimum Data Set ((MDS) dated [DATE] and Discharge MDS dated [DATE] revealed the resident had a Brief Interview of Mental Status Score of 4 indicating the resident had severe cognitive impairment. Continued review revealed the resident wandered daily. Medical record review of Resident #68's comprehensive care plan dated 7/26/19 revealed the resident was high risk for elopement and wandering. Continued review revealed .roam alert bracelet was applied to resident to reduce risk of elopement .monitor resident location with frequent visual checks .monitor doors when staff and visitors come and go . Continued review revealed the resident was at risk for falls. Medical record review of Resident #68's progress notes dated 7/26/19 through 8/6/19 revealed the resident wandered in and out of resident rooms. Medical record review of Resident #68's Elopement Risk Review dated 7/26/19 revealed .the resident had a history of [REDACTED].hangs around facility exits and/or stairways .responds poorly to staff re-direction when roaming into areas that are 'off limits' or unauthorized .has the physical ability to leave the building .becomes agitated, confused and/or disoriented or displays consistently poor judgement (would not be able to safely care for him/herself outside the facility) .at risk to elope and should be placed on the Elopement Risk Protocol .Resident has a history of trying to elope, he does not do redirection to (too) easily from staff . Medical record review of Resident #68's Wandering Risk assessment dated [DATE] revealed .Resident is cognitively impaired with poor decision making .resident is alert but non-compliant with facility protocols regarding leaving the unit .unauthorized opening doors to the outside without regard to their personal safety .lingering around exit doors, attempting to exit with visitors without authorization .displays behaviors, body language, indicating an elopement may be forthcoming . Medical record review of Resident #68's Fall Risk Review dated 7/26/19 revealed the resident was at risk for falls related to [MEDICAL CONDITION] and Dementia. Review of the facility's investigation for Resident #68 dated 7/27/19 revealed the resident exited the building through the front door of the facility. Interview with Licensed Practical Nurse (LPN) #5 on 11/5/19 at 4:19 PM in the conference room revealed she was working on 7/27/19 when Resident #68 exited the facility out the front entrance door. Continued interview revealed I was on the hallway and a 'tech' (Certified Nursing Assistant (CNA) # 6) came out of room [ROOM NUMBER] and yelled at us that (named resident) was outside. Telephone interview with LPN #6 on 11/5/19 at 4:48 PM revealed I was on the hall at the time he was visiting with family in the dining room. One of the CNA's saw him outside through another resident's window; she came out and told me he was outside so I went out to get him and bring him back inside. I was just concerned about getting the resident to safety. Telephone interview with CNA #6 on 11/5/19 at 5:01 PM confirmed I saw him walking outside in the parking lot out of room [ROOM NUMBER]'s window. I first thought his daughter was with him then when I looked again I realized she wasn't, nobody was; I came out of the room and yelled at other staff that (named resident) was in the parking lot. Observation on 11/5/19 at 5:10 PM from room [ROOM NUMBER]'s window revealed the inability to view the front entrance area of the building. Continued observation revealed the ability to view the side parking lot and the 4 lane highway. Telephone interview with Resident #68's family member on 11/6/19 at 2:42 PM revealed I was there, I had gone to the bathroom and when I came out he (Resident #68) was not where I left him, so I started looking for him. I walked all the hallways even looking in rooms to see if he was there. Continued interview revealed I walked around the building for approximately 10 minutes or so; then when I got to Station 1 (nurses' station 1) the staff started yelling 'he's outside' and then everybody started running toward the front door so I went too. When I got to the front door I saw him. He was already down to the road, fixing to get on the road. Interview with the Director of Nursing (DON) on 11/5/19 at 5:38 PM at the front entrance door revealed the DON confirmed Resident #68 was not safe outside. The facility's corrective action plan included the following: 1. On 7/27/19 Resident #68 was brought back into the facility by staff members without injury. A head to toe assessment was competed on Resident #68. The resident was placed on 1:1 staff monitoring. Education and Elopement Training was administered to staff. Confirmed placement and function of residents with wanderguards (Alarm bands placed on residents at risk for exiting the facility which alarms once the resident nears the exit doors) was completed on 7/27/19. The facility completed 100% of Elopement assessments on all residents on 7/27/19. Maintenance Director immediately reviewed all doors on 7/27/19. 2. Elopement drill was completed on 8/8/19. Elopement plans reviewed at an adhoc Quality Performance Improvement (QAPI) meeting on 8/20/19. 3. All residents facility wide had their assessments for elopement risk reviewed for accuracy. The surveyors verified the facility's corrective action plan as follows: 1. The surveyors interviewed staff to confirm the resident was brought back inside the facility to safety and placed on 1:1 monitoring. The surveyors verified a skin assessment was completed on Resident #68 with no skin issues identified. The surveyors reviewed the maintenance log for the functioning of the door alarm system on 7/27/19. The surveyors interviewed random staff concerning elopement in-services on 7/27/19 and what the procedures were for door alarms sounding and what they would do when an alarm sounds. The surveyors reviewed the facility's investigation dated 7/27/19. The surveyors checked the door alarms and the staff responded to the alarms immediately. 2. The surveyors Varified the facility elopement drill dated 8/8/19 and the adhoc Qapi meeting minutes. 3.The surveyors varified elopement risk assessments on all residents who resided in the facility on 7/27/19.",2020-09-01
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
1668,GRACE HEALTHCARE OF WHITES CREEK,445281,3425 KNIGHT DRIVE,WHITES CREEK,TN,37189,2019-06-18,600,G,1,0,QRE111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, facility investigation review, medical record review, and interview the facility failed to ensure the safety and well-being of a resident and failed to protect a resident from verbal abuse and threats of physical abuse for 1 (Resident #2) of 4 residents reviewed for abuse. This failure resulted in HARM to the resident. The findings included: Review of facility policy, Abuse Prevention, revised 2/26/18, revealed .This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical, and/or mental abuse, corporal punishment, involuntary seclusion, or misappropriation of resident property by anyone .All alleged violations involving abuse, neglect, exploitation, or mistreatment and misappropriation are reported immediately to the Administrator and DON .Verbal abuse is any use of oral, written, or gestured language that willfully includes the disparaging and derogatory terms to residents or within hearing distance, regardless of age, ability to comprehend, or infirmities .A screening process will be completed on all new hires .Training on activities that constitute abuse, neglect, exploitation, and misappropriation will be held in new hire orientation and annual training .All allegations will be thoroughly investigated under the direction of the Administrator .The completed investigation will be forwarded to the Facility's Quality Assurance/Performance Improvement Committee for review . 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 scored 9 on the Brief Interview for Mental Status (BIMS) indicating she was moderately cognitively impaired. Continued review of the MDS revealed Resident #2 required extensive assistance of 1 person with transfers, dressing, toileting, grooming, and bathing; and was frequently incontinent of bowel and bladder. Medical record review revealed on 6/5/19 Resident #2 reported to a staff member that nurse (CNA#2 ) came into the bathroom and was very angry at her. She was fussing at her for getting food on her clothing. The resident reported the employee threatened to spank her. She later reported to DON (Director of Nursing) and Administrator the employee actually shook her once. Review of facility investigation of a written report from RN (Registered Nurse) #2 and written statement from CNA (Certified Nursing Assistant)#2 dated 6/5/19 revealed . They found Resident #2 in her room sitting on the bed crying. When asked why she was crying (named Resident #2) reported verbally to the nurse and (named CNA #1) I'm in trouble I got spaghetti on my pants. She (CNA #2) was fussing at (named Resident #2) and said why do I always do this to her. I'm going to spank you. The resident described the nurse as being tall and wearing glasses. CNA #2 entered the room and resident stated that is her. Resident taken to private location . RN #2 reported this incident to the DON. Interview with the DON and ADON (Assistant Director of Nursing) on 6/18/19 at 2:30 PM in the conference room revealed Resident #2 has a [DIAGNOSES REDACTED]. When she told her story she was crying and was obviously afraid of CNA #2. The CNA is quite tall and loud. Even to this day (6/18/19) both the DON and ADON stated (named Resident #2) asks if that woman is coming back so there is definitely a fear factor present. Some aspects of her story changed in retelling but the issue of the CNA threatening to spank her has never changed - it comes out every time she talks about the incident. Interview with Resident #2 on 6/18/19 at 3:10 PM in the dining room revealed she remembered the incident and said the nurse (CNA #2) told her she was throwing one of her fits and she just needed a spanking. She said she didn't want that nurse (CNA#2) back. Interview with CNA #1 and RN #2 on 6/18/19 at 3:30 PM in the Administrator's office revealed he and (named RN #2) were walking past the room of (named Resident #2) and saw she was crying. When they asked what was wrong she said she was in trouble because she spilled spaghetti on her pants and changed them. They asked who was upset with her she said the tall nurse with glasses. At that point CNA #2 tried to enter the room but CNA #1 told her not to come into the room. When she saw CNA #2 the resident said that's her. She said CNA #2 is tall, very loud and to the point he has had to tell her not to be so loud in the halls. The Administrator asked CNA #2 to leave the building and sent someone to sit with her in the courtyard. (named Resident #2) is like a child in that they will change pants if they are soiled. As of this date (named Resident #2) asks CNA #1 daily if that nurse is coming back and says I don't want her. In summary, Resident #2 stated CNA #2 scolded the resident for changing her pants by herself and threatened to spank the resident. Resident #2 is still asking (6/18/19) if that nurse is coming back and states she does not want her. Resident #2 suffered psychological harm as a result of the actions of CNA #2.",2020-09-01
2087,SIGNATURE HEALTHCARE OF SOUTH PITTSBURG REHAB & WE,445343,201 EAST 10TH STREET,SOUTH PITTSBURG,TN,37380,2017-10-11,223,D,1,0,9Q7R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, facility investigation review, medical record review, and interview the facility failed to provide supervision to protect 2 residents (#2, #3) from the physical aggression of another resident of 5 residents reviewed for abuse on the secure unit. The findings included: Review of the facility's policy, Abuse, Neglect, and Misappropriation .revised 11/28/16, revealed, .C.Abuse Prevention and Protection .2. If a Stakeholder observes a resident exhibiting any form of abuse toward another resident, the Stakeholder will intervene immediately to interrupt the incident and remove and/or separate the residents involved and move them to an environment where the residents' safety can be assured. The charge nurse and/or Director of Nursing will ensure that the residents do not have access to one another until the circumstances of the incident can be determined . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Admission Information dated 1/27/17 revealed the resident exhibited the following behaviors: resists care, verbally abusive, physically abusive and inappropriate/disruptive. Continued review revealed .Elder arrived at facility by ambulance .is ambulating with unsteady gait, combative with care .hard to direct, incont (incontinent) B&B (bowel and bladder) . Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had been unable to complete a Brief Interview for Mental Status (BIMS), and was deemed to have short and long term memory deficits with severe cognitive impairment. Continued review of the MDS revealed Resident #1 had inattention and disorganized thinking behaviors. Continued review of the Behaviors section of the MDS revealed the resident had exhibited physical behaviors toward others 4 to 6 days out of 7, and had directed verbal behavior symptoms toward others 1 to 3 days out of seven. Continued review revealed the resident had rejected evaluation or care and wandering for 1 to 3 days a week during the assessment period. Medical record review of Resident #1's care plan dated 2/9/17 revealed, .Active Behavior Problems: Wanders, is resistive with care, is verbally and Hx (history) of physically aggressive; will sit in the floor; and is not easily redirected. At risk for causing harm to himself and/or others . Review of the facility investigation dated 10/2/17, 10:30 AM, revealed, .Elder had been aggressive entire morning. As female elder was walking by in the hallway, elder grabbed her by the arm. This nurse and activities saw him and ran into the hall to talk to elder and attempt to get him to let her go. Elder then grabbed female's wrist, along with her arm and started squeezing harder causing elder to scream. 2 CNAs were in the shower and heard female scream and came running. Staff finally convince elder to let female go .Elder was given a 1 x (time) dose of [MEDICATION NAME] 20 mg (milligrams) IM (intramuscular) per psych doctor. Medical record review of the care plan for Resident #1 dated 10/2/17 revealed .Separation, skin assessment Psych (psychiatric) NP (Nurse Practitioner) consult - new orders noted. In house NP assessment. Outpatient geri (geriatric) psych referral .10-2-17 separation skin assessment 1:1. Send to Hosp (hospital) ER (emergency room ) for psych consult. Medical record review of an Event Detail dated 10/2/17, revealed An aggressive elder (Resident #1) grabbed her (Resident #2) while she was walking by him in the hallway. This nurse and activities saw him and ran into the hall to talk to elder and attempt to get him to let her go. Then elder grabbed her arm and wrist . Continued review revealed the NP (Nurse Practitioner), Family, and DON (Director of Nurses) notified and no first aid required. Medical record review of a Social Service Director statement dated 10/9/17 revealed she was notified on 10/2/17 at 10:30 AM, by Licensed Practical Nurse #2, that Resident #1 had hit another resident and the nurse had notified the Psych NP, who placed Resident #1 on 1:1 monitoring and was attempting to get the resident sent out. Continued review revealed referrals were faxed, and the resident was accepted by a facility and sent out on 10/2/17 in the evening. Medical record review of a Physicians Order dated 10/2/17 at 10:30 AM revealed Give 20 mg (milligrams) IM (intramuscular) [MEDICATION NAME] x (times) 1 dose now R/T (related to) aggression. Medical record review of a Physicians Order dated 10/2/17 at 11:30 AM revealed Psych Referral for increased agitation. Medical record review of a Progress Note (Behavior Type) dated 10/2/17, 4:32 PM, revealed, Elder up in hallway wandering up/down and in/out of all rooms. Continues to exit seeking. Continues to be agitated. Verbal and physical aggression with care. Unable to redirect. Review of the facility's investigation dated 10/2/17, 4:55 PM, revealed, Resident #3 .walked into the dayroom to sit down. (Resident name) entered behind him and went in front of him and grabbed his R (right) leg and pulled it up .(Resident #3) tried to get away but .(Resident #1) had a hold of his leg .(Resident #3) grabbed onto the chair to get away when .(Resident #1) flipped him over the table onto the floor . Interview with LPN #2/Charge Nurse on 10/9/17 at 2:30 PM, by phone revealed, Resident #1 had been agitated on 10/2/17. Continued interview revealed he had been taken to an activity out front and was continuing to wander on the unit and Resident #2 walked by him and he grabbed her arm. Further interview revealed both CNAs were assisting a resident in the shower room so the Charge Nurse and the Activity staff member attempted to get Resident #1 to let go of Resident #2's arms; but he held the arm tighter. Further interview confirmed the CNAs came out of the shower room and were able to convince Resident #1 to let go. Continued interview confirmed the residents were separated; Psych was notified, and the resident received a [MEDICATION NAME] injection to decrease agitation. Continued interview with LPN #2 revealed Resident #1 went into the day room; grabbed Resident #3's leg and Resident #3 fell over the table. Resident #1 was placed on 1:1 till ambulance arrived for transport of Resident #1.",2020-09-01
2814,MADISONVILLE HEALTH AND REHAB CENTER,445457,465 ISBILL RD,MADISONVILLE,TN,37354,2018-08-08,609,D,1,0,J2VJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, facility investigation review, medical record review, and interview, the facility failed to report an allegation of abuse immediately to the Administrator and the State Survey Agency timely for 1 resident (#4) of 11 residents reviewed. The findings include: Review of facility policy Abuse Prevention/Reporting Policy and Procedure, dated 5/9/18 revealed .All reports whether from family, residents or staff will be reported immediately to the Administrator and Abuse Coordinator and/or D.O.N and the resident's Primary Health Care Provider .An Event Report will be initiated by the Charge Nurse upon discovery/allegation and the Administration (NHA and DON) will be notified immediately regardless of the time of discovery or allegation of Abuse .If the events that cause 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, to the administrator of the facility and to other officials . Review of a facility investigation dated 5/5/18 at 5:36 AM revealed on 5/4/18 at 11:30 PM Resident #5 entered Resident #4's room, sat down on Resident #4's bed, and attempted to pull Resident #4's pants off, yelled, and smacked him in an attempt to get Resident #5 out of bed. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with the following [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 13 of 15 (cognitively intact). Medical record review revealed Resident #5 was admitted on [DATE] and readmitted on [DATE] with the following [DIAGNOSES REDACTED]. Medical record review of the Admission MDS assessment dated [DATE] revealed the Resident #5 scored a 3 (cognitively impaired) on the BIMS. Telephone interview with Registered Nurse (RN) #1 on 8/7/18 at 11:02 AM, revealed staff heard Resident #4 yelling on 5/4/18 around 11:30 PM when Resident #5 was in Resident #4's room trying to pull him out of bed and was smacking him. Continued interview confirmed RN #1 contacted her supervisor about the incident on 5/5/18 at 3:00 AM (3 and 1/2 hours later). Interview with the Administrator, the Regional Quality Specialist, and the Regional Vice President on 8/8/18 at 8:00 AM, in the conference room, confirmed the facility failed to report an allegation of abuse immediately to the Administrator and to the State Survey Agency. Continued interview confirmed the facility failed to follow facility policy.",2020-09-01
2510,ETOWAH HEALTH CARE CENTER,445422,"409 GRADY ROAD, PO BOX 957",ETOWAH,TN,37331,2018-04-17,600,D,1,0,R7QB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, facility investigation review, medical record review, observations, and interviews, the facility failed to ensure 2 residents (#2 and #4) were free from abuse during resident to resident altercations of 7 residents reviewed for abuse. The findings included: Review of facility policy Abuse, Neglect & Exploitation Policy & Procedures dated 4/26/16 revealed .Policy .Residents are not to be subjected to abuse, neglect, and/or exploitation by anyone, including but not limited to, facility staff, other residents, consultants or volunteers .Abuse means the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain or mental anguish . Review of a facility investigation dated 4/8/18 revealed a written statement by Certified Nursing Assistant (CNA) #1. Continued review revealed CNA #1 was walking up the hall and observed Resident #1 slapping Resident #2's right hand. Further review revealed CNA #1 told Resident #1 to stop and Resident #1 said .You stop . Continued review revealed Resident #1 then used her right foot to start kicking at Resident #2 but the CNA was unable to verify if the resident actually kicked Resident #2. Further review revealed Resident #2 did not have any injuries. 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 was severely cognitive impaired and was totally dependent on staff for bed mobility, transfer, dressing, eating, and personal hygiene. 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 was severely cognitive impaired and required extensive assistance for transfer, dressing, and hygiene/bathing. Interview with CNA #1 on 4/16/18 at 2:25 PM, in the conference room, revealed on 4/8/18 she observed Resident #1 and #2 eating breakfast in the dining room prior to the incident but later observed Resident #2 in the lobby area. Further interview revealed CNA #1 observed Resident #1 slap Resident #2 on the right forearm, but she was unsure if Resident #1 kicked Resident #2's legs. Interview with the Director of Nursing (DON) on 4/17/18 at 1:10 PM, in the conference room, confirmed the facility failed to protect Resident #2 from being hit by Resident #1. Review of a facility investigation dated 4/14/18 revealed Resident #4 reported to the DON that Resident #3 got in her bed, smacked her on the arm, and told her to get out of her bed. Continued review revealed a CNA heard Resident #4 yelling and when the CNA entered Resident #4's room, Resident #3 was standing in front of the dresser at the foot of Resident #4's bed. Further review revealed Resident #4 said Resident #3 hit her on the left arm. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual MDS dated [DATE] revealed Resident #4 scored 15 (cognitively intact) on the Brief Interview for Mental Status and required supervision for transfer and ambulation 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 scored was severely cognitive impaired and required supervision for transfer and ambulation Medical record review of nursing progress notes dated 4/14/18 at 11:50 PM revealed the nurse was notified by a CNA of an incident. Further review revealed Resident #4 was heard yelling for help and when the CNA entered the room Resident #4 was in bed and awake with Resident #3 standing in front of the dresser in the room. Continued review revealed Resident #4 stated Resident #3 came into her room turned over the bedside table and repeatedly hit her in the left arm and left side of stomach. Further review revealed Resident #4 had a purple discoloration to the left forearm and top of right hand and light bruising was noted to the abdominal area, but Resident #4 denied any pain. Observation and interview with Resident #4 on 4/17/18 at 8:45 AM, in the resident's room, revealed the resident was in bed and had finished breakfast. Interview with Resident #4 revealed Resident #3 came into her room when she was asleep and told her to get out of her bed and then Resident #3 started slapping her on the left arm. Continued interview revealed Resident #4 stated she was fine and had no problems after the incident and was able to go back to sleep. Further interview revealed after the staff removed Resident #3 from her room Resident #3 did not return and has not been seen since. Interview with Licensed Practical Nurse (LPN) #3 on 4/17/18 at 10:20 AM, in the conference room, revealed Resident #3 does like to walk up and down the hallway carrying stuffed animals or plastic flowers in her arms and wanders the entire facility all day long. Further interview revealed Resident #3 will refuse to have her clothes changed at times, refuses showers, becomes combative with staff and will curse, yell, punch at staff, especially when trying to redirect her. Interview with the DON and Administrator on 4/17/18 at 12:55 PM, in the conference room, confirmed the facility failed to protect Resident #4 from being hit by Resident #3. Telephone interview with CNA #3 on 4/18/18 revealed she heard Resident #4 yell stop and get away from me and when she got to the room of Resident #4 she observed Resident #3 standing next to the dresser at the foot of Resident #4's bed. Continued interview revealed Resident #4 reported Resident #3 hit her on the left arm and Resident #4 stated she was not in pain and she was okay.",2020-09-01
2645,MT JULIET HEALTH CARE CENTER,445439,2650 NORTH MT JULIET ROAD,MOUNT JULIET,TN,37122,2019-03-13,689,D,1,1,O5E111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, facility investigation, medical record review, and interview the facility failed to prevent a fall for 1 of 8 residents (#68) reviewed. The findings include: Record review of the facility policy Fall Risk assessment dated ,[DATE] revealed .Implement interventions, including adequate supervision, consistent with a resident's needs, goals, plan of care nd current standards of practice in order to reduce the risk of a fall . Medical record review revealed Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] and the Quarterly MDS dated [DATE] revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. Continued interview revealed Resident #68 required total dependence with 2 people for transfers. Record review of the facility investigation dated 2/6/19 Resident #68 slid from the wheelchair during a transfer by only 1 staff member. Record review of the facility investigation dated 2/6/19 revealed a witness statement from a Certified Nurse Aide #4 revealed Resident #68 told CNA #4 she was a 1 person transfer. Continued review revealed CNA #4 realized Resident #4 could not assist in the transfer and lowered Resident #68 to the floor. Interview with Resident #68 on 3/13/19 at 11:23 AM revealed staff member attempted to transfer the resident to the wheelchair but could not and the resident was then lowered to the floor. Interview with Registered Nurse #3 on 3/13/19 at 2:45 PM 100 hallway revealed, the tech was trying to transfer Resident #68 alone and could not so she lowered her to the floor. Continued interview revealed she could not remember who provided care to Resident #68. Interview with the Director of Nursing on 3/13/19 at 8:03 PM in the Administrators office confirmed Resident #68 was transfered by 1 staff member. Continued interview confirmed .I would expect the staff to use 2 persons to assist the resident if the care plan and MDS requires it .",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
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
1468,AHC CUMBERLAND,445262,4343 ASHLAND CITY HIGHWAY,NASHVILLE,TN,37218,2017-09-13,224,E,1,0,F0U711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record reivew, facility investigation review, observation, and interview, the facility failed to prevent misappropriation of resident narcotic medication for 7 residents (#1, #2, #3, #4, #5, #8, #11) of 16 residents reviewed for abuse. The findings included: Review of facility policy, Abuse, effective 7/2014, revealed .The facility practices the concept of zero tolerance for patient abuse. Nurse management must strive to ensure the patients are free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, and misappropriation of property. ANY report of actual or suspected abuse MUST be acted upon immediately .Conduct a thorough investigation that is well documented . Review of facility policy, Controlled Medications, revealed .All nurses must be inserviced on the procedure for accountability for controlled drugs on hire and annually thereafter . Review of facility policy, Controlled Drug Accountability Procedure, effective 7/2014, revealed : .Each dose administered is to be signed out by the nurse on the controlled drug record and on the patient's eMAR (electronic Medication Administration Record). Follow-up documentation for effectiveness should be accomplished on the eMAR also .The count of each controlled substance must be audited at every shift change by the nurse coming on duty and the nurse going off duty. Visual checks of the entire medication card for missing medications and the record sheet must be done by both nurses .Both nurses must sign the Narcotic Control Record indicating the count has been completed; the date, time, number of medication cards, and the number of controlled drug record sheets must be documented .If the count is incorrect the Director of Nursing (DON) must be notified immediately. No exchange of med cart keys should be done and the off-going nurse should not leave the facility . Review of facility policy, Destruction of Medications, effective 7/2/14, revealed .Each facility medication room must have a container labeled for the collection of all patients' medication to be considered for credit or destruction .Controlled medications set to destroy must be destroyed by the Director of Nursing (DON) or designee and the consultant pharmacist . 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 scored 15 on the Brief Interview for Mental Status (BIMS) indicating he was alert, oriented, and able to make his needs known. Continued review revealed Resident #1 required extensive assistance with transfers and bathing; limited assistance with dressing and grooming; and supervision with eating. Medical record review of physician's orders [REDACTED].#1 was ordered [MEDICATION NAME] 7.5/325 milligrams (mg) every 6 hours as needed for pain. Review of the Controlled Drug Record revealed on 8/15/17, [MEDICATION NAME] 7.5/325 mg was signed out at 9:00 PM, 10:00 PM, 2:00 AM. Continued review revealed [MEDICATION NAME] was also signed out on 8/16/17 at 6:00 AM, all by the same Agency Nurse #1. Medical record review of the Medication Administration Record (MAR) revealed [MEDICATION NAME] 7.5/325 mg was documented as administered at 3:40 PM on 8/15/17 and at 1:33 PM on 8/16/17. None of the other times from the evening and night shifts were documented on the MAR. Review of the facility investigation revealed Resident #1 was interviewed on 8/16/17 and stated he received pain medication about 8:30 PM on 8/15/17 but did not receive any pain medication during the night on the 11:00 PM - 7:00 AM shift and he slept through the night. 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 15 on the BIMS indicating she was alert, oriented, and able to make her needs known. Medical record review of physician's orders [REDACTED].#2 was ordered [MEDICATION NAME] 7.5/325 mg every 4 hours as needed for pain. Review of the Controlled Drug Record revealed [MEDICATION NAME] 7.5/325 mg was signed out at 12:00 AM, 2:00 AM, 6:00 AM, 6:45 AM, and 6:55 AM, all by Agency Nurse #1. Continued review of the record revealed only 1 tablet was signed out at 12:00 AM but the count was documented as 29 before the tablet was removed and 27 after the tablet was removed. Further review revealed only 1 tablet was signed out at 2:00 AM but the count was documented as 27 before the tablet was removed and 25 after the tablet was removed. Continued review revealed 1 tablet was signed out at 6:00 AM but the count was documented as 25 before the tablet was removed and 23 after the tablet was removed. Further review revealed at 6:45 AM and 6:55 AM Agency Nurse #1 documented removing 2 tablets each time. Medical review of the MAR revealed [MEDICATION NAME] 7.5/325 mg was documented as administered on 8/15/17 at 10:53 PM but nothing was documented for 8/16/17. Review of the facility investigation revealed Resident #2 was interviewed on 8/16/17 and she stated she received pain medication on the 3:00 PM - 11:00 PM shift but did not have any pain medication during the night and was not having any increase in her pain. Observation of Resident #2 on 9/11/17 revealed she was lying in bed watching TV. She stated the pain medication was effective in controlling her pain and she receives pain medication when she asks for it. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual MDS dated [DATE] revealed Resident #3 scored 13 on the BIMS indicating she had slight cognitive impairment. Medical review of physician's orders [REDACTED].#3 was ordered [MEDICATION NAME] 5/325 mg every 12 hours as a scheduled medication. Review of the Controlled Drug Record dated 8/5/17 revealed [MEDICATION NAME] 5/325 mg was signed out at 6:00 PM and 11:00 PM while on 8/6/17 it was signed out at 6:00 AM, 5:00 PM, and 11:00 PM. Continued review revealed on 8/7/17 [MEDICATION NAME] was signed out at 5:30 AM, 9:00 PM, and 11:00 PM while on 8/9/17 it was signed out at 9:30 PM, 10:30 PM, and one was wasted at 11:30 PM. Further review revealed on 8/10/17 [MEDICATION NAME] was signed out at 6:00 AM and on 8/13/17 was signed out at 12:00 AM and 6:00 AM. Continued review revealed on 8/14/17 [MEDICATION NAME] was signed out at 12:00 AM, again for 12:00 AM, 6:00 AM, 6:30 AM, and 6:50 AM. Further review revealed on 8/15/17 [MEDICATION NAME] was signed out at 4:00 PM and 10:00 PM while on 8/16/16 it was signed out at 12:00 AM, 6:00 AM, and 6:45 AM. All of these removals were signed out by Agency Nurse #1. Medical record review of the MAR revealed the only documentation of administration of [MEDICATION NAME] was 8/7/17 at 5:30 AM. There was no documentation for the rest of the tablets of [MEDICATION NAME] which were removed. Observation of Resident #3 on 9/11/17 at 1:50 PM revealed her lying in bed asleep. Observation on 9/12/17 at 8:05 AM revealed the resident was in bed watching TV and stated she had no pain currently. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE] revealed Resident #4 scored 15 on the BIMS, indicating he was alert, oriented, and able to make his needs known. Medical record review of physician's orders [REDACTED]. Review of the Controlled Drug Record revealed on 8/5/17 [MEDICATION NAME] was signed out at 6:15 PM and 11:45 P0 AM; on 8/12/17 it was signed out at 2:00 AM; on 8/13/17 it was signed out at 3:15 AM; on 8/14/17 it was signed out at 12:00 AM and 6:00 AM; on 8/15/17 it was signed out at 7:00 PM' and on 8/16/17 it was signed out at 1:00 AM. All these removals were signed out by Agency Nurse #1. Medical record review of the MAR revealed no documentation on the MAR of any of these medications being administered. Observation of Resident #4 on 9/11/17 at 1:40 PM revealed Resident #4 sitting up in bed with Podus boots on both lower extremities. He stated his pain was controlled with medication. Observation of the resident on 9/12/17 at 8:10 AM revealed Resident #4 revealed he was still asleep with the door closed. 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 Resident #5 scored 3 on the BIMS indicating she was severely impaired cognitively. Medical record review of physician's orders [REDACTED].#5 was ordered [MEDICATION NAME] 5/325 mg three times daily. Review of Controlled Drug Record dated 8/3/17 revealed [MEDICATION NAME] was signed out at 5:00 PM, 10:00 PM, 11:00 PM, again at 11:00 PM, and 11:30 PM. Continued review revealed on 8/4/17 [MEDICATION NAME] was signed out at 5:00 PM, 5:30 PM, 10:30 PM, and 11:00 PM. Further review revealed on 8/6/17 [MEDICATION NAME] was signed out at 5:00 AM, 5:00 PM, and 11:00 PM. Continued review revealed on 8/12/17 [MEDICATION NAME] was signed out at 12:00 AM, 4:00 AM, and 6:00 AM while on 8/13/17 it was signed out at 12:00 AM and 6:00 AM. Further review revealed on 8/14/17 [MEDICATION NAME] was signed out at 12:00 AM and 6:00 AM while on 8/15/17 it was signed out at 10:00 PM, 10:30 PM, 12:00 AM, and 6:00 AM. These removals were all signed out by Agency Nurse #1. Medical record review of the MAR revealed none of these removals were documented as having been administered. Observation of Resident #5 on 9/12/17 at 8:15 AM revealed the resident lying uncovered in bed, yelling out unintelligibly. When the CNA entered the room she spoke with the resident but was unable to understand what was wanted. Review of the facility investigation revealed the discrepancies were discovered when Resident #2 asked RN #1 for pain medication on 8/16/17. When RN #1 looked at the Controlled Drug Record to determine when the last dose of [MEDICATION NAME] was administered she saw the count on the 3:00 PM - 11:00 PM was 29 tablets and the count at the 11:00 PM - 7:00 AM shift was 19 tablets. At the same time RN #1 noted the frequency with which [MEDICATION NAME] was signed out. At this point she shared her concerns with the Administrator. Both the Administrator and DON began an investigation, looking at all the Controlled Drug Records for all residents. They interviewed the residents who had [MEDICATION NAME] signed out during the night shift as to when they last received pain medication and if they received any pain medication during the night of 8/15/17 - 8/16/17. All the residents stated they had pain medication on evenings but had not required any during the night. The Administrator and DON reviewed MARs for those residents and found concerns. At this point they had narrowed the concern to Agency Nurse #1 and they began to watch the video footage of the night shift. They determined the discrepancies with all 5 residents included the times on the Controlled Drug Record were not on the MAR; the times on the controlled Drug Record do not match the video footage; and times on the controlled Drug Record do not match the physician's orders [REDACTED].#2 and all were negative. At this point the agency was notified Agency Nurse #1 was to be removed from the facility rotation. The Administrator spoke with the Branch Manager of the staffing agency regarding her concerns with Agency Nurse #1. The Branch Manager reviewed the videos and terminated Agency Nurse #1 from the agency. Review of the video footage from 8/15/17 and 8/16/17 revealed Agency Nurse #1 not entering the room of Resident #1 except for morning medication pass. On 8/15/17 she is seen at 8:02 PM flipping through the Controlled Drug Records then she places an empty cup on the cart. She opens the narcotic box; takes out a pill and places it in the cup. She goes to another card; flips out a tablet and adds it to the cup; flips through the book a third time; removes a narcotic from a card; and adds it to the cup. She fills a cup with water and walks around for 30 minutes. She enters the room of Resident #4 at 8:25 PM and exits at 8:34 PM with no cups. Resident #4 is only on 1 narcotic. On 8/16/17 at 3:48 AM she is seen flipping through narcotic cards in the narcotic drawer; reaching to the left and placing something on the med cart; filling a cup with water; walking into the medication room; and not returning with anything. At 6:45 AM she is seen removing a tablet from the narcotic card; filling a cup with water; walking down the hall to a room on the right which was not the room of any of the residents; and coming out of the room with nothing. On 8/16/17 Agency Nurse #1 signed out [MEDICATION NAME] for Resident #3 at 5:05 AM and 5:55 AM but the video showed her at the medication card checking narcotic cards in the box and comparing them to the Controlled Drug Records. Interview with Registered Nurse (RN #1) on 9/12/17 at 1:35 PM in the conference room revealed she was the nurse on 7:00 AM - 3:00 PM. Continued interview revealed Resident #2 was in her care and asked for something for pain. Further interview revealed RN #1 checked the Controlled Drug Record to see when the last dose was given. Continued interview revealed she notes the date and times of [MEDICATION NAME] withdrawal as well as the fact the count at 11:00 PM was 29 [MEDICATION NAME] remaining and at 7:00 AM there were only 19 remaining. Further interview revealed she noted 1 tablet was removed at times and 2 tablets were removed at others. Continued interview revealed she also saw [MEDICATION NAME] signed out at 6:15 AM and again at 6:45 AM so she pulled the sign out sheet and took it to the Administrator. Interview with the Administrator on 9/12/17 at 2:20 PM in the Administrator's Office, revealed when RN #1 brought the sign out sheet to her with her concerns, she and the DON began pulling sign out sheets from other residents. All nurses with access to the [MEDICATION NAME] of Resident #2 were drug tested and all were negative. In reviewing the sign out sheets the Administrator and DON determined there were many irregularities in narcotics signed out and they pointed to Agency Nurse #1. They began watching the video footage of 8/15/17 and 8/16/17 to compare sign out times with times Agency Nurse #1 entered resident rooms. When they found many discrepancies the Administrator contacted the staffing agency to request the nurse not be sent back to the facility. When she spoke to the Branch Manager and the Manager viewed the video footage, the nurse was terminated and reported to the Board of Nursing. In summary, Residents #1, #2, #3, #4,and #5 had [MEDICATION NAME] signed out on the Controlled Drug Record at various times but there was no corresponding documentation on the MAR of medication administration. The [MEDICATION NAME] was signed out consistently by Agency Nurse #1. Review of video footage showed her flipping through narcotic cards and the Controlled Drug Record and removing narcotics. The videos also failed to show Agency Nurse #1 entering the rooms of these residents at the times the medications were signed out. Residents #1, #2, #3, #4 who were alert and oriented, stated they received no [MEDICATION NAME] during the 11:00 PM - 7:00 AM shift but Agency Nurse #1 had signed out [MEDICATION NAME] as having been administered during that time. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #8 was discharged on [DATE]. Medical record review of Physician's admission orders [REDACTED]. Review of the facility investigation revealed on 3/13/17 at 2:00 AM Licensed Practical Nurses (LPN) #5 and #6 signed the Discontinued Narcotic Control Record that 27 tablets of [MEDICATION NAME] 5/325 mg were placed in the lock box. Continued review revealed on 3/21/17 the DON and Pharmacist signed the Discontinued Narcotic Control Record that the [MEDICATION NAME] was not destroyed. Further review revealed the card with 27 tablets of [MEDICATION NAME] was missing along with the sign-out sheet. Continued review revealed the medication room as well as the medication cart were searched and the card of [MEDICATION NAME] was not found. Further review revealed the two nurses who placed the card in the locked box and another nurse who had access to the box were all drug tested and were negative. Continued investigation revealed the previous Administrator has obtained a key to the lock box but was not available for drug testing. Review of a written statement from LPN #5 dated 3/21/17 revealed .on 3/13/17 (LPN #6) asked him to drop a narcotic card for a discharged patient, (Resident #8). The card contained [MEDICATION NAME] 5/325 mg #27 remaining in pack. This nurse opened top of discontinued narcotic box, the med card was inserted by the nurse (LPN #6) who then had to forcefully shut the door twice to get med to drop. Both nurses then verified med had dropped. This nurse locked door back and both nurses left the med room . Review of a written statement from LPN #6 revealed .I went to discard (Resident #8) [MEDICATION NAME] due to the resident being discharged . I and (LPN #5) went to the med room. I logged med into the book. (LPN #5) had key to drop box and unlocked box. (LPN #5) and myself both verified the amount of meds on card. Card was wrapped with the narcotic sheet and rubber band applied. Meds with sheet put into box. Med dropped and door slammed x 2. Med dropped down into box and (LPN #5) locked box. We both walked out of med room together . Review of a written statement from Registered Nurse (RN) #3 who was the only other person placing medications into the locked box revealed .On 3/13/17 I witnessed and documented a narcotic destruction with another nurse. The narcotic was placed in the narcotic box located in the medication room of the facility. All cards of narcotics removed from the cart dropped into the box. The narcotic box was locked back afterwards . Interview with LPN #6 on 9/12/17 at 6:45 AM at the nurses' station revealed she and LPN #5 disposed of the [MEDICATION NAME] from Resident #8. She completed the log while LPN #5 opened the lock box. They had a card of [MEDICATION NAME] with 27 pills remaining in it. They wrapped the sign-out sheet around the card of pills and secured it with a rubber band. They dropped the card in the box and heard it fall. LPN #5 locked the box and they both left the medication room. Interview with the Administrator on 9/13/17 at 2:20 PM in the Administrator's office revealed the three nurses were drug tested and were negative. Continued interview revealed the previous Administrator had Maintenance make him a key for the lock box but he had been terminated so could not be drug tested . Further interview confirmed the card and 27 pills were not located even after a completed search of the lock box, medication room, and medication carts. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #11 scored 12 on the BIMS, indicating she was slightly cognitively impaired. Medical record review of physician's orders [REDACTED].#11 was ordered [MEDICATION NAME] 10/325 mg every 8 hours as needed. Review of the Controlled Drug Record revealed 60 tablets of [MEDICATION NAME] 10/325 mg were delivered to the facility on [DATE]. Continued review of the record revealed under Quantity Received and Quantity Dispensed, the 60 had been overwritten with 30. Further review revealed the only withdrawal occurred on 9/5/17 by LPN #2. Review of the facility investigation revealed the Pharmacy was called and verified 60 tablets were delivered to the facility. The delivery manifest was given to the facility which showed 60 tablets delivered. The second card with 30 tablets of [MEDICATION NAME] and the Controlled Drug Record were missing and have not been located. Observation of Resident #11 on 9/13/17 at 9:35 AM revealed her in bed asleep with somewhat labored respirations and a dressing over her right eye from recent surgery. Interview with the Administrator on 9/13/17 at 2:20 PM confirmed medications had been misappropriated from residents.",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
345,"THE WATERS OF GALLATIN, LLC",445124,555 EAST BLEDSOE STREET,GALLATIN,TN,37066,2019-12-18,600,D,1,1,BPQR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview the facility failed to ensure 1 (#66) of 94 residents was free from abuse. Facility policy review Resident Rights & Facility Responsibilities, undated, revealed .The right to live in a caring environment free from abuse, mistreatment and neglect . Facility policy review Abuse Prevention Program, dated 1/19/17, revealed .It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property .This facility will not tolerate resident abuse or mistreatment by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies, family members, legal guardians, friends or other individuals . Review of facility investigation initiated on 11/11/19 revealed Resident #24 was observed with his hand on Resident #66's torso. Continued review revealed Resident #24 was removed and placed on 1 on 1 supervision and both residents were assessed by staff with no skin issues noted. Resident #24 was sent to local hospital for further evaluation with medication adjustments made; upon return to facility the resident was moved to a different unit to a private room. Continued review revealed staff were educated on abuse from 11/11/19 through 11/22/19. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident received a [DIAGNOSES REDACTED]. Medical record review of Resident #24's Order Summary Report dated (MONTH) 2019 revealed .[MEDICATION NAME] Sprinkles 125 MG (milligram) give 1 tablet at bedtime for sexual impulsivity 11/15/19 .Flutamide 250 mg one time daily at bedtime for sexual inappropriate behaviors 11/12/19 . Medical record review of Resident #24's History and Physical dated 11/12/19 revealed .Pt (patient) is being seen per nursing request. Pt has had an episode of sexually inappropriate behavior with another resident. Pt sent to ED (emergency department) for evaluation. He was found to have mild PNA (pneumonia) and is taking [MEDICATION NAME] 750 mg by mouth daily. He returned back to the facility and has been moved to another wing away from other resident . Medical record review of Resident #24's Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 6 indicating the resident had severe cognitive impairment. Continued review revealed the resident exhibited physical behaviors directed toward others 1-3 days of the 7 day look back period. Medical record review of Resident #24's comprehensive care plan dated 5/5/19 and revised on 10/15/19 revealed .the resident exhibits sexually inappropriate behavioral symptoms related to dementia. Behavioral symptoms are manifested by: making inappropriate comment toward staff members, attempting to get females to lie down in bed with him, grabbing staff members during care. Grabs nurses and sexual remarks . Medical record review revealed Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #66's MDS dated [DATE] revealed the resident was severely impaired for decision making. Continued review revealed the resident exhibited no behaviors. Medical record review of Resident #66's comprehensive care plan revealed the resident had communication impairment. Medical record review of an incident note for Resident #24 and #66 dated 11/11/19 revealed .around 17:20 - 17:25, I walked by female resident's room (Resident #66) (she was lying in bed) and noticed the resident (Resident #24) was in her room sitting in his w/c (wheel chair) beside the bed. The lights were off, so I turned the lights on as I walked in. the blanket was at the female resident's waist, her gown was around her neck and the resident had his left hand on her left breast. I immediately pulled him away, pulled the female resident's gown down and covered her with the blanket. I comforted and reassured the female resident, she was unable to tell me what happened, no obvious skin injury or other injury noted . Continued review revealed Resident #24 was taken to the nurse station and placed on 1 on 1 supervision. Interview with Resident #24 on 12/16/19 at 12:08 PM in his room revealed when asked if he touched Resident #24 on her breast he stated no, I don't remember that. Interview with the Administrator on 12/17/19 at 8:15 AM in her office revealed the facility unsubstantiated the allegation of abuse between Residents #24 and #66 due to both residents' cognition and there was no intent identified. Continued interview revealed the facility deemed the incident as a wandering, rummaging type of behavior. Telephone interview with Licensed Practical Nurse (LPN) #2 on 12/17/19 at 11:32 AM confirmed I was walking down the hall past (named) Resident #66's room when I saw another resident sitting in her room in a wheelchair beside her bed; I went into the room and turned on the light and she had her gown up close to her neck and (named) Resident #24 had his left hand on her left breast; I addressed him and he moved his hand. Continued interview she stated she removed the male resident to the hall way and assessed the female resident's skin with no issues identified. Continued interview revealed she placed the male resident in the main nurse station and notified the Assistant Director of Nursing. Continued interview revealed Resident #24 was placed on 1 on 1 supervision and was transferred to the hospital for further evaluation. Interview with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) on 12/17/19 at 1:14 PM in the DON's office revealed staff notified them of the incident on 11/11/19 with Resident #24 and #66. Continued interview the ADON confirmed (named) LPN #2 came to me and reported she found (named) Resident #24 in (named) Resident #66's room with his hand on her chest with her covers pulled back; I immediately notified the DON and the Administrator; (named) Resident was placed on 1 on 1 supervision and then sent to the hospital for evaluation.",2020-09-01
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
443,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2018-08-03,686,D,1,0,Q36011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview the facility failed to notify the physician of a new area of skin breakdown for 1 of 3 sampled residents (Resident #11) reviewed for pressure ulcer/injury to the skin. The findings include: The facility's Pressure Ulcer/Injury Risk Assessment policy revised (MONTH) (YEAR) documented, .Notify attending MD (medical doctor) if new skin alteration noted . The facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol policy revised (MONTH) 2014 documented, .The physician will authorize pertinent orders related to wound treatments .and application of topical agents if indicated for type of skin alteration . The facility's Pressure Ulcers/Injuries Overview policy revised (MONTH) (YEAR) documented, .Shearing occurs when layers of skin rub against each other or when the skin remains stationary and the underlying tissue moves and stretches and angulates or tears the underlying capillaries and blood vessels causing tissue damage . Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed the resident was sometimes understood with a cognitive score of 3 of 15 indicating severe cognitive impairment and the presence of disorganized thinking; required extensive assistance of 2 staff for bed mobility; was dependent for toileting;and was always incontinent of bowel and bladder. Review of the comprehensive plan of care initiated following the admission MDS assessment dated [DATE] and updated 7/24/18 revealed appropriate care plan interventions were implemented for assessed problems and needs which included risk for skin impairment related to incontinence, immobility, combativeness, resistance and refusal of care during personal care. Review of the C.N.[NAME] (Certified Nursing Assistant (CNA)) SKIN CARE ALERT dated 7/19/18 revealed a new red area was identified on Resident #11's right upper buttocks during bathing. Following the CNA notifying Licensed Practical Nurse (LPN) #2, the LPN documented her assessment findings in a SKIN OBSERVATION TOOL - (Licensed Nurse) dated 7/19/18. Review of her skin assessment revealed the resident's right and left buttocks had excoriated areas and documented, .two small areas of open areas smaller than a penny . There was no documentation in the nursing progress notes or physician telephone orders of the physician being notified of the change in the condition of the resident's skin or receipt of any orders for treatment of [REDACTED]. Review of a nursing progress note dated 7/23/18 revealed LPN #1, the wound care nurse, was notified of Resident #11's change in skin condition, assessed the skin, notified the Wound Physician and received new treatment orders. The Wound Physician would follow up to evaluate the resident's wound on 7/25/18. Review of a physican order dated 7/23/18 revealed orders for daily and as needed wound cleansing, treatment and dressing change. Review of a wound assessment follow up note by LPN #1 dated 7/29/18 revealed the resident's buttocks wounds and surrounding area of skin appeared to be caused by shearing and additional appropriate care plan interventions were put into place. Interview with the 4th floor Unit Manager (UM) and LPN #1 on 7/23/18 at 3:25 PM in the 4th floor UM office, the UM was asked about Resident #11's skin breakdown identified by the CNA on 7/19/18. The UM revealed, LPN #1 and the Wound Physician had evaluated Resident #11's skin on 7/18/18 and he had no wounds present at that time. The UM and LPN #1 were not notified of the resident's skin breakdown until 7/23/18. The UM revealed, according to her review of documentation and interview with staff on duty on 7/19/18, the CNA had documented and notified the nurse on duty of the appearance of Resident #11's skin and nursing documentation revealed open areas on his buttocks. The UM stated, .The nurse didn't reach out or document . LPN #1 was asked if Resident #11 was turned and repositioned. LPN #1 revealed the resident resisted turning and repositioning and braced his hands on the upper side rails, pushing against staff who were trying to reposition him. Interview with LPN #1 on 7/26/18 at 12:25 PM in the Chapel, when asked about Resident #11's change in skin condition identified on 7/19/18, LPN #1 confirmed the resident's prior buttock wound had healed on 6/13/18, and on 7/19/18 new areas on his buttocks were identified. LPN #1 stated the preventive barrier cream in use prior to the new skin breakdown was not an appropriate treatment for [REDACTED].#2 should have notified her or the physician of the change in condition. LPN #1 stated when she was made aware of Resident #11's skin condition on 7/23/18, she had assessed the resident's skin and contacted the Wound Physician for appropriate treatment orders. Interview with the Director of Nursing (DON) on 8/1/18 at 12:15 PM in the DON's office, when asked about the facility's protocol for notification of changes in residents' skin, the DON stated, .for open areas, the nurse should notify her (LPN #1) immediately or the physician .",2020-09-01
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
4679,GREENHILLS HEALTH AND REHABILITATION CENTER,445267,3939 HILLSBORO CIRCLE,NASHVILLE,TN,37215,2016-08-11,514,D,1,0,NRXS11,"**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 complete and accurate documentation for 1 (Resident #3) resident of 4 resident's reviewed. The findings included: Review of a facility policy titled Enteral Nutrition revised 1/13 revealed, .Key documentation elements: Type, amount, rate of feeding formula; Patency; Tolerance; Condition of stoma site; and Oral hygiene . Medical record review revealed Resident #3 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission assessment dated [DATE] revealed the resident had short and long-term memory loss, and had difficulty being understood by others. He had a Gastrointestinal Tube (GT) in his abdomen for feedings and medication administration, and he was totally dependent on staff for all Activities of Daily Living (ADL's). Medical record review of an Admission Nursing assessment dated [DATE] revealed no documentation for an incision or staples present for Resident #3. Medical record review of a Nursing Daily Skilled Charting note dated 4/16/16 revealed lung sounds were not documented; Cardiac and circulation were not documented; Feeding tube assessment was left unanswered; Mood and behavior were not documented; and no documentation of an incision or staples was present for Resident #3. Medical record review of a Nursing Daily Skilled Charting note dated 4/17/16 at 4:04 PM revealed LPN #1 documented the resident had a barrel chest. Continued review revealed no documentation of lung sounds, respiratory rate, or oxygen saturation. Continued review revealed the presence of a GT was left blank. The skin assessment was left blank. A nurses note documented, .staples intact to abd (abdomen) . Further review revealed the Skilled and Additional Services section was left blank. Medical record review of Enteral Feed Orders dated 4/15/16 revealed: Feeding: Administer [MEDICATION NAME] 1.5 (high protein nutrional supplement) per GT via Pump. Rate: 30 ml's/hr, (milliliters per hour), for 23 hours/day with water flush at 20 ml/hr. Care: Check tube for proper placement by visual inspection of aspirated stomach content prior to instilling medication, initiating a feeding or when there is an interruption of feeding or at least every shift for continuous feeding. Care: Elevate head of bed 30-45 degrees (semi-fowler's position) during feedings and at least 1 hour after feeding to prevent aspiration/pneumonia. Flush: Flush with 5-10 ml's H20 (water) between each medication. Hydration: Observe for signs of intolerance, i.e. diarrhea, N&V (nausea and vomiting), constipation, abdominal distention/cramping, dehydration, fluid overload, aspiration, increased gastric residual, hypo/hyper-glycemia (low or high blood sugar) every shift. Tube care: Inspect surrounding skin of stoma for redness, tenderness swelling irritation, purulent drainage, or signs of infection. Observe for [MEDICAL CONDITION], skin irritation. Tube care: Complete tube site care and change syringe daily. Medical record review of the Enteral Orders MAR/TAR (medical administration record and treatment administration record) for 4/16 for Resident #3 revealed no documentation the [MEDICATION NAME] tube feeding or water flush was administered; no documentation the GT was checked for proper placement; no documentation the head of bed was elevated 30-45 degrees during feeding; no documentation the GT was flushed between each medication; no documentation the resident was observed for signs of dehydration, intolerance, fluid overload or aspiration; no documentation the surrounding skin of the stoma was inspected for irritation, drainage or signs of infection; and no documentation the GT syringe was changed daily on 4/15/16 on the night shift, 4/16/16 on the day, evening, or night shift, or on 4/17/16 on the day shift. Interview with Licensed Practical Nurse (LPN) #1 on 8/10/16 at 11:33 AM in the Conference room confirmed she had cared for Resident #3 on 4/17/16 on the day shift (7 am-3:30 pm). When the LPN was shown the MAR/TAR for Enteral Orders she stated, I didn't know the Enteral Tube Feeding existed on EMar (Electronic Medical Administration Record). Continued interview revealed the LPN confirmed she had not completed the documentation on the Enteral Feed Orders MAR/TAR for Resident #3 on 4/17/16. Interview with the Director of Nursing (DON) on 8/10/16 at 2:30 PM in the conference room revealed when shown the Enteral Feed Order MAR/TAR for Resident #3 the DON stated, They still need more education on documentation. Continued interview revealed when shown the nursing admission assessment and daily skilled charting assessments for Resident #3 stated,They are not complete and they don't paint a clear picture of what happened to the resident. The DON confirmed the facility failed to provide complete and accurate documentation for Resident #3.",2019-08-01
1470,AHC CUMBERLAND,445262,4343 ASHLAND CITY HIGHWAY,NASHVILLE,TN,37218,2017-09-13,250,D,1,0,F0U711,"**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 medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 resident (#10) of 17 residents reviewed. The findings included: Review of facility policy, Social Services, dated (MONTH) (YEAR) revealed .Social workers are to provide support to the patient and their families and other individuals involved with the patient's care. Social workers are to be the patient's advocate to ensure they receive appropriate care and treatment . 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 had a Brief Interview for Mental Status of 4 indicating she was severely cognitively impaired. Further review revealed the resident had no impairment of the lower extremities and was not steady, only able to stabilize with staff assistance with moving from seated to standing position, moving on/off toilet and surface-to-surface transfer. Medical record review of a Clinical Note dated 5/18/17 revealed edema in right ankle. Resident #10 expressed facial grimaces when the nurse touched the ankle and declined to get out of bed. Medical record review of a Physician assessment dated [DATE] revealed .Pt's (patient's) rt (right) ankle swollen, erythemoatous, possible deformity noted. Very painful (with) palpitation. Pt doesn't recall any injury to ankle. Was called last night regarding pain to pts hip/ankle, ordered uric acid level for today which is (negative) will get xray . Medical record review of a Radiology Report dated 5/19/17 revealed .There are comminuted angulated and mildly displaced acute fractures of the distal tibia and distal fibula, well above the joint space. The bones are osteopenic. There appears to be narrowing of the ankle joint. No there acute fractures seen. No other incidental findings .Acute fracture of the distal tibia and fibula . Medical record review of a Clinical Note dated 5/19/17 revealed the Nurse Practitioner (NP) ordered an xray of the resident's right ankle. The findings showed comminuted and mildly displaced acute fracture of the tibia and fibula above the joint. The NP ordered the resident to be sent to Emergency Department (ED). Medical record review of an ED report dated 5/19/17 revealed Resident #10 had a .tib-fib (tibia-fibula) fracture . which was splinted. The resident was to follow-up with the Orthopedic Physician within 5 to 7 days. Review of a medical record report dated 7/21/17 revealed Resident #10 had a follow-up appointment with an orthopedic specialist. Further review revealed .She was seen on (MONTH) 19, (YEAR), when x-rays at nursing facility showed a right distal tibia fracture. She was placed in a splint, but unfortunately never followed up until this week. She is here with her daughter. I questioned her daughter why they never brought her back even with the followup information that I clearly showed her and that the daughter had with her today and the daughter says she just thought the nursing home would do it .when we touched her right leg, she started screaming .There is a procurvatum deformity at the right distal tibia and equinus flexion contracture of the ankle .Right distal third extraarticular tib-fib fracture sustained 2 months ago, was seen in the ER and told to followup and has not until now .patient is not an operative candidate. Will have to balance the orthopedic treatment for [REDACTED]. She may have a nonunion of the tibia that we treat with bracing long term .we will put her in a short leg cast for some stability at the fracture site. Hopefully this will stimulate some healing .will see her back in a month. We can cut cast off, get another set of x-rays and check on her symptoms. She may be a candidate for a molded removable splint, that may be a good long term option for her . Review of Resident #10's medical records from (MONTH) (YEAR) until Sept (YEAR) revealed the resident was never seen by social services. Review of a medical record dated 3/6/17 by social services revealed .(Resident #10) received mental health services on this date. A clinical noted has been provided and will be scanned into the system for staff review. This social worker will assist (Resident #10) with any social services needs as they arise . Interview with the Social Worker (SW) #1 on 9/12/17 at 4:30 PM in his office revealed he was responsible for making follow-up appointments. SW #1 stated he was not aware Resident #10 had a fracture. SW #1 confirmed he did not make Resident #10 a follow-up as ordered by the ED physician. SW #1 stated he had not seen Resident #10 from timeframe (MONTH) (YEAR)-July (YEAR). Interview with the Administrator on 9/12/17 at 4:42 PM in her office confirmed the facility failed to ensure Resident #10 received a follow-up orthopedic appointment as ordered. Interview with Administrator on 9/13/17 at 12:45 PM revealed she expected social services to have contact with residents at least quarterly if not more. The Administrator confirmed Resident #10 had not been assessed by Social Services from (MONTH) (YEAR)-September (YEAR). The Administrator confirmed the facility failed to provide medically related Social Services to attain or maintain the highest practicable physical, mental and psychosocial well-being for Resident #10.",2020-09-01
613,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-07-11,609,D,1,0,CCNJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, it was determined the facility failed to report allegations of abuse within 2 hours for 2 of 2 (Resident #1 and #2) sampled residents reviewed for alleged abuse. The findings include: The facility's Abuse, Neglect and Exploitation policy documented, .Report allegations or suspected abuse, neglect or exploitation immediately to State Agencies . Medical record review revealed Resident #1 was admitted to facility 6/20/18 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS), which indicated no cognitive impairment for decision making. Interview with Resident #1 on 7/9/19 at 11:00 AM, in the Social Service office, Resident #1 stated, He hit me in the back of the head two times so I let go of walker and his wheelchair fell backwards into the grass . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed Resident #2 scored 15 on the BIMS, which indicated no cognitive impairment for decision making. Review of the Occurrence Report dated 6/20/19 documented, .(Resident #2) was push (pushed) by another resident (#1) causing wheel (wheelchair) to go off pavement cause (causing) him (Resident #2) to fall . Interview with the Director of Nursing (DON) on 7/11/19 at 1:00 PM, in her office, the DON confirmed the date of the incident was 6/20/19 and was not reported until 6/22/19. The DON was asked if the alleged abuse was reported timely. The DON stated, Probably not.",2020-09-01
814,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2018-02-23,656,D,1,0,42HQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to develop a plan of care to address moods for 1 of 7 samples residents (Resident #6). Findings include: Review of the undated facility policy MDS/Care Plans revealed .The facility must develop a comprehensive care plan to meet a resident's .needs . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed adequate hearing and vision, clear speech, usually made self understood, and understood others; Brief Interview for Mental Status (BIMS) was 13/15, indicating he was cognitively intact, and exhibited little interest, feeling down/depressed, tired, and change of appetite for 2-6 days of the review period. Medical review of the Quarterly MDS dated [DATE] revealed the BIMS score of 14/15; and exhibited feeling down/depressed for 2-6 days of the review period. Medical record review of the care plan with completion date of 11/30/17 and revised in 1/19/18 revealed feeling down/depressed and tired were not addressed. Interview with the Registered Nurse (RN) #1/ MDS Coordinator on 2/21/18 at 8:45 AM in the conference room confirmed the care plan with completion date of 11/30/17 failed to address the resident was down/depressed and tired. Further interview confirmed the care plan with the completion date of 1/19/18 failed to address feeling down/depressed.",2020-09-01
846,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-09-25,626,D,1,0,GEY211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to document its inability to meet the resident's needs for 1 (#5) of 7 residents reviewed for Admission/Transfer/Discharge criteria. The findings include: Review of facility policy, Transfer Agreement, revised 3/2017, revealed .Our facility has a transfer agreement in place with a designated hospital should our residents need care that is beyond the scope of our available care and services .The agreement ensures that residents are transferred from the facility to the hospital and admitted in a timely manner in an emergency situation by another practitioner .The agreement specifies restrictions with respect to the types of services available and types of residents or health conditions that will not be accepted by the hospital or the facility .Inquiries related to the transfer agreement should be referred to the Administrator . Medical record review revealed Resident #5 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 scored 15 on the Brief Interview for Mental Status (BIMS) indicating he was alert, oriented, and able to make his needs known. Continued review of the MDS revealed Resident #5 was dependent on 2 people for transfers and bathing; required extensive assistance of 2 people with bed mobility, dressing, toileting, and grooming; and was frequently incontinent of bowel and bladder. Medical record review revealed multiple episodes of refusing care; yelling and cursing at staff; family trying to use a mechanical lift to transfer him without staff being present; and family bringing in medications and other materials not associated with his care. Medical record review revealed Resident #5 was sent to the hospital with unresponsiveness and the facility refused to allow him to return due to inability to meet his needs. Medical record review revealed no documentation the Ombudsman was notified of the Residents discharge. Medical record review revealed no documentation in the record of the specific needs which could not be met at the facility; attempts made by the facility to meet those needs, or the services another facility could provide. This failure of documentation was confirmed by the Administrator on 9/25/19 at 4:40 PM in the conference room.",2020-09-01
4971,LIFE CARE CENTER OF MORRISTOWN,445314,501 WEST ECONOMY ROAD,MORRISTOWN,TN,37814,2016-06-15,333,G,1,0,SVOA11,"**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 (#174) was free from significant medication errors, of 6 residents reviewed for medication administration of 27 residents reviewed. This failure resulted in Harm to Resident #174. The findings included: Review of Clinical Services Policies & Procedures, Nursing Volume 1, physician's orders [REDACTED].to ensure accurate delivery of medications .confirm that the order is correct . Medical record review revealed Resident #174 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5 Day Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (a test for cognitive ability) score of 14, indicating the resident was cognitively intact. Medical record review of Resident #174's admission orders [REDACTED]. Medical record review of a Physician/Prescriber order per fax dated 6/29/15 revealed .Glimiperide (oral diabetes medication) 1 mg (millegram) PO (by mouth) BID (twice a day) (Hold if FS (finger stick blood sugar reading by glucometer) = (less than or equal to) 100 . Medical record review of the Fax order request/notification form dated 6/29/15 revealed . OK (with) Glimiperide (Hold if FS = 100) . Medical record review of the Medication Administration Record (MAR) for 6/15 and 7/15 revealed, .Glimiperide 1 mg po BID start 6/29/15 9:00 AM 5:00 PM . Medical record review of the Sliding Scale Insulin Form, dated 7/15, on which the finger stick blood sugars were documented, revealed on 7/2/15 at 6:00 AM Resident #174 had a blood sugar of 91. Continued review revealed at 4:00 PM the resident's blood sugar was 74. Continue review revealed no documentation to hold Glimiperide 1 mg po if the finger stick blood sugars were 100 or less. Medical record review of Resident #174's Medication Administration Record (MAR) dated 6/15 and 7/15 revealed .Glimiperide 1 mg po BID start 6/29/15 9 am 5 pm . Further review revealed the Glimiperide 1 mg po had been given at 9:00 AM on 7/2/15 with a 6:00 AM finger stick blood sugar reading of 91. Continued review revealed the Glimiperide 1 mg po had been given at 5:00 PM on 7/2/15 with a 4:00 PM finger stick blood sugar reading of 74. Continued review revealed the Glimiperide had not been held as ordered by the physician. Continued review revealed no instruction documented on the MAR to hold Glimiperide 1 mg po bid if finger stick blood sugar reading was equal to or less than 100. Medical record review of a Resident #174's electronic Nurses Note dated 7/2/15 and entered at 10:56 PM revealed .less responsive, drooling from right side of mouth. No hand grips .Checked pt blood sugar .read 72. Transported by .EMS (Emergency Medical Service) .Sent out at 8:45 pm. Medical record review of EMS records dated 7/2/15 at 8:49 PM revealed, .upon arrival found unresponsive female setting in wheel chair .nursing staff said they had checked her blood sugar and read 72 .ordering [MEDICATION NAME] to be given .Meds given and blood sugar checked and read 31 . Continued review revealed EMS transported the resident to a local hospital emergency department. Medical record review of the emergency room documentation dated 7/2/15 at 10:17 PM revealed .The patient presents with confusion, decreased mental status, decreased responsiveness . Continued review revealed at 11:20 PM the blood glucose was 31, with a critical range of less than 40. Continued review revealed Resident #174 was admitted to the hospital, with preliminary [DIAGNOSES REDACTED]. Interview with the Director of Nursing on 6/15/16 at 12:52 PM in the conference room confirmed Glimiperide 1 mg po BID (Hold if FS = 100) was incorrectly transcribed on to the MAR, was administered incorrectly and resulted in Harm to Resident #174. Telephone interview with Resident #174's Primary Care Physician on 6/15/16 at 1:00 PM in the conference confirmed Glimiperide 1 mg po BID should not have been administered with finger sticks of 91 and 74 on 7/2/15 and the facility failed to follow the physician order. This facilities' failure to correctly administer the Glimiperide resulted in Harm to Resident #174.",2019-06-01
3341,LIFE CARE CENTER OF OLD HICKORY VILLAGE,445509,1250 ROBINSON ROAD,OLD HICKORY,TN,37138,2017-06-07,333,E,1,0,RZM511,"**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 (#2) was free from significant medication errors, of 4 residents' records reviewed for accurate admission medication administration. The findings included: Review of Clinical Services Policies & Procedures, Nursing Volume 1, physician's orders [REDACTED].to ensure accurate delivery of medications .confirm that the order is correct . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission assessment Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (a test for cognitive ability) score of 13, indicating the resident was cognitively intact. Medical record review of Resident #2's Discharge Medications Orders from recent hospital admission and return to the facilty 3/18/17 revealed .[MEDICATION NAME] (TRADE NAME: [MEDICATION NAME]) 400 MG ORAL TWICE DAILY .[MEDICATION NAME] (TRADE NAME: [MEDICATION NAME]) 125 MCG ORAL DAILY .TRAVOPROST (TRADE NAME: [MEDICATION NAME] Z 0.004% Ophth Drops) 1 DROP EACH EYE BEDTIME . Medical record review of the Physician order [REDACTED].[MEDICATION NAME] (Trade name: [MEDICATION NAME]) 112 MCG .PO (oral) DAILY .[MEDICATION NAME] (Trade name: [MEDICATION NAME]) 2% - 0.5% ophth drops) Left eye only Intraocular daily . No orders noted for [MEDICATION NAME] (TRADE NAME: [MEDICATION NAME]) 400 MG ORAL TWICE DAILY, [MEDICATION NAME] (TRADE NAME: [MEDICATION NAME]) 125 MCG ORAL DAILY or TRAVOPROST (TRADE NAME: [MEDICATION NAME] Z 0.004% Ophth Drops) 1 DROP EACH EYE BEDTIME. Medical record review of the Medication Administation Record (MAR) 3/18/2017 2:04 PM revealed administration of [MEDICATION NAME] (Travoprost) Drops Left eye only Inraocular daily from 3/19/17 throught 3/24/17 and [MEDICATION NAME] ([MEDICATION NAME]) 112 mcg po daily. Medical record review of a laboratory report collected 3/24/17 revealed TSH ([MEDICAL CONDITION] stimulating hormone) 11.72 (H) (high) Reference Range 0.35 - 5.50. Medical record review of Physician order [REDACTED]. Medical record review of the physician's orders [REDACTED].Send only Brand Name [MEDICATION NAME] for [MEDICATION NAME] 125 cg PO QD .Travoprost ([MEDICATION NAME] 0.004% opth) Administer 1 drop in each eye @ HS .Aminodarone 400 mg PO QD - hold HR Apical Medical record review of the Medication Administration Record [REDACTED].[MEDICATION NAME] 400 mg po qd - Hold for Apical Heart Rate Medical record review of the MAR beginning 3/26/17 revealed .Check VS (vital signs) q (every) 2 (hours) x 24 (hours) *take manually* . 4 PM . (last vital signs for q 2 hours completed on 3/27/17) 4 PM . No documentation of Resident #2's heart rate being less than 60 beats per minute. Interview with the Director of Nursing on 6/6/17 at 9:24 AM in the conference room confirmed the facility failed to accurately transcribe a physician's orders [REDACTED].#2 was readmitted to the facility on [DATE]. Continued interview confirmed the facility failed to ensure Resident #2 was free of a significant medication error.",2020-09-01
3468,CHRISTIAN CARE CENTER OF MEMPHIS,445522,6500 KIRBY GATE BOULEVARD,MEMPHIS,TN,38119,2018-04-02,760,E,1,0,JLWX11,"**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 2 of 3 (Resident #1 and 5) sampled residents with physician ordered anticoagulant medication were free from significant medication errors. The findings included: 1. The facility's Emergency Pharmacy Service policy documented, Emergency pharmaceutical service will be available on a 24-hour basis. Emergency needs for medication will be met by using the facility's approved emergency drug kit (EDK) or special order from the pharmacy supplier . 2. Medical record review revealed Resident #1 was admitted to the facility 3/9/18 with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED].#1 was to receive [MEDICATION NAME] (anticoagulant medication) 70 milligrams (mg) subcutaneously twice daily at 6:00 AM and 6:00 PM. Review of the Medication Administration Record [REDACTED]. The nurse documented, .Held due to not available. reordered (Reordered) from pharm (pharmacy) . Observations in Resident #1's room on 3/26/18 at 5:15 PM, revealed the resident was alert and oriented to person and place and had difficulty speaking clearly and fluidly due to [MEDICAL CONDITION]. Paresis (weakness or paralysis) was noted on the resident's right upper and lower extremities. A family member was present and assisted during the interview with the resident's permission. There was no evidence of a negative outcome due to the missed dose of [MEDICATION NAME]. Interview with Resident #1 and a family member in the resident's room on 3/26/18 at 5:15 PM, this Surveyor was informed the resident had missed her 6:00 AM (morning) dose of [MEDICATION NAME] because it was not available in the medication cart and had to be ordered from pharmacy. Interview with the Complainant in the conference room on 3/26/18 at 8:05 PM, this Surveyor was informed the missed AM dose of [MEDICATION NAME] had been available in the facility's EDK but the nurse had failed to use the emergency supply. 3. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. The nurse had documented on 3/18/18, .Held due to not available; pharmacy notified . On 3/20/18 the nurse had documented, .Held due to Not available . Observations in Resident #5's room on 3/31/18 at 10:45 AM, revealed the resident to be resting quietly in bed, eyes closed, respirations regular and unlabored. There was no evidence of a negative outcome due to the missed doses of [MEDICATION NAME]. Interview with the Director of Nursing (DON) in the conference room on 3/31/18 at 9:10 AM, when asked about availability of [MEDICATION NAME] in the EDK, the DON confirmed the medication was available, nurses were trained to use the EDK and were given an access code by the pharmacy during the new hire orientation period. Observations and interview with the Licensed Practical Nurse (LPN) Supervisor in the medication room on 3/31/18 at 11:00 AM, confirmed the EDK to be fully functional and [MEDICATION NAME] was available for administration if needed.",2020-09-01
3342,LIFE CARE CENTER OF OLD HICKORY VILLAGE,445509,1250 ROBINSON ROAD,OLD HICKORY,TN,37138,2017-06-07,425,D,1,0,RZM511,"**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 procedures were in place to provide accurate medication transcription, for 1 resident (#2), of 4 residents reviewed for accurate medication administration. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's Discharge Medications Orders from recent hospital admission and return to the facilty 3/18/17 revealed .AMIODARONE (TRADE NAME: Cordarone) 400 MG ORAL TWICE DAILY .LEVOTHYROXINE (TRADE NAME: Synthroid) 125 MCG ORAL DAILY .TRAVOPROST (TRADE NAME: Travatan Z 0.004% Ophth Drops) 1 DROP EACH EYE BEDTIME . Medical record review of the Physician order [REDACTED].LEVOTHYROXINE (Trade name: Synthroid) 112 MCG .PO (oral) DAILY .Cosopt (Trade name: Travatan) 2% - 0.5% ophth drops) Left eye only Intraocular daily . Continued review revealed no orders noted for AMIODARONE (TRADE NAME: Cordarone) 400 MG ORAL TWICE DAILY, LEVOTHYROXINE (TRADE NAME: Synthroid) 125 MCG ORAL DAILY or TRAVOPROST (TRADE NAME: Travatan Z 0.004% Ophth Drops) 1 DROP EACH EYE BEDTIME. Medical record review of the Medication Administation Record (MAR) 3/18/2017 2:04 PM revealed administration of Cosopt (Travoprost) Drops Left eye only Inraocular daily from 3/19/17 throught 3/24/17 and levothyroxine (Synthroid) 112 mcg po daily. Medical record review of a laboratory report collected 3/24/17 revealed TSH (thyroid stimulating hormone) 11.72 (H) (high) Reference Range 0.35 - 5.50. Medical record review of Physician order [REDACTED]. Medical record review of the physician's orders [REDACTED].Send only Brand Name Synthroid for Levothyroxine 125 cg PO QD .Travoprost (Travatan 0.004% opth) Administer 1 drop in each eye @ HS .Aminodarone 400 mg PO QD - hold HR Apical Medical record review of the Medication Administration Record [REDACTED].Amiodarone 400 mg po qd - Hold for Apical Heart Rate Medical record review of the MAR beginning 3/26/17 revealed .Check VS (vital signs) q (every) 2 (hours) x 24 (hours) *take manually* . 4 PM . (last vital signs for q 2 hours completed on 3/27/17) 4 PM . No documentation of Resident #2's heart rate being less than 60 beats per minute. Interview with the Director of Nursing on 6/6/17 at 9:24 AM in the conference room confirmed the facility failed to accurately transcribe a physician's orders [REDACTED].#2 was readmitted to the facility on [DATE]. Continued interview confirmed the facility failed to ensure medication transcription procedures were accurate and complete.",2020-09-01
1513,GREEN HILLS CENTER FOR REHABILITATION AND HEALING,445267,3939 HILLSBORO CIRCLE,NASHVILLE,TN,37215,2019-02-13,622,D,1,1,7IKK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to facilitate a safe discharge to home for 1 of 3 residents (#288) reviewed for discharge. The findings include: Review of the facility policy, Transfer and Discharge Procedure, dated 12/2017 revealed .Transfer and discharge procedures must provide sufficient preparation and orientation of the resident to ensure a safe, orderly transfer or discharge from the facility . Medical record review revealed Resident #288 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #288 had a Brief Interview for Mental Status score of 13 indicating no cognitive impairment. Further review revealed the resident was on a mechanical altered diet, enteral feeding and required extensive assistance with two people for eating. Medical record review of the Physician Telephone Orders dated 10/30/18 revealed .Hospital bed with air mattress: DME (Durable Medical Equipment), [DIAGNOSES REDACTED].Discharge home on 11/2/18 Foley cath (catheter) by home health PRN (as needed) . Medical record review of the MDS dated [DATE] revealed Resident #288 was discharged to the community on 11/2/18. Medical record review of the Orders Only Report dated 11/3/18 revealed .presents to the ED (Emergency Department) complaining of not having all the equipment he needs to feed himself. Per EMS (Emergency Management Services) he was discharged yesterday from rehab (rehabilitation) with a peg tube in place, and his tube remains in place and he has the food he needs, however he doesn't have a pump for the tube .He states that his tube feeds come in bags which makes it impossible for him to use syringes to feed himself, requiring a pump that will arrive at his house on Monday . Telephone interview with the Care Manager on 2/11/19 at 3:09 PM revealed she had placed a call to Resident #288 fiance on 11/3/18 to check if the resident had .everything he needed . Continued interview revealed the Fiance reported to the Case Manager Resident #288 was sent home with .no feeding pump, feeding formula, and the home health orders were not signed . Continued interview revealed the Case Manager made multiple calls to the facility and did not receive a call back. Interview with the Social Worker on 2/11/19 at 5:04 PM in his office revealed when asked who was responsible for implementing the discharge orders and follow up care, the Social Worker stated .I get the orders signed, and I have to get them signed before I send them out to the DME and home health agency. I wait closer to discharge to send signed orders to the home health agency and DME. I send the demographics to the home health agency to see if they will accept the patient. If they accept the patient I wait closer to discharge to send orders especially if there are any changes to the orders . Continued interview revealed .what was not on the order was the feeding tube, the pump, and feeding. I did not know those items would not be available to him when he got home . Interview with Registered Nurse (RN) #3 also known as the Unit Manager on 2/11/19 at 6:00 PM in her office revealed, when asked who was responsible for implementing the discharge orders and follow up care, the RN stated .The social worker tells us they are going home on care (home health care), we get an order from the doctor, nursing is suppose to know if they (home health agency) need tube feeding. I thought every thing would be sent to his home. Nursing is responsible for tube feeding and education of the feeding . Telephone interview with the Home Health Agency Nurse on 2/12/19 at 11:07 AM revealed she went into the home on 11/3/18 and discovered Resident #288 needed enteral feedings. Continued interview revealed the Fiance mistakenly identified the Hematologist (specializes, diagnose, treat and prevent blood disorders) as the PCP (Primary Care Physician). Continued interview revealed the Home Health Nurse needed orders for the feeding pump, the rate, amount, and supplies. The Home Health Nurse stated .usually that would have been delivered to the home. It should have been (delivered) before he got in the home . Continued interview with the Home Health Nurse revealed .the problem was I couldn't get the feeding pump in right then and there. I suggested for him to go to the ER (emergency room ) due to him already not having any feeding, and was worried about dehydration . Telephone interview with the Fiance on 2/12/19 at 12:31 PM revealed when Resident #288 was discharged from the nursing home he was discharged home with no feeding pump and formula. Continued interview revealed she had to go back to the facility to pick up the resident's belongings and 3 bottles of tube feeding. Continued interview revealed the Home Health Agency Nurse came to the home and saw Resident #288 without the feeding pump and suggested Resident #288 go the emergency room because .she did not want him to wait till Monday to get the feeding . Interview with the Administrator on 2/13/19 at 11:58 AM in his office revealed . Resident #288 was here on a brief stay. We got him signed up with home health orders, and we sent him home with tube feeding. The issue was the physician that we were told was the PCP, we got the information from the fiance, and when the home care agency reached out to the physician it was not the PCP. The physician did not want to be his PCP just his Hematologist physician. I suggested he come back to the facility. I can't tell you if we had any dialogue with the home health agency prior . Interview with the Administrator on 2/13/19 at 2:28 PM in his office when asked if he could produce the documents supporting the orders regarding enteral feeding, the feeding pump and supplies he replied .That is all I have .",2020-09-01
4142,MT PLEASANT HEALTHCARE AND REHABILITATION,445374,904 HIDDEN ACRES DR,MOUNT PLEASANT,TN,38474,2016-11-03,226,J,1,0,J51L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to implement the abuse policy when 3 Certified Nurse Aides were aware a swallow-impaired, aspiration-risk resident was force fed food and fluid by a syringe for 1 resident (#1) of 6 residents who were totally dependent on staff for eating. This failure placed all residents at risk for aspiration and requiring total dependence on staff for eating 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 of a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on [DATE] at 3:00 PM in the Administrator's office. F226 is Substandard Quality of Care The findings included: Review of policy, Abuse Prevention/Reporting Policy and Procedure, revised [DATE], revealed .Every resident has the right to be free from .neglect .Definitions 6. Negligence: Failing to properly care for a resident in a manner conducive to professional care standards. 7. Neglect: failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness .Abuse Prevention Procedures .Prevention 5. Staff will be provided with information regarding the process for reporting a witnessed abuse, suspected abuse .Staff will be provided through education .the process for reporting abuse to their immediate Supervisor, Abuse Coordinator, local authorities and State department of health . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 60 day Minimum (MDS) data set [DATE] revealed Resident #1 had adequate hearing, clear speech, could make self understood, was able to understand others, was severely cognitively impaired per the ,[DATE] score on the Brief Interview for Mental Status, was totally dependent with one person assist for eating, had no swallowing disorder, and received 95 minutes of speech therapy. Medical record review of the Speech Therapy (ST) Evaluation and Plan of Treatment dated [DATE] revealed Resident #1 had mildly impaired swallowing abilities, and the Assessment for Swallowing section documented .Clinical S/S (signs and symptoms) of Dysphagia (swallowing difficulty): effortful mastication (chewing process) . The ST Recertification and Update of Treatment Plan dated [DATE] to [DATE] revealed the skilled services provided was dysphagia therapy and the diet was changed to pureed (blenderized food) due to pocketing (food getting stuck in mouth), increased feeding time and lethargy. Further review revealed Resident #1 had used general swallowing techniques/precautions and upright posture during meals 70% (percent) of the time by [DATE], was tolerating the pureed diet while fed by staff, caregiver/staff were educated on safe swallowing strategies including bite/sip, small bites, and positioning. The swallowing treatment training included small bites/sips (,[DATE] to ,[DATE] teaspoon) and facilitation of body positioning to increase safety with intake. Resident #1's Swallow Ability was moderately impaired, and had declined since the initial evaluation when he was mildly impaired. Medical record review of the Progress Notes revealed the following: [DATE] at 11:30 PM .No further emesis noted, had earlier after lunch x (times) 1. Afebrile . [DATE] at 2:15 PM .Moderately large emesis noted during activity in dining room. Afebrile . [DATE] at .1:30 PM Res (resident) consumed 100% of meal with asst (assist) with no dysphagia. Res vomited very large amt (amount) of liquid et (and) pureed food. Res entered Cheyne-Stokes (abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing) respirations et was unresponsive. Nurse at this x (time) went to supply closet to obtain suction equipment .at 1:34 PM Re-entered room. Noted absence of pulse, B/P (blood pressure) et respirations. Skin pale/gray et cool to touch. RN (Registered Nurse) #1 Supervisor notified .at 1:40 PM Pronounced deceased . Interviews with Licensed Practical Nurse (LPN) #5 on [DATE] at 2:55 PM and at 4:25 PM on the long hall and the conference room, [DATE] at 11:10 AM in the conference room, [DATE] at 4:10 PM in the conference room, and on [DATE] at 8:30 AM, on the long hall revealed Resident #1 had general decline as time passed including pocketing food, had ,[DATE] vomiting episodes after eating, had .fed (Resident #1) Magic Cup (nutritional supplement) and fluids ,[DATE] times by syringe .a couple of months before hospice started .I gave Magic Cup and water by syringe the morning of [DATE] . and (Resident #1) .wanted water and could no longer suck on a straw .I didn't want him dehydrated .because not able to suck through straw and when you held a cup to the lips the resident could blow into it so I tried a syringe, he knew to swallow once something in mouth . When asked what Certified Nurse Aide (CNA) #4 was doing when the LPN entered the resident's room on [DATE] at lunch, the LPN stated the CNA .was spoon feeding the resident lunch and I told her there was a syringe available if she needed it . When asked why the LPN used the syringe the LPN stated .I was trying to help the man out, I don't know if (CNA #4) was trained to use syringe . Interviews with CNA #4 on [DATE] at 9:25 AM and [DATE] at 10:15 AM and 12:35 PM, in the conference room and the nursing station revealed CNA #4 had been spoon feeding Resident #1 lunch on [DATE] when LPN #5 entered the resident's room and informed the CNA .syringe in drawer and she told me to try to use it. I got syringe out, liquefied the pureed food with the fluid on the tray and put a little in his mouth, he swallowed, I asked if he wanted more and he said 'Uh Huh', I took my time feeding him and he ate all the food, 100% and when I was done feeding he started vomiting. His head of bed was up but I put it up as high as it could go and yelled for help. (CNA #1) came to room and she yelled for (LPN #5) to come to room . (LPN #5) and (RN #1) came in the room .resident had thrown up so bad and stopped breathing . When asked when she was spoon feeding the resident lunch how had the resident been accepting the food by mouth, the CNA stated .he wasn't taking it like before . When asked why she used the syringe, CNA #4 stated .(LPN #5) told her the LPN had been using the syringe throughout the day with magic cup and juice and he did fine . When asked what happened to the syringe, CNA #4 stated .(CNA #1) told her that (LPN #5) told (CNA #1) to tell (CNA #4) to get the syringe out of there, I threw it in the trash in the resident's room then I removed it and took it to the hopper room trash . Interview with CNA #7 on [DATE] at 9:15 AM, in the conference room revealed when asked if she was aware of a syringe being used, the CNA stated .The first time I saw the syringe was at lunch when (CNA #4) was using it to feed (Resident #1) and I turned and left the room .I went and told (CNA #3) what I had seen .I knew we don't do that syringe feeding . When asked if CNA #7 reported the syringe to supervisors, the CNA stated No, I went back to caring for my residents .I knew we had no physician orders .I don't know why I didn't tell the Charge Nurse .I knew it was wrong to feed with a syringe . Interview with CNA #3 on [DATE] at 11:20 AM, in the conference room revealed when asked what she knew about a syringe being used, the CNA stated .(CNA #7) came to room I was at and said she walked in (Resident #1's) room and saw (CNA #4) feeding him with a syringe. I said 'She what?' and then (CNA #7) left the room and I went on feeding my resident. When I got done with my resident I went to (Resident #1's) room but he had passed . Further interview revealed, when asked if she had reported the use of the syringe to supervisors she stated No. Interviews with the Director of Nursing (DON) on [DATE] at 3:40 PM, [DATE] at 10:50 AM and 4:40 PM, [DATE] at 12:53 PM, and on [DATE] at 8:35 AM and 1:45 PM, in the conference room revealed the facility did not have a policy on syringe feeding a resident, and did not have a policy on aspiration/aspiration precautions. Further interview revealed the DON was not aware a syringe was being used to feed a resident prior to the event. When asked if the DON was aware (CNA #7) had seen (CNA #4) using the syringe to feed (Resident #1) on [DATE] and then (CNA #7) told (CNA #3) what she had seen and none of the CNAs had reported the syringe use stated No, I didn't know that. Refer to F154 J, F155 J, F157 J, F224 J SQC, F225 J SQC",2019-11-01
1718,FAIRPARK HEALTH AND REHABILITATION,445286,307 N FIFTH ST BOX 5477,MARYVILLE,TN,37801,2018-01-19,842,F,1,0,8BQY11,"**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 a complete and accurate medical record for 7 residents (#1, #2, #3, #5, #6, #7, and #8) of 8 residents reviewed for activities of daily living (ADLs). The findings included: Review of the facility policy Documentation of Resident's Health Status, Needs and Services dated [DATE] and updated [DATE] revealed, .Rationale .The resident's record is a continuing account of the resident's health status and needs .if care item is not completed for that day .document time, date, and reason the care was not given (e.g, resident refused shower etc.) including any re-attempts at care .record supportive documentation in the resident's progress notes . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #1 expired on [DATE]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of ,[DATE] indicating the resident was severely cognitively impaired. Continued review revealed Resident #1 required extensive assistance with 2 or more staff for bed mobility and physical help with 1 person in part of bathing activity. Medical record review of the ADL (Activities of Daily Living) Flow Record and Documentation Survey Report, both dated (MONTH) (YEAR), revealed Resident #1 received a bath on [DATE], [DATE] and [DATE]. Review of Resident #1's medical record from (MONTH) through (MONTH) (YEAR) revealed no further documentation regarding baths. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE] revealed Resident #2 had a BIMS score of ,[DATE] indicating the resident was cognitively intact. Continued review revealed Resident #2 was independent with 1 person physical assistance for bed mobility. Medical record review of the Documentation Survey Report dated (MONTH) (YEAR) revealed Resident #2 received a bath on [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of Resident #2's medical record from (MONTH) through (MONTH) (YEAR) revealed no further documentation regarding baths. 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 had a BIMS score of ,[DATE] indicating the resident was cognitively intact. Continued review revealed Resident #2 required extensive assistance with 1 person physical assist for bed mobility and physical help in part for bathing. Medical record review of the Documentation Survey Report dated (MONTH) (YEAR) revealed Resident #3 received a bath on ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. Medical record review of the Documentation Survey Report dated (MONTH) (YEAR) revealed Resident #3 received a bath on ,[DATE], ,[DATE], ,[DATE], and ,[DATE]. Review of Resident #3's medical record from (MONTH) through (MONTH) (YEAR) revealed no further documentation regarding baths. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Unscheduled Assessment MDS dated [DATE] revealed Resident #5 had a BIMS score of ,[DATE] indicating the resident was severely cognitively impaired. Continued review revealed Resident #5 was totally dependent on 2 person physical assist for bed mobility and transfers. Medical record review of the ADL Flow Record and Documentation Survey Report, both dated (MONTH) (YEAR), revealed Resident #5 received 1 bath on [DATE]. Review of Resident #5's medical record from (MONTH) through (MONTH) (YEAR) revealed no further documentation regarding baths. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of ,[DATE] indicating Resident #6 was severely cognitively impaired. Continued review revealed Resident #6 was totally dependent on 2 person physical assist for all ADLs. Medical record review of the ADL Flow Record and Documentation Survey Report, both dated (MONTH) (YEAR), revealed Resident #6 received a bath on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of Resident #6's medical record from (MONTH) through (MONTH) (YEAR) revealed no further documentation regarding baths. 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 a BIMS score of ,[DATE], indicating Resident #7 was severely cognitively impaired. Continued review revealed Resident #7 required extensive assistance with 2 person physical assist for bed mobility and totally dependent on staff for bathing. Medical record review of the ADL Flow Record and Documentation Survey Report, both dated (MONTH) (YEAR), revealed Resident #7 received a bath on [DATE], [DATE], and [DATE]. Medical record review of the Documentation Survey Report dated (MONTH) (YEAR) revealed Resident #7 received a bath on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Medical record review of the Documentation Survey Report dated (MONTH) (YEAR) revealed Resident #7 received a bath on [DATE], [DATE], [DATE], [DATE], and [DATE]. Medical record review of the Documentation Survey Report dated (MONTH) (YEAR) revealed Resident #7 received 1 bath on [DATE]. Review of Resident #7's medical record from (MONTH) through (MONTH) (YEAR) revealed no further documentation regarding baths. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of ,[DATE], indicating Resident #8 was severely cognitively impaired. Continued review revealed Resident #8 required limited 1 person physical assist for bed mobility and physical help with 1 person in part of bathing activity. Medical record review of the ADL Flow Record and Documentation Survey Report, both dated (MONTH) (YEAR), revealed Resident #8 received a bath on [DATE], [DATE], [DATE], [DATE], and [DATE]. Medical record review of the Documentation Survey Report dated (MONTH) (YEAR) revealed Resident #8 received a bath on [DATE], [DATE], [DATE], and [DATE]. Medical record review of the Documentation Survey Report dated (MONTH) (YEAR) revealed Resident #8 received a bath on [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of Resident #8's medical record from (MONTH) through (MONTH) (YEAR) revealed no further documentation regarding baths. Interview with the Administrator on [DATE] at 11:25 AM, in the conference room, confirmed the facility failed to maintain complete and accurate medical records for Resident #1, #2, #3, #5, #7, and #8. Continued interview confirmed the facility failed to follow their policy on documentation of tasks, specifically resident baths.",2020-09-01
719,GOOD SAMARITAN HEALTH AND REHAB CENTER,445170,500 HICKORY HOLLOW TERRACE,ANTIOCH,TN,37013,2019-01-08,842,D,1,0,KGXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to maintain complete and accurate medical record for 1 resident (#1) of 3 records reviewed. The findings include: Review of the facility policy, Medication Administration, dated 1/15/12, revealed .Medications shall be administered .as prescribed .The individual administering the medication must initial the resident's Medication Administration Record (MAR) on the appropriate line after giving the medication . Medical record review revealed Resident #1 was admitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. The resident was discharged to an acute hospital on [DATE]. Medical record review of Resident #1's Pain Tool form dated 12/6/18 revealed the location of pain in right and left knees (front), pain was relieved by Tylenol 650 milligrams, effected the resident's sleep, social and physical activities/mobility, and emotions; and pain was made worse with movement and weather change. Medical record review of Physician Orders dated 12/6/18 revealed .Aspirin 81 milligrams (mg) 1 time daily for pain related to fracture, Monitor pain every shift, and Tylenol 325 mg Give 2 tablets every 8 hours as needed (PRN) for pain/fever . Medical record review of the Pain Interview form dated 12/13/18 revealed Resident #1 had occasional pain in last 5 days; pain did not make it hard to sleep; pain did limit day-to-day activities in past 5 days; intensity of pain 5 out of 10; indicators of pain/possible pain-vocal complaints; frequency with which resident complains or shows evidence of pain or possible pain-3 to 4 days; .Treatment .Received PRN pain medication-[MEDICATION NAME] 325 mg (milligrams) give 2 tablets po (by mouth) every 8 hr (hours) as needed-effective .Receive non-pharmaceutical intervention-Repositioning, Dim Light/Quiet environment, sometimes not effective (12/9, 12/10); Comments - resident has moderately cognitive impairment which can affect his perception of pain . Medical record review of the Admission Minimum (MDS) data set [DATE] revealed Resident #1 had experienced occasional pain within the past 5 days of the review period which limited his day-to-day activity with an intensity of 5 out of 10. Medical record review of the 12/2018 Daily Skilled Charting forms regarding Resident #1's complaints of pain revealed the following: 12/8 at 1:48 PM D (Days) .Describe pain .Bilateral legs and lower back; Received PRN pain medication or was offered and declined; and Comments- Has order for Tylenol 650mg, no relief noted, placed on MD (Medical Doctor) communication book for 12/9/18 . Review of the MD communication book on 12/8/18 revealed no documentation regarding pain for Resident #1. 12/8 at 6:14 PM [NAME] (Evening) . Describe pain .BLE/Back (Bilateral Lower Extremities/Back); Received PRN pain medication or was offered and declined . 12/9 at 11:19 AM D .Describe pain .Bilateral Lower Extremities, greater to knees, low back; Received PRN pain medication or was offered and declined; Comments-MD aware . 12/10 6:34 PM [NAME] .Describe pain .in BLE, back; Received PRN pain medication or was offered and declined . 12/11 at 7:50 PM [NAME] .Describe pain .BLE; Received PRN pain medication or was offered and declined . 12/12 at 6:18 PM [NAME] .Describe pain .BLE, lower back; Received PRN pain medication or was offered and declined . Medical record review of the 12/2018 MAR revealed the Aspirin was administered daily as ordered and the pain was monitored every shift. The pain level was zero except for 12/8/18 at 9:00 AM when it was 5 out of 10. The PRN Tylenol was administered on 12/6/18 at 11:06 PM and on 12/12/18 at 12:38 PM. The level of pain monitored every shift revealed on 12/6/18 at 11:06 PM was 7; on 12/8/18 was 5 for day shift, 6 for evening shift, 2 for night shift; on 12/9/18 was 4 for day shift, was 5 for evening shift; and on 12/11/18 was 4 on evening shift. Interview with Licensed Practical Nurse (LPN) #2/Nurse Supervisor on 1/8/19 at 9:55 AM by the nursing station when asked if the Daily Skilled Charting form had the resident complaining of pain and PRN pain medication was administered what was the LPN's expectation of documentation in the MAR. The LPN stated she would .expect the MAR to indicate the PRN pain medication was administered . Further interview at 10:25 AM in the conference room confirmed the MAR failed to address the administration of the PRN medication when compared to the Daily Skilled Charting forms dated 12/8/18 to 12/12/18. Interview with the Director of Nursing (DON) on 1/8/19 at 10:10 AM in the conference room stated her expectation of .staff was to initial the MAR when a medication was administered . When asked if the Daily Skilled Charting form stated the resident was complaining of pain and the PRN pain medication was administered would she expect the MAR to reflect the administration, the DON stated Yes.",2020-09-01
4143,MT PLEASANT HEALTHCARE AND REHABILITATION,445374,904 HIDDEN ACRES DR,MOUNT PLEASANT,TN,38474,2016-11-03,241,J,1,0,J51L11,"**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 the dignity to a swallow-impaired, aspiration risk resident when a syringe was used to force feed food and liquids for 1 resident (#1) of 6 residents who were totally dependent on staff for eating. This failure placed all residents at risk for aspiration and requiring total dependence on staff for eating 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 of a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on 11/2/16 at 3:00 PM in the Administrator's office. The findings included: Review of facility policy, Quality of Life-Dignity, revised 12/11/15, revealed .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .Policy Interpretation and Implementation .'Treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .Staff shall keep the resident informed .Procedures shall be explained before they are performed .Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed .Staff shall treat cognitively impaired residents with dignity and sensitively . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum (MDS) data set [DATE] revealed Resident #1 had adequate hearing, clear speech, could make self understood, was able to understand others, was severely cognitively impaired per the 3/15 score on the Brief Interview for Mental Status, was totally dependent with one person assist for eating, and had no swallowing disorder. Interviews with Licensed Practical Nurse (LPN) #5 on 10/24/16 at 2:55 PM and 4:25 PM on the long hall and the conference room, on 10/25/16 at 11:10 AM in the conference room, on 10/26/16 at 4:10 PM in the conference room, and on 11/3/16 8:30 AM, on the long hall revealed Resident #1 had general decline as time passed including pocketing (food getting stuck in mouth) food, and had 2-3 vomiting episodes after eating. Further interview revealed LPN #5 had .fed (Resident #1) Magic Cup (nutritional supplement) and fluids 2-3 times by syringe .a couple of months before hospice started .I gave Magic Cup and water by syringe the morning of 10/1/16 . and Resident #1 .wanted water and could no longer suck on a straw .I didn't want him dehydrated . When questioned about the resident's advanced directive of no artificial feeding, why was a syringe okay to use, the LPN stated .because not able to suck through straw and when you held a cup to the lips the resident could blow into it so I tried a syringe, he knew to swallow once in mouth . When asked why the LPN used the syringe, the LPN stated .I was trying to help the man out, I don't know if Certified Nurse Aide (CNA) #4 was trained to use syringe . When asked what CNA #4 was doing when the LPN entered the resident's room on 10/1/16 at lunch, the LPN stated the CNA .was spoon feeding the resident lunch and I told her there was a syringe available if she needed it . When asked since you used a syringe to force food and fluid into his mouth and informed another staff member to use the syringe, do you think you violated his dignity, the LPN stated .it was against his wishes .I took away his autonomy . Interviews with CNA #4 on 10/25/16 at 9:25 AM and on 11/2/16 at 10:15 AM and 12:35 PM, in the conference room and the nursing station revealed CNA #4 had been spoon feeding Resident #1 lunch on 10/1/16 when LPN #5 entered the resident's room and informed the CNA .syringe in drawer and she told me to try use it. I got syringe out, liquefied the pureed food with the fluid on the tray and put a little in his mouth, he swallowed, I asked if he wanted more and he said 'Uh Huh', I took my time feeding him and he ate all the food, 100%, and when I was done feeding he started vomiting. His head of bed was up but I put it up as high as it could go and yelled for help. (CNA #1) came to the room and she yelled for (LPN #5) to come to the room .(LPN #5) and (RN #1) came in the room .resident had thrown up so bad and stopped breathing . When asked when she was spoon feeding the resident lunch how had the resident been accepting the by mouth food, the CNA stated .he wasn't taking it like before . When asked why she used the syringe, CNA #4 stated .(LPN #5) told her the LPN had been using the syringe throughout the day with magic cup and juice and he did fine . When asked what happened to the syringe, CNA #4 stated .(CNA #1) told her that (LPN #5) told (CNA #1) to tell (CNA #4) to get the syringe out of there, I threw it in the trash in the resident's room, and then I removed it and took it to the hopper room trash . Interviews with the Director of Nursing (DON) on 10/24/16 at 3:40 PM, on 10/25/16 at 10:50 AM and 4:40 PM, on 10/26/16 at 12:53 PM, and on 11/2/16 at 8:35 AM and 1:45 PM, in the conference room revealed the DON was not aware a syringe was being used to feed a resident prior to the event. When asked if the facility maintained the resident's dignity, the DON stated No. Refer to F154 J, F155 J, F157 J, F224 J SQC, F225 J SQC and F226 J SQC.",2019-11-01
1543,GREEN HILLS CENTER FOR REHABILITATION AND HEALING,445267,3939 HILLSBORO CIRCLE,NASHVILLE,TN,37215,2017-10-31,511,J,1,0,EO0911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to notify the Physician or Nurse Practitioner of a [MEDICAL CONDITION] for 1 resident (#1) of 7 residents reviewed. This 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 the resident. The District Director of Operations was notified of the Immediate Jeopardy on 10/30/17 at 3:00 PM in the Administrator's Office. The findings included: Review of facility policy, Changes in Resident Condition, revised 2/2017 revealed, .Prompt notification is required when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention . Medical record review revealed Resident #1 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located in the secured unit on the 3rd floor of the facility Medical record review of a Radiology Report for Resident #1 dated 8/2/17 at 5:57 PM eastern time (4:47 PM central time) revealed, .Acute fracture, left femoral neck . Continued review revealed the report was faxed to the facility on [DATE] at 6:01 PM eastern time (5:01 PM central time). Medical record review of a Medical Progress Note dated 8/3/17 revealed, .(Patient) seen at staff request regarding fall .last evening resulting in pain to left hip. X-ray of hip ordered and has returned .with (positive) left femoral neck fracture. (Patient) was recently hospitalized for [REDACTED].according to staff thought she could walk .got up without assistance and fell . No further details of events surrounding were known by the (Nurse Practitioner) at this time .General Appearance .Disheveled .(positive) pain with slight abduction (moving the leg away from the middle of the body) of (Left Lower Extremity) .Radiography .Testing Reviewed: Date 8/03/17 Test Results: Left femoral neck fracture .Administration to (evaluate) and investigate falls for any possible cause of recurrent falls and for future fall precautions interventions .(positive) pain during transfer to stretcher . Interview with the NP #1 on 10/24/17 at 2:20 PM in the conference room confirmed she was notified of the fall for Resident #1 on 8/2/17 verbally by staff. Continued interview confirmed she ordered an X-ray on 8/2/17. Further interview confirmed she was not notified on 8/2/17 the X-ray results revealed a fracture to Resident #1's left hip. Continued interview confirmed the Nurse Practitioner learned of the fracture for Resident #1 on 8/3/17 when she began rounding between 6:30 AM and 7:00 AM and found the results herself. Interview with the DON on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed the facility failed to report X-ray results of a fracture to the Physician or Nurse Practitioner for Resident #1 on 8/2/17 at 5:01 PM which caused a delay in treatment to Resident #1 until she was transferred to the hospital on [DATE] at 8:30 AM resulting in Immediate Jeopardy. Refer to F 224 K SQC Refer to F-309 K SQC Refer to F-323 K SQC Refer to F-353 K SQC Refer to F-490 K Refer to F-501 K Refer to F-520 K",2020-09-01
3392,NASHVILLE CENTER FOR REHABILITATION AND HEALING LL,445512,832 WEDGEWOOD AVENUE,NASHVILLE,TN,37203,2019-11-26,580,D,1,0,133K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to notify the resident representative of 2 room changes for 1 resident (#2) of 4 residents reviewed with room changes. The findings included: Review of the facility policy, Transfer-Room to Room, revised on 10/2012, revealed .That his or her family and visitors will be informed of the room change .Documentation-The following information should be in the resident's medical record .the date and time the room transfer was made . Review of the facility policy, Transfers or Discharge Documentation, revised 8/2014, revealed .When a resident is transferred or discharged , the reason for the transfer or discharge will be documented in the medical record .Documentation .concerning all transfers or discharges must include .The reason for the transfer or discharge .That the appropriate notice was provided to the resident and/or representative .The date and time of the transfer or discharge . Medical record review revealed Resident #2 was admitted to the facility on [DATE]. On 12/12/17 he was discharged to the hospital for elevated blood sugar and readmitted to the facility on [DATE]. On 12/26/17 he was discharged to the hospital for having pulled out the tube feeding tubing and was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #2 was severely cognitively impaired with a score of zero (0) on the Brief Interview for Mental Status (BIMS) and required extensive or total 2 person assistance for all activities of daily living Medical record review of the room location for Resident #2 revealed from 6/30/17 through 2/1/18 he was in room [ROOM NUMBER] B. On 8/8/19 he was moved to private room [ROOM NUMBER]. On 8/13/19 he was relocated to room [ROOM NUMBER] [NAME] On 8/16/19 he remained in the same room but changed bed location to 510 B where he currently resides. Medical record review of the Nurse Practitioner (NP) #2's progress note dated 8/8/19 revealed Resident #2 had [MEDICAL CONDITION]/blisters on the right lateral torso and a single blister on the right lateral thigh. The NP plan was to start isolation precautions for possible [MEDICAL CONDITION]. Medical record review of NP #1's progress note dated 8/9/19 revealed Resident #2 had raised [MEDICAL CONDITION], mild [DIAGNOSES REDACTED] (redness of skin) in diaper area to abdomen and upper thigh. The plan was .irritant [MEDICAL CONDITION]-rash appears to be in diaper area. Start [MEDICATION NAME] with zinc (steroid/antifungal medication with mineral supplement for healing) every day for 10 days and follow-up . Medical record review of the Medication Review Report dated 8/2019 revealed on 8/10/19 [MEDICATION NAME] cream mixed with zinc to be applied to abdomen and upper legs every day for 10 days had been ordered. Medical record review of the 8/2019 Medication Administration Record [REDACTED]. Medical record review of the Nursing Progress Note dated 8/9/19 revealed .Late Entry .Resident's daughter at desk inquiring why her father was moved, nurse informed her he needed a private room until he was evaluated for shingles. Daughter stated family was not notified, (named Licensed Practical Nurse #1/Unit Manager) was notified and informed daughter she thought nurse had called the family and she would investigate and take care of it on Monday . Medical record review of NP #2's progress note dated 8/12/19 revealed Resident #2 had no rash visible. Review of the facility census revealed from 8/8/19 through 8/11/19 there were 117 residents. The facility was licensed for 119 bed capacity. Interview with Registered Nurse (RN) #1 and the Administrator on 11/18/19 at 4:50 PM in the conference room revealed on 8/8/19 NP #2 had assessed Resident #2 as possibly having shingles and the resident was placed in a private room, 412. The following day, 8/9/19, NP #1 assessed the resident and determined it wasn't shingles. By that time the room the resident had vacated on 8/8/19 had been occupied by another resident so the resident went next door (510) but he had the hallway bed not the window bed like he had before. Further interview revealed when the window bed became available, the next day, he was relocated to the B bed. Further interview revealed the Social Worker (SW) was responsible to notify the resident's representative of the room changes. Interview with the SW on 11/20/19 at 10:29 AM in her office revealed the SW was responsible to inform the resident's representative of any room changes. Further interview confirmed she failed to notify Resident #2's representative of the room changes on 8/8/19 and on 8/13/19.",2020-09-01
3607,NHC PLACE AT COOL SPRINGS,445475,211 COOL SPRINGS BLVD,FRANKLIN,TN,37067,2017-04-05,224,D,1,0,BOVY11,"**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 verbal abuse of one 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, revised 11/28/16, revealed .Abuse, Neglect, Misappropriation of Patient Property and exploitation, as hereafter defined, will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitors, or any other individual in this center .Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .Verbal Abuse is 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 regardless of their age, ability to comprehend, or disability . 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 .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 property did or did not occur .The Administrator or Director of Nursing will determine the direction of the investigating once notified of the alleged incident . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility investigation revealed CNA #1 was overheard on 3/22/17 telling the resident she was dirty, stunk, and needed a bath. Continued review revealed CNA #3 reported to the facility Team Coordinator that CNAs were verbally and physically inappropriate during early morning resident care. Further review revealed CNA #1 was suspended during the investigation and CNA #2 was inserviced on the types of abuse and what to do if abuse was suspected. Review of a report by Resident #1 given to Social Services revealed CNA #1 told her You stink, and are dirty and need a bath. Continued review revealed CNA #1 also hit her on the back of the head with her hand and stated since the resident had dirtied her Depend (disposable undergarment) she could throw it away. Review of a written statement from the nurse on duty on 3/22/17 revealed he entered the room of Resident #1 to give her morning medications. Continued review revealed the resident said she had something to tell him and had a frightened look on her face. She stated the two CNAs were very disrespectful and truly rude to her. Review of a written statement from the Social Worker on 3/22/17 revealed she spoke with Resident #1 who stated at 6:00 AM the 2 techs, CNA #1 and CNA #2, were helping her in the bathroom. She sat on the commode when they told her she stunk. She replied No ma'am, I don't stink. Continued review revealed CNA #1 hit the resident on the back of the head with her hand and stated, You dirtied your Depend so you can be the one to throw it away. Further review revealed the CNAs made her pick up her Depend from the floor multiple times because she missed the garbage can several times. Review of a written statement by the ADON on 3/22/17 revealed Resident #1 reported CNA #1 said comments which were hurtful to her and hit her on the back of the head. CNA #1 said she was dirty, stunk, and popped her on the right side of the back of the head. Continued review revealed the ADON assessed the resident and found no obvious injury. Neurological checks were within normal limits. Review of a written statement by CNA #2 on 3/22/17 revealed she told CNA #1 to sit Resident #1 on the toilet and turn on the shower. CNA #2 was making the bed but could hear CNA #1 and Resident #1 getting into it. Continued review revealed Resident #1 kept saying CNA #3 gave me a bath last night. I am not dirty CNA #1 said Your Depend is dirty. You stink. This is a new day. You need a shower. Interview with the Administrator and Director of Nursing on 4/5/17 at 1:30 PM in the conference room confirmed the incident of verbal abuse by CNA #1 and the termination of CNA #1.",2020-08-01
3120,MCKENDREE VILLAGE,445491,4347 LEBANON ROAD,HERMITAGE,TN,37076,2019-06-19,600,D,1,1,VV4U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review and interview, the facility failed to protect Resident #130 from physical abuse by a facility Certified Nurse Technician (CNT). The findings include: Facility policy review, Abuse Prevention/Reporting Policy and Procedure, updated 5/9/18, revealed .Every resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to employees, other residents, physicians, consultants, volunteers, family members, legal guardians, friends or other individuals .the facility has developed and instituted policies and procedures for screening and training employees in regard to the protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment and misappropriation of property . Facility policy review, Resident Rights, revised (MONTH) (YEAR), revealed .Employees shall treat all residents with kindness, respect, and dignity . Review of the facility's investigation dated 6/1/19 revealed Licensed Practical Nurse (LPN) #3 witnessed CNT #5 slap the back of Resident #130's arms. Continued review revealed the facility conducted a thorough investigation resulting in suspension and termination of CNT #5 related to the allegation. Review of the Incident/Accident Report dated 6/1/19 revealed Resident #130 .skin unremarkable . Medical record review revealed Resident #130 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #130 was rarely/never understood. Further review revealed Resident #130 required total assist with one person with bed mobility, dressing and personal hygiene. Medical record review of the Medical physician progress notes [REDACTED].#130 revealed .does not have any bruises consistent with an injury .unable to provide any history due to advanced dementia .appears comfortable . Medical record review of the Psychiatric physician progress notes [REDACTED].#130 revealed .patient to be seen due to an alleged altercation between patient and a tech .Patient smiling. No marks on patient noted. Patient not acting as if had been traumatized or is in fear or scared. No stress reaction noted. Patient most likely does not have any memory of event is clearly showing no signs of [MEDICATION NAME] trauma . Review of CNT #5's employee record revealed CNT #5 was not on the abuse registry and trained in abuse on 5/9/19. Further review revealed CNT #5 was suspended on 6/1/19 and terminated from the facility on 6/14/19. Review of In-services/trainings dated 6/1/19, 6/2/19, 6/3/19 and 6/4/19 revealed facility educated staff on abuse/neglect/exploitation/reporting and approaches/dealing with combative residents. Observation on 6/17/19 at 11:43 AM revealed Resident #130 was sitting in recliner with eyes closed, in the spa therapy room, groomed in personal clothing with one staff in the spa therapy room with Resident #130 and 3 other residents. Continued observation revealed no concerns of abuse. Observation on 6/17/19 at 11:55 AM revealed Resident #130 was sitting in the dining room, groomed in personal clothing, sitting at a table with one other resident; staff interacting and talking with the resident. Further observation revealed staff delivered a meal tray to the resident and the resident was observed smiling and interacting with staff. Observation on 6/18/19 at 8:28 AM revealed Resident #130 was sitting in a wheelchair in the dining room eating the breakfast meal with 3 other residents at the table, and 2 staff were assisting residents with the breakfast meal. Further observation revealed Resident #130 was groomed in personal clothing and assisting self with the meal. Continued observation revealed no concerns of abuse. Telephone interview with Licensed Practical Nurse #3 on 6/18/19 at 6:02 PM revealed, when she walked into Resident #130's room she witnessed CNT #5 smack the resident on both arms. Further interview revealed Resident #130 was lying in the bed and CNT #5 was trying to get the resident's arms back through the sleeves of the resident's shirt and the resident was combative. Further interview revealed LPN #3 immediately called CNT #5 out into the hallway. Further interview LPN #3 stated I called LPN #4 to the hallway to witness me confronting CNT#5; I said I saw what you done and she (CNT #5) said I'm sorry. Continued interview revealed LPN #3 and LPN #4 immediately removed CNT #5 from resident care and from the facility. Further interview revealed LPN #3 contacted the Unit Manager and began skin assessments and interviews with residents. Continued interview with LPN #3 revealed no concerns with abuse training. Telephone interview with CNT #5 on 6/18/19 at 6:22 PM revealed while she was attempting to put the resident's arms in the resident's shirt sleeves the resident tapped her (CNT #5) arm and she stated she said ouch. Further interview revealed when CNT #5 reached over the resident's left arm she stated, I accidently tapped her on the left shoulder; I did not hit the resident. Further interview revealed LPN #3 told CNT #5 to clock out and go home. Further interview revealed CNT #5 clocked out and left the facility. Continued interview with CNT #5 revealed no concerns with abuse training. Interview with LPN #4 on 6/19/19 at 9:33 AM in the 1 North dining room revealed LPN #3 motioned for LPN #4 to come to hallway where LPN #3 and CNT #5 were. When LPN #4 arrived on the hallway LPN #3 informed LPN #4 she witnessed CNT #5 striking Resident #130. Further interview revealed LPN #3 and LPN #4 removed CNT #5 from resident care and contacted the Administrator. Further interview revealed LPN #4 walked CNT #5 out of the building, assessed Resident #130 and other residents with no apparent injury noted to any residents. Continued interview revealed interviews were conducted with residents with no concerns of abuse identified. Further interview revealed LPN #4 had never witnessed CNT #5 have any altercations with residents and residents had no complaints about the care CNT #5 provided. Continued interview revealed no concerns with trainings on abuse. Interview with the Director of Nursing (DON) on 6/19/19 at 2:01 PM in the chapel revealed she received a phone call from the Unit Manager regarding LPN #3 witnessing CNT #5 slap Resident #130. Further interview revealed she (DON) immediately came to the facility. Further interview revealed when she arrived at the facility CNT #5 was already removed from the building by LPN #3 and LPN #4. Further interview revealed the DON started an investigation, conducted skin assessments and interviews including skin assessment on Resident #130. Further interview revealed Resident #130 did not have any areas not even a pink mark. Further interview revealed the DON contacted the resident's family and physician. Further interview revealed the resident's medical physician and psychiatric physician assessed the resident and the resident did not have any adverse effects from the incident. Further interview revealed the DON immediately began in-servicing the staff on abuse and on how to handle combative residents. Interview with the Administrator on 6/19/19 at 7:28 PM in the conference room revealed when asked how she ensured the residents were kept free from abuse she stated by ensuring staff were screened for abuse before hire and staff were in-serviced on abuse 4 times yearly and as needed. Continued interview revealed staff were trained to report abuse immediately and staff were required to report abuse to state agencies within 2 hours. Continued interview revealed she was notified immediately concerning the incident involving resident #130 and CNT #5. Continued interview revealed CNT #5 was immediately removed from resident care, suspended and terminated.",2020-09-01
1475,AHC CUMBERLAND,445262,4343 ASHLAND CITY HIGHWAY,NASHVILLE,TN,37218,2017-10-26,333,E,1,0,ORE211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, Administration History review, and interview, the facility failed to ensure significant medications were administered in a timely manner for 4 residents (#2, #4, #7, #8) of 8 residents reviewed for medication administration. The findings included: Review of facility policy, Medication Administration, revised 9/5/13, revealed .Safe and accurate drug administration requires proficiency with administration techniques, assessment skills, and knowledge of the drugs .Medications should not be administered 60 minutes earlier or later than the scheduled time of administration .Before meals means 15 to 30 minutes before a meal is served .With meals means medications are given during a meal or up to 30 minutes after a meal is eaten .Routine med administration should not occur in the dining room .The nurse must immediately chart the med given on the electronic Medication Administration Record [REDACTED]. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Entry Minimum (MDS) data set [DATE] revealed Resident #2 was severely impaired cognitively. Review of the Administration History revealed medications administered to Resident #2 from 10/01/17 - 10/25/17 included: Humalog (insulin) sliding scale insulin: 10/3/17 due at 7:30 AM and given at 9:48 AM;10/5/17 due at 7:30 AM and given at 9:35 AM; 10/05/17 due at 9:00 PM and given at 1:20 AM; 10/10/17 due at 7:30 AM and given at 9:27 AM; 10/11/17 due at 5:30 PM and given at 12:43 AM; 10/14/17 due at 11:30 AM and given at 1:16 PM; 10/14/17 due at 5:30 PM and given at 10:42 PM; 10/14/17 due at 9:00 PM and given at 10:42 PM; 10/16/17 due at 7:30 AM and given at 10:28 AM; 10/17/17 due at 5:30 PM and given at 9:37 PM; 10/20/17 due at 5:30 PM and given at 10:15 PM; 10/21/17 due at 7:30 AM and given at 1:37 PM; 10/21/17 due at 11:30 AM and given at 1:37 PM; 10/21/17 due at 5:30 PM and given at 11:50 PM; 10/21/17 due at 9:00 PM and given at 11:50 PM; 10/22/17 due at 5:30 PM and given at 12:15 AM; 10/22/17 due at 9:00 PM and given at 12:15 AM. Levetiracetam ([MEDICAL CONDITION]) 500 mg twice daily: 10/04/17 due at 5:00 PM and given at 10:52 PM; 10/10/17 due at 5:00 PM and given at 8:26 PM; 10/11/17 due at 5:00 PM and given at 12:43 AM; 10/14 17 due to 5:00 PM and given at 10:42 PM; 10/17/17 due at 5:00 PM and given at 9:37 PM; 10/18/17 due at 5:00 PM and given at 9:04 PM; 10/20/17 due at 5:00 PM and given at 10:15 PM; 10/21/17 due at 5:00 PM and given at 11:50 PM; 10/22/17 due at 5:00 PM and given at 12:15 AM. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the ?Significant Change MDS dated [DATE] revealed Resident #4 scored 15 on the Brief Interview for Mental Status, indicating she was alert, oriented, and able to make her needs known. Review of the Administration History revealed medications administered to Resident #4 on 10/1/17 - 10/25/17 included: [MEDICATION NAME] 10 mg twice daily: 10/01/17 due at 8:00 AM and given at 10:32 AM; 10/02/17 due at 8:00 AM and given at 10:37 PM; 10/04/17 due at 4:00 PM and given at 9:43 PM; 10/05 17 due at 8:00 AM and given at 10:23 AM; 10/05/17 due at 4:00 PM and given at 12:47 AM; 10/07/17 due at 8:00 AM and given at 12:59 PM; 10/08/17 due at 8:00 AM and given at 12:17 PM; 10/08/17 due at 4:00 PM and given at 6:45 PM; 10/10/17 due at 8:00 AM and given at 10:10 AM ; 10/10/17 due at 4:00 PM and given at 9:19 PM; 10/11/17 due at 8:00 AM and given at 10:52 AM; 10/11/17 due at 4:00 PM and given at 10:19 PM; 10/12/17 due at 8:00 AM and given at 10:21 AM; 10/12/17 due at 4:00 PM and given at 7:37 PM; 10/13/17 due at 8:00 AM and given at 11:43 AM; 10/14/17 due at 8:00 AM and given at 11:20 AM; 10/14/17 due at 4:00 PM and given at 11:01 PM; 10/16/17 due at 9:00 PM and given at 11:14 PM; 10/17/17 due at 8:00 AM and given at 10:44 AM; 10/17/17 due at 4:00 PM and given at 9:40 PM; 10/19/17 due at 8:00 AM and given at 11:28 AM; 10/20/17 due at 4:00 PM and given at 7:03 PM; 10/21/17 due at 8:00 AM and given at 10:24 AM; 10/21/17 due at 4:00 PM and given at 6:42 PM; 10/22/17 due at 8:00 AM and given at 11:25 AM; 10/22/17 due at 4:00 PM and given at 9:57 PM; 10/23/17 due at 4:00 PM and given at 11:08 PM; 10/24/17 due at 4:00 PM and given at 9:37 PM. 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 Resident #7 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 #7 required extensive assistance of 1 person with transfers, dressing, grooming, and bathing; required setup for eating; was occasionally incontinent of bowel; and was continent of urine. Review of the Administration History revealed medications administered to Resident #7 from 10/01/17 - 10/25/17 included: [MEDICATION NAME] 25 units twice daily subcutaneous:10/01/17 due at 8:00 AM and given at 2:30 PM; 10/02/17 due at 8:00 PM and given at 10:28 PM; 10/04/17 due at 8:00 AM and given at 10:02 AM; 10/04/17 due at 8:00 PM and given at 10:04 PM; 10/05/17 due at 8:00 PM and given a 11:33 PM; 10/06/17 due at 8:00 PM and given at 11:11 PM; 10/08/17 due at 8:00 PM and given at 11:06 PM; 01/10/17 due at 8:00 PM and given at 11:16 PM; 10/13/17 due at 8:00 PM and given at 11:14 PM; 10/14/17 due at 8:00 PM and given at 11:01 PM; 10/15/17 due at 8:00 AM and given at 1:14 PM; 10/16/17 due at 8:00 PM and given at 10:58 PM; 10/17/17 due at 8:00 PM and given at 10:31 PM; 10/18/17 due at 8:00 AM and given at 10:48 AM; 10/23/17 due at 8:00 PM and given at 11:36 PM. [MEDICATION NAME]3 units three times daily before meals: 10/01/17 due at 11:30 AM and given at 2:30 PM; 10/01/17 due at 7:30 AM and given at 2:30 PM; 10/02/17 due at 5:30 PM and given at 10:28 PM; 10/03/17 due at 7:30 AM and given at 9:03 AM; 10/03/17 due at 5:30 PM and given at 8:03 PM; 10/04/17 due at 7:30 AM and given at 10:02 AM; 10/04/17 due at 11:30 AM and given at 3:15 PM; 10/06/17 due at 5:30 PM and given at 11:11 PM; 10/10/17 due at 5:30 PM and given at 11:16 PM; 10/11/17 due at 5:30 PM and given at 9:35 PM; 10/12/17 due at 7:30 AM and given at 9:24 AM; 10/14/17 due at 7:30 AM and given at 9:07 AM; 10/14/17 due at 5:30 PM and given at 11:01 PM; 10/15/17 due at 11:30 AM and given at 1:14 PM; 10/15/17 due at 7:30 AM and given at 1:14 PM; 10/15/17 due at 5:30 PM and given at 8:37 PM; 10/16/17 due at 7:30 AM and given at 9:10 AM; 10/17/17 due at 11:30 AM and given at 3:14 PM; 10/18/17 due at 7:30 AM and given at 10:48 AM; 10/18/17 due at 5:30 PM and given at 8:38 PM; 10/22/17 due at 5:30 PM and given at 9:36 PM; 10/23/17 due at 7:30 AM and given at 11:00 AM; 10/24/17 due at 11:30 AM and given at 4:03 PM. [MEDICATION NAME] 5 mg twice daily: 10/02/17 due at 9:00 AM and given at 11:44 AM; 10/02/17 due at 9:00 PM and given at 10:28 PM; 10/05/17 due at 9:00 AM and given at 11:32 AM; 10/05/17 due at 9:00 PM and given at 11:33 PM; 10/06/17 due at 9:00 PM and given at 11:11 PM; 10/07/17 due at 9:00 AM and given at 10:49 AM; 10/08/17 due at 9:00 PM and given at 11:00 PM; 10/09/17 due at 9:00 AM and given at 11:24 AM; 10/10/17 due at 9:00 AM and given at 10:32 AM; 10/10/17 due at 9:00 PM and given at 11:16 PM; 10/12/17 due at 9:00 PM and given at 11:01 PM; 10/13/17 due at 9:00 PM and given at 11:14 PM; 10/14/17 due at 9:00 PM and given at 11:01 PM; 10/15/17 due at 9:00 AM and given at 1:14 PM; 10/16/17 due at 9:00 PM and given at 10:58 PM; 10/17/17 due at 9:00 PM and given at 10:31 PM; 10/18/17 due at 9:00 AM and given at 10:36 AM; 10/21/17 due at 9:00 PM and given at 10:56 PM; 10/22/17 due at 9:00 AM and given at 12:07 PM; 10/23/17 due at 9:00 AM and given at 11:00 AM; 10/23/17 due at 9:00 PM and given at 11:36 PM. [MEDICATION NAME] 50 mg daily for high blood pressure: 10/02/17 due at 9:00 AM and given at 11:44 AM; 10/05/17 due at 9:00 AM and given at 11:32 AM; 10/07/17 due at 9:00 AM and given at 10:49 AM; 10/09/17 due at 9:00 AM and given at 11:24 AM; 10/10/17 due at 9:00 AM and given at 10:32 AM; 10/15/17 due at 9:00 AM and given at 1:14 PM; 10/18/17 due at 9:00 AM and given at 10:48 AM; 10/22/17 due at 9:00 AM and given at 12:07 PM; 10/23/17 due at 9:00 AM and given at 11:00 AM. [MEDICATION NAME] 25 mg twice daily for blood pressure:10/01/17 due at 9:00 AM and given at 2:30 PM; 10/02/17 due at 9:00 AM and given at 11:44 AM; 10/02/17 due at 9:00 PM and given at 10:28 PM; 10/05/17 due at 9:00 AM and given at 11:32 AM; 10/05/17 due at 9:00 PM and given at 11:33 PM; 10/06/17 due at 9:00 PM and given at 11:11 PM; 10/07/17 due at 9:00 AM and given at 10:49 AM; 10/08/17 due at 9:00 PM and given at 11:06 PM; 10/09/17 due at 9:00 AM and given at 11:24 AM; 10/10/17 due at 9:00 PM and given at 11:16 PM; 10/12/17 due at 9:00 PM and given at 11:01 PM; 10/13/17 due at 9:00 PM and given at 11:14 PM; 10/14/17 due at 9:00 PM and given at 11:01 PM; 10/15/17 due at 9:00 AM and given at 1:14 PM; 10/16/17 due at 9:00 PM and given at 10:58 PM; 10/17/17 due at 9:00 PM and given at 10:31 PM; 10/18/17 due at 9:00 AM and given at 10:38 AM; 10/21/17 due at 9:00 PM and given at 10:56 PM; 10/22/17 due at 9:00 AM and given at 12:07 PM [MEDICATION NAME] inhaler 2 puffs every 6 hours: 10/01/17 due at 12:00 PM and given at 2:30 PM; 10/02/17 due at 6:00 PM and given at 10:28 PM; 10/03/17 due at 12:00 AM and given at 4:16 AM; 10/03/17 due at 6:00 PM and given at 8:03 AM; 10/04/17 due at 12:00 PM and given at 3:14 PM; 10/05/17 due at 6:00 PM and given at 11:33 PM; 10/06/17 due at 6:00 PM and given at 11:11 PM; 10/09/17 due at 12:00 AM and given at 1:44 AM; 10/09/17 due at 6:00 AM and given at 7:36 AM; 10/09/17 due at 6:00 PM and given at 8:30 PM; 10/10/17 due at 6:00 AM and given at 7:38 AM; 10/10/17 due at 6:00 PM and given at 8:30 PM; 10/11/17 due at 12:00 AM and given at 4:53 AM; 10/11/17 due at 6:00 PM and given at 9:35 PM; 10/12/17 due at 12:00 AM and given at 4:16 AM; 10/14/17 due at 6:00 PM and given at 11:01 PM; 10/15/17 due at 6:00 PM and given at 8:37 PM; 10/17/17 due at 12:00 PM and given at 3:14 PM; 10/18/17 due at 12:00 AM and given at 3:36 AM; 10/18/17 due at 6:00 AM and given at 7:34 AM; 10/18/17 due at 6:00 PM and given at 8:38 PM; 10/21/17 due at 12:00 AM and given at 1:58 AM; 10/21/17 due at 6:00 AM and given at 8:01 AM; 10/22/17 due at 12:00 PM and given at 1:50 PM; 10/22/17 due at 6:00 PM and given at 9:36 PM; 10/22/17 due at 6:00 AM and given at 11:00 AM; 10/24/17 due at 12:00 PM and given at 4:03 PM; 10/25/17 due at 12:00 AM and given at 2:33 PM Medical record review revealed Resident #8 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 #8 scored 15 on the BIMS, indicating she was alert, oriented, and able to make her needs known. Review of the Administration History revealed medications administered to Resident #8 from 10/01/17 - 10/25 17 included: [MEDICATION NAME] 10 mg twice daily for heart: 10/12/17 due at 9:00 PM and given at 1:33 AM; 10/23/17 due at 9:00 PM and given at 11:25 PM; 10/05/17 due at 9:00 PM and given at 11:47 PM; 10/14/17 due at 9:00 PM and given at 11:07 PM; 10/16/17 due at 9:00 PM and given at 11:02 PM. [MEDICATION NAME] 15 units every bedtime: 10/05/17 due at 9:00 PM and given at 12:53 AM; 10/12/17 due at 9:00 AM and given at 12:53 AM; 10/14/17 due at 9:00 PM and given at 11:47 PM; 10/22/17 due at 9:00 PM and given at 11:25 PM; 10/03/17 due at 9:00 AM and given at 11:41 AM; 10/04/17 due at 9:00 AM and given at 11:19 AM; 10/05 17 due at 9:00 PM and given at 11:47 PM; 10/12/17 due at 9:00 PM and given at 1:33 AM; 10/23/17 due at 9:00 PM and given at 11:25 PM. [MEDICATION NAME]5 units three times daily; 10/01/17 due at 11:30 AM and given at 5:40 PM; 10/01/17 due at 7:30 AM and given at 5:40 PM; 10/01/17 due at 4:30 PM and given at 10:16 PM; 10/04/17 due at 7:30 AM and given at 11:19 AM; 10/04/17 due at 4:30 PM and given at 9:39 PM; 10/05/17 due at 7:30 AM and given at 10:58 AM; 10/05 17 due at 4:30 PM and given at 1:53 AM; 10/08/17 due at 7:30 AM and given at 9:39 AM; 10/10/17 due at 7:30 AM and given at 10:51 AM; 10/10/17 at 4:30 PM and given at 9:28 PM; 10/11/17 due at 2:30 PM and given at 9:59 PM; 10/12/17 due at 4:30 PM and given at 7:41 PM; 10/13/17 due at 7:30 AM and given at 10:16 AM; 10/15/17 due at 4:30 PM and given at 9:39 PM; 10/16/17 due at 4:30 PM and given at 11:02 PM; 10/17/17 due at 11:30 AM and given at 2:55 PM; 10/19/17 due at 11:30 AM and given at 2:46 PM; 10/22/17 due at 4:30 PM and given at 10:03 PM; 10/23/17 due at 4:30 PM and given at 11:25 PM. For these residents there were 751 medications administered and 243 medications were administered 1 1/2 to 4 hours late. These were significant medications including insulin, antihypertensives, [MEDICAL CONDITION] medication, and cardiac medications. During interview with the Administrator and Director of Nursing on 10/26/17 at 3:30 PM, it was confirmed medications were administered late.",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
4678,GREENHILLS HEALTH AND REHABILITATION CENTER,445267,3939 HILLSBORO CIRCLE,NASHVILLE,TN,37215,2016-08-11,322,D,1,0,NRXS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview the facility failed to check gastrostomy tube (GT) placement; failed to irrigate the GT before and after medication administration; failed to change the irrigation set and syringe every 24 hours; failed to monitor for hydration, fluid overload and aspiration; and failed to inspect the surrounding skin of the stoma for 1 (Resident #3) resident of 1 residents reviewed with tube feedings. The findings included: Review of a facility policy titled Enteral Nutrition revised 1/13 revealed, .A resident who is fed by .gastrostomy tube receives the appropriate treatment and services .The nurse checks .gastrostomy placement .periodically during continuous feeding, and prior to flushes and/or medication administration .The nurse irrigates the feeding tube with 30-60 cc (cubic centimeters) tap water before and after administration of medications and 5-10 cc in between administration of multiple medications (or as ordered by the physician), before initiating a feeding, or when there is an interruption of feeding .administration sets are changed every 24 hours .The irrigation syringe is changed every 24 hours .Nursing .routinely monitor the following factors for evaluation of therapeutic efficacy, adverse effects, and clinical changes .Hydration .The resident is evaluated for intolerance to the Enteral feeding regimen .The skin surrounding a gastrostomy .is kept clean and free from irritation and/or infections. The site is evaluated for signs of [DIAGNOSES REDACTED] (redness), Tenderness, Drainage .Key documentation elements: Type, amount, rate of feeding formula; Patency; Tolerance; Condition of stoma site; and Oral hygiene . Medical record review revealed Resident #3 was admitted to the facility on [DATE] at 4:55 PM, and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission assessment dated [DATE] revealed the resident had short and long-term memory loss, and had difficulty being understood by others. He had a Gastrointestinal Tube (GT) in his abdomen for feedings and medication administration. Medical record review of Enteral Feed Orders dated 4/15/16 revealed: Feeding: Administer [MEDICATION NAME] 1.5 (high protein nutritional supplement) per GT via Pump. Rate: 30 ml's/hr, (milliliters per hour), for 23 hours/day with water flush at 20 ml/hr. Care: Check tube for proper placement by visual inspection of aspirated stomach content prior to instilling medication, initiating a feeding or when there is an interruption of feeding or at least every shift for continuous feeding. Care: Elevate head of bed 30-45 degrees (semi-fowler's position) during feedings and at least 1 hour after feeding to prevent aspiration/pneumonia. Flush: Flush with 5-10 ml's H20 (water) between each medication. Hydration: Observe for signs of intolerance, i.e. diarrhea, N&V (nausea and vomiting), constipation, abdominal distention/cramping, dehydration, fluid overload, aspiration, increased gastric residual, hypo/hyper-glycemia (low or high blood sugar) every shift. Tube care: Inspect surrounding skin of stoma for redness, tenderness swelling irritation, purulent drainage, or signs of infection. Observe for [MEDICAL CONDITION], skin irritation. Tube care: Complete tube site care and change syringe daily. Telephone interview with a family member of Resident #3 on 8/9/16 at 1:45 PM stated the facility staff did not look at the skin or change the dressing around the site of the GT. The family member stated when the resident was discharged from the facility and taken to the Emergency Department she was asked by hospital staff if she knew when the dressing had last been changed and told them it had never been changed. The family member stated the site around the GT looked nasty, and had green pus on it. Medical record review of the Enteral Orders MAR/TAR (medical administration record and treatment administration record) for 4/16 for Resident #3 revealed no documentation the [MEDICATION NAME] tube feeding or water flush was administered; no documentation the GT was checked for proper placement; no documentation the head of bed was elevated 30-45 degrees during feeding; no documentation the GT was flushed between each medication; no documentation the resident was observed for signs of dehydration, intolerance, fluid overload or aspiration; no documentation the surrounding skin of the stoma was inspected for irritation, drainage or signs of infection; and no documentation the GT syringe was changed daily on 4/15/16 on the night shift, 4/16/16 on the day, evening, or night shift, or on 4/17/16 on the day shift. Interview with Licensed Practical Nurse (LPN) #1 on 8/10/16 at 11:33 AM in the Conference room confirmed she had cared for Resident #3 on 4/17/16 on the day shift (7 AM-3:30 PM). When the LPN was shown the MAR/TAR for Enteral Orders she stated, I didn't know the Enteral Tube Feeding existed on EMar (Electronic Medical Administration Record). Continued interview revealed the LPN could not confirm she inspected the skin surrounding the GT, or if the dressing was changed. LPN #1 confirmed she had not completed all orders on the Enteral Feed Orders MAR/TAR for Resident #3. Interview with the Director of Nursing (DON) on 8/10/16 at 2:30 PM in the conference room confirmed the EMar system for documentation had been in place when she began working at the facility in 12/15 and no further updates or changes to the system had been completed since then. Continued interview revealed when shown the Enteral Feed Order MAR/TAR the DON stated, They still need more education on documentation. Continued interview with the DON revealed she could not tell when or if the resident received his tube feedings, if GT placement was done prior to feeding and medication administration, if the head of the bed was elevated 30-45 degrees, if the GT was flushed prior to and after feeding, medication administration or interruption, if the skin surrounding the GT site had been inspected, if the resident was monitored for dehydration, intolerance, fluid overload or aspiration, or if the GT syringe was changed daily. The DON confirmed the facility failed to provide the services and complete the care Resident #3 required related to his gastrostomy tube on 4/15/16 night shift, on 4/16/16 day, evening, and night shift, and on 4/17/16 day shift.",2019-08-01
3279,"THE WATERS OF SMYRNA, LLC",445502,202 ENON SPRINGS ROAD EAST,SMYRNA,TN,37167,2018-01-16,661,D,1,0,POU411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview the facility failed to complete a discharge summary, which included a recapitulation of the resident's stay, a final summary of the resident's status at the time of discharge, and a post-discharge plan of care for 1 resident (#6) of 5 residents reviewed for transfer/discharge requirements. The findings included: Review of facility policy Transfer and Discharge Policy and Procedure, dated 1/1/17 revealed when a resident was discharged to home or another long-term care facility, staff were to Complete a Discharge Summary Form. Medical record review revealed Resident #6 was admitted to the facility on [DATE] for long term care with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set (MDS), 10/1/17 revealed the resident had severe cognitive impairment, based on a Brief Interview for Mental Status (BIMS) score of 3/15. Continued review of the MDS revealed the resident had delusions, required supervision with ambulation, and wandered daily. Further review of the MDS revealed the resident's behavior of daily wandering did not place her at significant risk of getting to a potentially dangerous location, and did not significantly intrude on the privacy of others. Continued review of the Admission Minimum Data Set (MDS) dated revealed no discharge planning was in effect. Medical record review of the resident's nursing Progress Notes revealed the resident had multiple instances of removing her Wanderguard (personal alarm to notify staff a resident is wihin close proximity to an exit of a set perimeter) device which was worn to prevent elopement. The resident was also able to exit the building on 2 separate occasions - 10/14/17 and 10/18/17. Medical record review of a Discharge Planning/Discharge Progress Note, dated 10/31/17, revealed the facility contacted the family to inform them the resident was not a good fit due to safety concerns and would need to be discharged to another facility. Further medical record review revealed no evidence of a discharge summary. Medical record review of the resident's Comprehensive Care Plan, initiated on 9/22/17 and canceled on 11/13/17, revealed no evidence of a post-discharge plan of care to assist the resident in adjusting to her new living environment. The facility failed to provide the resident's hard copy health record for review to determine if it contained the required discharge summary information. Interview with the Social Services Director (SSD) on 1/10/18 at 9:56 AM in the conference room confirmed there should have been a discharge summary, with all the required information, documented in the facility's medical record. Continued interview revealed the facility had not completed a discharge summary. Further interview confirmed the SSD stated, I didn't. I'm the one responsible for initiating it, but I'm still getting used to our system. Further interview with the SSD on 1/10/18 at 11:08 AM in the Director of Nursing (DON)'s office,confirmed the discharge summary was required to be completed within 30 days of discharge.",2020-09-01
4486,"SUMMIT VIEW OF FARRAGUT, LLC",445258,12823 KINGSTON PIKE,KNOXVILLE,TN,37923,2016-09-20,309,D,1,0,VQPS11,"**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 physician's orders for 1 resident (#3) of 7 residents reviewed. The findings include: Review of the facility's job description titled, Treatment Nurse (2003 Med-Pass, Inc.) states, Duties and Responsibilities, Initiate requests for consultation or referral. Respond to requests from the resident, physician, or nursing staff. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. nervous system and sense organs, Personal history of other mental and behavioral disorders, Presence of Aortocoronary Bypass Graft. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 9 out of 10 on Brief Interview for Mental Status indicating the resident had moderate impaired cognition. Continued review revealed the resident required limited assistance of one person with bed mobility and transfers, was totally dependent of 1 person with locomotion on the unit and off the unit, toilet use and bathing, and needed extensive assistance of 1person with dressing and personal hygiene. Continued review revealed the resident received Occupational Therapy and Physical Therapy. Review of the Interdisciplinary Progress Notes (IDT) dated 1/29/16 (late entry) for the Admission entry on 1/27/16, revealed the resident had been admitted for Physical Therapy, had a history of [REDACTED]. Continued review revealed the resident had an AAA surgery pending in 4 to 8 weeks, was diabetic, and had surgical incisions in the right groin and right ankle area. Review of the document (discharge orders) titled, Tennova Healthcare External Skilled Nursing Facility Orders signed and dated by the facility 1/27/16 at 2:40 PM states .12. *Ask vascular surgery for [REDACTED]. Record review of the facility's admission orders [REDACTED]. Interview with the Director of Nursing (DON) and the Wound Care Nurse on 9/20/16 at 8:00 PM, in the conference room confirmed the Vascular Surgeon had not been contacted by the facility to follow up on the resident status [REDACTED]. decision to make, really. Interview with the DON 9/20/16 at 8:40 PM, in the conference room, confirmed, The Vascular Surgeon should have been notified, that is what I would expect.",2019-09-01
4159,ETOWAH HEALTH CARE CENTER,445422,"409 GRADY ROAD, PO BOX 957",ETOWAH,TN,37331,2016-11-23,226,D,1,0,2VL411,"**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 their abuse policy for immediate suspension of an employee accused of abusive behavior toward 1 Resident (#1) of 5 residents reviewed. The findings included: Review of the facility policy, Abuse, Neglect & Exploitation Policy & Procedures dated 4/25/16 revealed .Immediately upon receiving an allegation of or when there is a suspicion of abuse, neglect, mistreatment, misappropriation or exploitation, the staff in charge at the facility will protect the resident from harm and conduct a preliminary investigation through interviews with the person alleging or expressing a suspension of abuse .In the event an employee has been identified as the potential perpetrator of the incident, the employee will be suspended from work pending the outcome of the investigation. This can be done by the supervisor of the employee relieving them of all duties pending the outcome of the investigation . Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating Resident #1 had moderate cognitive impairment. Review of the staffing schedule dated 10/30/16 revealed Certified Nurse Aide (CNA) #1 was scheduled to work 8 hours on D hallway. Review of the employee time card dated 10/30/16 revealed CNA #1 worked 8.25 hours on D hallway. Review of the facility's investigation, Notice of Suspension, related to allegation of abuse, neglect, exploitation and/or misappropriation of resident property for CNA #1 dated 10/31/16 revealed, .Telephone notification 10/31/16 at 11:15 . Interview with Licensed Practical Nurse (LPN) #1 on 11/21/16 at 2:17 PM, in the conference room confirmed LPN #1 was on duty on 10/30/16. Further interview confirmed Resident #1 alleged CNA #1 had hit him. Continued interview confirmed LPN #1 notified the Director of Nursing (DON) who instructed LPN #1 to keep CNA #1 on hallway D, and not to go into Resident #1's room. Further interview confirmed CNA #1 completed the 2:30 PM - 11:00 PM shift on 10/30/16 on hallway D. Interview with the DON and the Administrator on 11/21/16 at 3:00 PM, in the conference room, confirmed CNA #1 completed the 2:30 PM to 11:00 PM shift on 10/30/16, and was not suspended until 10/31/16. Further interview confirmed the CNA was not suspended immediately, and the facility had failed to follow their abuse policy.",2019-11-01
3841,BETHESDA HEALTH CARE CENTER,445427,444 ONE ELEVEN PLACE,COOKEVILLE,TN,38501,2017-02-23,323,D,1,0,DI9N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview the facility failed to implement an intervention to prevent a fall for 1 resident (#2) of 3 residents reviewed for falls of 10 residents reviewed. The findings included: Review of the facility policy, Fall Risk/ Fall Prevention Guidelines, dated 9/2014 revealed, .identifying potential risk factors can assist in preventing falls . our facility must strive to provide a safe environment with methods to reduce accidents . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) was 6, indicating the resident had severe cognitive impairment. Medical record review of the nurse's event note dated 2/18/17 revealed, . I pivot patient over to wheelchair and as patient bottom sat on wheelchair CNA (Certified Nursing Assistant) stated that patient's wheelchair wasn't locked and wheel chair rolled back . Review of the facility's investigation statement dated 2/18/17 revealed, .heard yelling from the nurse's station went to the end of 400 hall to observe pt (patient) sitting on bottom in bathroom floor . Interview with the ADON (Assistant Director of Nursing) on 2/23/17 at 10:22 AM, in the conference room, confirmed the resident was transferred to an unlocked wheelchair and the CNA's were to lock wheelchairs prior to transferring residents. Further interview confirmed the facility failed to ensure the wheelchair was locked resulting in a fall for Resident #2.",2020-02-01
1067,RAINTREE MANOR,445216,415 PACE STREET,MC MINNVILLE,TN,37110,2019-09-25,600,D,1,0,X6BC11,"**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 residents (#4 and #5) of 5 residents reviewed for abuse. The findings include: Review of the facility policy, Abuse Prevention Policy and Procedure, revised 2/26/18 revealed, The scope of this program shall apply to the prevention of abuse committed by anyone, including but not limited to, staff, other residents .This facility shall not condone any acts of resident .physical and/or mental abuse .RESIDENT-TO-RESIDENT ABUSE POLICY .It is the policy of this facility to take all steps reasonable and necessary to protect the residents from harm at all times, including protection from physical .abuse from other residents . 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 dated 3/15/18 (active) revealed .(Resident #4) has agitation towards others, verbally abusive toward staff . Medical record review of Resident #4's Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 indicating Resident #4 was severely cognitively impaired. Medical record review of Resident #4's Nurse Note dated 9/17/19 revealed .ACCORDING TO RESIDENT (Resident #5) AT APPROXIMATELY 3PM (Resident #4) ENTERED HIS OLD ROOM AND ATTEMPTED TO GET IN HIS OLD BED WHEN (Resident #5) NOW IN THIS ROOM WAS LYIGN (lying) DOWN .(Resident #4) THEN PR[NAME]EEDED TO REMOVE THE BED COVERS AND YELL AT (Resident #5) TO GET OUT OF HIS BED .(Resident #5) DID NOT MOVE AND (Resident #4) BEGAN TO PULL ON HIS CLOTHING UNTIL HE RIPPED (Resident #5's) SHIRT .AT THAT TIME (Resident #5) HIT (Resident #4) IN THE GROIN AND (Resident #4) THEN STARTED TO EXIT ROOM .(Resident #5) CAME TO DOORWAY AND WAS ASKED WHAT HAPPENED TO HIS SHIRT WHEN HE REPORTED THE INCIDENT TO THE 100 HALL NURSE . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #5's Quarterly MDS dated [DATE] revealed the Resident had a BIMS of 15 indicating the resident was cognitively intact. Medical record review of Resident #5's Care Plan dated 9/6/19 (active) revealed .Resident exhibits physically aggressive and socially inappropriate behaviors .attempting to hit, yelling and cursing . Review of facility documentation dated 9/17/19 revealed .(Resident #5) came to doorway and nurse (nurse name) saw . his shirt was ripped and asked what happened .(Resident #5) states that another resident (Resident #4) came into his room and pulled his cover of (off) and told him to get up and out of his bed .(Resident #4) the (then) pulled on his clothes and ripped his shirt when he didn't get up .(Resident #5) states he hit the other resident in the privates and he left the room . Interview with License Practical Nurse (LPN) #1 on 9/24/19 at 2:55 PM, in the conference room, confirmed LPN #1 had interviewed both Residents #4 and #5 following the physical altercation on 9/17/19. Continued interview confirmed resident to resident abuse occurred. Interview with LPN #2 on 9/24/19 at 3:07 PM, in the conference room, confirmed she was the first nurse on the scene after the incident. Continued interview confirmed she noted Resident #5 had a ripped shirt. Further interview confirmed the physical altercation occurred between Residents #4 and #5. Continued interview confirmed the facility failed to prevent abuse for Residents #4 and #5. Interview with Resident #5 on 9/24/19 at 3:21 PM, in the resident's room, confirmed . (Resident #4) tried to get me out of bed .Ripped my shirt I hit Resident #5 . Interview with the Director of Nursing (DON) on 9/24/19 at 3:39 PM, in the conference room, confirmed there was physical contact between Resident #4 and #5. Continued interview confirmed the facility failed to prevent abuse for Residents #4 and #5. Interview with the Administrator (Abuse Coordinator) on 9/24/19 at 3:57 PM, in the conference room, confirmed the facility failed to prevent abuse for Residents #4 and #5.",2020-09-01
2803,SWEETWATER NURSING CENTER,445456,978 HWY 11 SOUTH,SWEETWATER,TN,37874,2017-08-16,157,D,1,0,5ODH11,"**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 notification for a change in health status for 1 resident (#1) of 3 residents reviewed for notification of change. The findings included: Review of the facility policy Changes in a Resident's Condition or Status Effective Date ,[DATE] Revised ,[DATE] revealed .Nursing Services shall be responsible for notifying the Resident and responsible party when: .there is a significant change in the Resident's physical, mental, or emotional status . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to the hospital on [DATE] where he subsequently expired. Review of a Minimum Data Set ((MDS) dated [DATE] for Resident #1 revealed a Brief Interview of Mental Status was unable to be completed .short term memory problem .long term memory problem .moderately impaired - decisions poor; cues/supervision required . Review of the Nurse Practitioner (NP) note dated [DATE] revealed, .nurse requested visit for decline .was walking when first admitted ; now not walking. On exam resident with respiratory distress, unresponsive .CNA's (certified nurse aides) report some coughing with intake. SLP (speech language pathologist) evaluated yesterday and unable to fully participate with exam .respiratory tachypnea (rapid breathing) . Review of a Physician's Order dated [DATE], revealed, .stat 2 view CXR (chest xray), [MEDICAL CONDITION]. [MEDICATION NAME] stat (now) q (every) 6 hrs (hours) .Respiratory therapy to evaluate .) Review of the Mobile Images (chest xray) report revealed, acute right lower lobe infiltrate . Review of the NP note dated [DATE] revealed, .visit requested by Respiratory Therapy. Resident with shortness of breath and rhonchi . Interview with the Regional Client Operations Consultant on [DATE] at 4:00 PM, in the conference room confirmed expectations were the families would be notified of a significant change in a resident's medical condition unless the resident was able to make the decision, and they did not want the family to be notified. Further interview confirmed if a resident was their own responsible party and had a significant change the expectation was the family would be notified. Interview with the Director of Nursing on [DATE] at 4:30 PM, in her office confirmed it was expected the family be notified when a resident had a significant change in condition, and the facility had failed to notify Resident #1's family of his change in health status.",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
1348,HARTSVILLE CONVALESCENT CENTER,445256,649 MCMURRY BLVD,HARTSVILLE,TN,37074,2018-01-25,600,D,1,0,YR5Q11,"**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 mental abuse for 1 resident (#3) of 3 residents reviewed. The findings included: Review of facility policy revealed Policy and Procedure Abuse, Neglect, Misappropriation of Property & Exploitation undated .the willful infliction of injury, unreasonable containment, intimidation, punishment with resulting physical harm, pain or mental anguish, also includes deprivation of goods/services that are necessary to attain or maintain physical, mental, psychosocial, wellbeing .MENTAL ABUSE- mental abuse includes, but not limited to humiliation, harassment, threats of punishment, or deprivation . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #3 on 1/24/18 at 11:25 AM in her room revealed Resident #3 could not recall what day the incident took place but recalled it was at night. Continued interview revealed Resident #3 stated, The first two women acted like lunatics from the asylum. They came through the door, and were talking together in a foreign tongue. They came together straight to my bed and came at me with their fingers up to my neck. Continued interview revealed Resident #3 stated the Certified Nurse Aide (CNA) stated I'm going to take you out Saturday night and we gonna drink whiskey and get drunk. Continued interview revealed Resident #3 expressed it concerned and scared her. Resident #3 stated she felt staff was making fun of an elderly person by hollering turn out that light. Further interview revealed Resident #3 stated They act like lunatics trying to inflict pain on someone. They were going to flip me and change my diaper, but I wouldn't let them. I'm scared of them. They have frightened me out of my mind. They don't need to be working in a nursing home, that's no way to treat a human being. Further interview revealed Resident #3 stated This has been so horrendous; I'm scared it's going to happen every night. Resident #3 informed Social Services Director (SSD) she did not want those staff taking care of her anymore. Interview with CNA #2 on 1/24/18 at 12:30 PM by phone revealed CNA #2 and NA #2 were in Resident #3's room to provide incontinence care. Continued interview revealed after telling Resident #3 what they were about to do the resident told them to get out. Further interview revealed the staff attempted to enter the room later but Resident #3 would not allow them. Interview with NA #2 on 1/24/18 at 12:45 PM by phone revealed she worked on 1/21/18 with CNA #2 . NA #2 and CNA #2 went into Resident #3's room talking and went over to her bed and turned on the light which startled Resident #3. Continued interview revealed that they were going to provide incontinent care. Resident #3 did not let them touch her and stated we scared her. Interview with the SSD on 1/24/18 at 1:11 PM in the conference room revealed she spoke with Resident #3 about the two CNA's. Continued interview with revealed Resident #3 told the SSD that two CNA's came into her room really loud and talking in low voices. Continued interview revealed Resident #3 stated the CNA's turned on the lights and motioned their fingers like ghosts. Continued interview with the SSD revealed Resident #3 stated she is scared and does not want them in her room and they are crazy. Further interview revealed SSD spoke with Resident #3's roommate who had stated she heard the comment about the whiskey. Interview with Resident #3's roommate on 1/24/17 at 2:57 PM in her room revealed staff had made fun of Resident #3 and stated They were going to poor some whiskey down her. They scared her. Continued interview revealed the roommate stated staff does not knock at times, and does not explain what they are coming in there to do. Interview with Licensed Practical Nurse (LPN) #2 on 1/25/17 at 7:20 AM at the upstairs nurse station revealed Resident #3 told LPN #2 about the incident but LPN #2 could not get a good understanding of what happened. Continued interview with LPN #2 revealed Resident #3 demonstrated how staff motioned their hands towards her. Further interview with LPN #2 revealed Resident #3 told her she does not want CNA #2 and NA #2 in her room anymore. Interview with the Director of Nursing (DON) on 1/25/18 at 8:47 AM in the conference room revealed she expected staff to knock on the door before entering the room, speak in a low calm voice, notify residents of what they are doing and call the residents by their name before providing care. DON confirmed the facility failed to prevent mental abuse for Resident #3.",2020-09-01
1347,HARTSVILLE CONVALESCENT CENTER,445256,649 MCMURRY BLVD,HARTSVILLE,TN,37074,2018-01-25,550,D,1,0,YR5Q11,"**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 care in a dignified manner for 1 resident (#3) of 3 residents reviewed. The findings included: Review of facility policy revealed Policy and Procedure Abuse, Neglect, Misappropriation of Property & Exploitation undated .the willful infliction of injury, unreasonable containment, intimidation, punishment with resulting physical harm, pain or mental anguish, also includes deprivation of goods/services that are necessary to attain or maintain physical, mental, psychosocial, wellbeing . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #3 on 1/24/18 at 11:25 AM in her room revealed Resident #3 could not recall what day the incident took place but recalled it was at night. Continued interview revealed Resident #3 stated The first two women acted like lunatics from the asylum. They came through the door, and were talking together in a foreign tongue. They came together straight to my bed and came at me with their fingers up to my neck. Continued interview revealed Resident #3 stated the Certified Nurse Aide (CNA) stated I'm going to take you out Saturday night and we gonna drink whiskey and get drunk. Continued interview revealed Resident #3 expressed concerned and it scared her. Resident #3 stated she felt staff was making fun of an elderly person by hollering turn out that light. Further interview revealed Resident #3 stated They act like lunatics trying to inflict pain on someone. They were going to flip me and change my diaper, but I wouldn't let them. I'm scared of them. They have frightened me out of my mind. They don't need to be working in a nursing home, that's no way to treat a human being. Further interview revealed Resident #3 stated This has been so horrendous; I'm scared it's going to happen every night. Resident #3 informed Social Services Director (SSD) she did not want those staff taking care of her anymore. Interview with CNA #2 on 1/24/18 at 12:30 PM by phone revealed CNA #2 and NA #2 were in Resident #3's room to provide incontinence care. Continued interview revealed after telling Resident #3 what they were about to do,the resident told them to get out. Further interview revealed the staff attempted to enter the room later but Resident #3 refused. Interview with NA #2 on 1/24/18 at 12:45 PM by phone revealed she worked on 1/21/18 with CNA #2 . NA #2 and CNA #2 went into Resident #3's room talking and went over to her bed and turned on the light which startled Resident #3. Continued interview revealed that they were going to provide incontinence care. Resident #3 did not let them touch her and stated we scared her. Interview with the SSD on 1/24/18 at 1:11 PM in the conference room revealed she spoke with Resident #3 about the two CNA's. Continued interview with revealed Resident #3 told the SSD that two CNA's came into her room really loud and talking in low voices. Continued interview revealed Resident #3 stated the CNA's turned on the lights and motioned their fingers like ghosts. Continued interview with the SSD revealed Resident #3 stated she is scared and does not want them in her room and they are crazy. Further interview revealed SSD spoke with Resident #3's roommate who had stated she heard the comment about the whiskey. Interview with Resident #3's roommate on 1/24/18 at 2:57 PM in her room revealed staff had made fun of Resident #3 and stated They were going to poor some whiskey down her. They scared her. Continued interview revealed the roommate stated staff does not knock at times, and does not explain what they are coming in there to do. Interview with Licensed Practical Nurse #2 on 1/25/18 at 7:20 AM at the upstairs nurse station revealed Resident #3 told LPN #2 about the incident but LPN #2 could not get a good understanding of what happened. Continued interview with LPN #2 revealed Resident #3 demonstrated how staff motioned their hands towards her. Further interview with LPN #2 revealed Resident #3 told her she does not want CNA #2 and NA #2 in her room anymore. Interview with the Director of Nursing (DON) on 1/25/18 at 8:47 AM in the conference room revealed she expected staff to knock on the door before entering the room, speak in a low calm voice, notify residents of what they are doing and call the residents by their name before providing care. DON confirmed the facility failed to provide care in a dignified manner.",2020-09-01
4716,OVERTON COUNTY HEALTH AND REHAB CENTER,445419,318 BILBREY STREET,LIVINGSTON,TN,38570,2016-08-18,314,D,1,0,HM2S11,"**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 pressure ulcers accurately and measure ulcers in a consistent manner for 1 (Resident #4) of 6 residents reviewed. The findings included: Review of facility policy entitled Skin/Wound Management Protocols in the section on Unstageable Pressure Ulcer or Full Thickness Wounds with Eschar or Slough revealed unstageable is defined as .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 . Topical wound management includes selecting a product that will promote moist wound healing properties. Dressing choice should be determined by wound characteristics such as size, depth, amount of drainage. If the wound does not progress within 2-4 weeks contact a physician for further evaluation For wound with dead space (craters) gently fill with dressing product but do not pack tightly as this will impede healing. Monitor patient for signs and symptoms of infection. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 scored 4/15 on the Brief Interview for Mental Status indicating she was severely impaired cognitively. Continued review of the MDS revealed Resident #4 was totally dependent on 2 staff for transfers and bathing; was totally dependent on 1 person for eating; required extensive assistance of 2 people for dressing and grooming; had a Foley catheter in place; and was frequently incontinent of bowel. Medical record review of the Nursing Admission assessment dated [DATE] revealed Resident #4 had an excoriated area to the right anterior thigh, skin tear to left posterior shoulder, and a skin tear to the right inner thigh. Continued review revealed .Multiple pressure areas noted to buttocks et coccyx area . Medical record review of wound care notes revealed Resident #4 was admitted with a skin tear to the right upper shoulder measuring 1.5 centimeters (cm) x (by) 1.0 cm with the edges not well approximated. Continued review revealed Resident #4 was also admitted with a skin tear to the right breast measuring 1.5 cm x 3.0 cm with its edges not well approximated. Further review revealed Resident #4 was also admitted with a ruptured blister to the right inner thigh measuring 2.5 cm x 1.5 cm with scant serous drainage. Continued review revealed Resident #4 was admitted with a sacral pressure ulcer which was unstageable due to slough but measured 6.0 cm x 9.0 cm x 4.0 cm. Continued review revealed the wound bed was 75% eschar and 25% slough with macerated borders of the wound and a moderate amount of serosanguinous drainage. Medical record review of wound care notes dated 12/30/15 revealed the sacral wound measured 8.5 cm x 10 cm x 3.8 cm with 75% eschar and 25% slough. Continued review revealed the wound bed was covered with [MEDICATION NAME] cream and the wound was packed with gauze. Medical record review of wound care notes dated 1/10/16 revealed the sacral wound was still unstageable and measured 11.0 cm x 7.0 cm x 3.5 cm with 25% [MEDICATION NAME] and 75% slough. Medical record review of wound care notes dated 1/20/16 revealed the sacral wound was still unstageable and measured 10.0 cm x 9.0 cm x 3.0 cm. Continued review revealed the wound bed was 100% slough with purulent drainage and macerated wound edges. Medical record review of wound care notes dated 1/27/16 revealed the sacral wound was still unstageable due to slough/eschar and measured 10.0 cm x 13.0 cm x 2.0 cm. Continued review revealed the wound bed was 100% slough and there was a small amount of serous drainage. Further review revealed there was undermining at 12,1 and the wound had a slight mal odor. Medical record review of a communication with the resident's personal physician revealed .unstageable wound to sacrum showing decline. Modest amount of purulent drainage noted. Applied [MEDICATION NAME] per (named wound care physician) orders. She continues to follow up with him next appt (appointment) is Feb. 15th. Any new orders? . Continued review revealed the physician wrote OK on the communication. Further review revealed no notification of the wound care physician concerning the decline of the sacral pressure ulcer. Review of the Nursing Admission Assessment from the hospital dated 1/27/16 revealed Resident #4 had a Stage IV pressure ulcer to the coccyx which measured 10 cm x 6 cm x 3.5 cm with undermining with yellow slough in the middle and necrotic tissue around the edge and bloody drainage. Continued review revealed a Stage II pressure ulcer on the right buttock measuring 5 cm x 3.8 cm with yellow wound bed. Further review revealed a stage II pressure ulcer to the right buttock measuring 2 cm x 1.8 cm. Continued review revealed 4 stage II pressure ulcers around the rectum. Review of the admission History and Physical revealed under the skin assessment .revealed a large stage IV decubitus ulcer measuring 6 or 8 cm across located in the decubitus area. There is some purulence in them, some surrounding redness and some shallow stage II ulcerations, 2 of which I saw just to the right of the larger decubitus ulcer . Medical record review of a physician's note dated 2/13/16 revealed Resident #4 was transferred to the hospital for a .large gaping coccygeal wound. Since discharge a culture has been obtained of her coccygeal wounds had has grown out E-Coli with ESBL characteristics (organisms normally in feces with antibiotic resistant tendency). She has a large decubitus ulcer that is at least a Grade 4 is noted on the coccygeal area that measures 6-8 cm. Continue wound care as is being done now. If it does not improve we may want to revisit another wound care evaluation . Interview with the Director of Nursing (DON) on 8/16/16 at 2:20 PM in the Administrator's office revealed the Wound Care Nurse who treated the sacral ulcer of Resident #4 was no longer employed by the facility. Continued interview revealed the new Wound Care Nurse had only been in the position for 2 1/2 months. In further interview the DON confirmed the sacral ulcer was the only ulcer documented as being treated from admission on 12/22/15 through 1/27/16. Continued interview revealed without a picture it was difficult to read the wound reports since it was not clear in which direction the Wound Care Nurse was measuring due to inconsistent changes in measurements.",2019-08-01
4782,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2016-07-14,514,F,1,0,E5B511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to complete Activities of Daily Living (ADL) Flow Sheet Record forms on 5 (Resident #1, 8, 9, 10, 11) of 5 residents reviewed for pressure ulcers and on 1 (Resident #3) of 6 residents reviewed for ADLs; failed to complete the Diet Flow Sheet for 3 (Resident #2, 7, 10) of 5 residents reviewed for weight loss; and failed to document pressure ulcer care on the Treatment Administration Record (TAR) for 1 (Resident #9 ) of 5 residents reviewed for pressure ulcers. The findings included: Review of the facility policy entitled Turning and Positioning the Resident revealed .Proper positioning and regular repositioning helps to prevent pressure sores, contractures, and stagnation of respiratory secretions. Residents who are unable to reposition themselves should be turned and repositioned every 2 hours . Medical record review revealed Resident #1 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 #1 was dependent on one person for dressing, bathing, grooming, and eating; had a suprapubic (directly into bladder) catheter in place; and was always incontinent of bowel. Further review revealed Resident #1 received tube feeding of Nestle [MEDICATION NAME] at 95 milliliters (ml) per hour for 22 hours and water 60 ml 6 times a day. Medical record review of the Activities of Daily Living, (ADL) Flow Sheet Record (FSR) form revealed the form was completed daily on each shift for residents to depict the resident's performance in bed mobility, transfers, toileting, dressing, fluid intake, grooming, bathing, and bowel and bladder function. Continued review of the form revealed the amount of support provided was also to be documented, including setup, one or two person assist, or activity did not occur the entire shift. Medical record review of the (MONTH) (YEAR) ADL FSR form revealed 2 signatures were missing for the night shift and 2 signatures were missing for the evening shift for bed mobility which was described as .How the resident moves to and from lying position, turns side to side, and positions body while in bed . Review of the ADL FSR form for (MONTH) (YEAR) for bed mobility revealed 16 signatures were missing from the day shift and 7 signatures were missing from the evening shift. Continued review of the (MONTH) and (MONTH) (YEAR) ADL FSR forms revealed there was no documentation the resident was turned and repositioned on 27 occasions due to the missing documentation. Further review of the (MONTH) and (MONTH) (YEAR) ADL FSR forms revealed many blank boxes therefore there was no documentation the facility provided basic care of toileting, dressing, grooming, and bathing. Interview with Licensed Practical Nurse (LPN) #2 on 7/12/16 at 10:15 AM on the 200 hall, and again on 7/13/16 at 12:30 PM in the anteroom confirmed, blank spaces on the ADL Flow Record meant no documentation of activity and an inability to determine if the task was completed. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 day MDS dated [DATE] revealed Resident #2 scored 5/15 on the Brief Interview for Mental Status indicating she was moderately cognitively impaired. Continued review revealed Resident #2 required limited assistance of 1 person for bed mobility, transfers, ambulation, eating, and grooming; required extensive assist of 1 person for dressing and bathing; was occasionally incontinent of bladder; and was continent of bowel. Medical record review of dietary notes dated 11/3/15 revealed Resident #2 weighed 82 pounds and was placed on a high calorie high protein diet. Continued review of a note dated 2/13/16 revealed Resident #2 weighed 76 pounds and House Supplement 240 milliliters (ml) three times daily was added to her diet. Further review of a note dated 4/15/16 revealed a Diet Flow Sheet was started with % (percentage) intake for each meal as well as fluids would be documented. Continued review of a note dated 5/16/16 revealed Resident #2 weighed 70 pounds so continued on the house supplement 3 times daily; was ordered a snack 2 times daily; and was placed on weekly weights. Further review of an Interdisciplinary Team Meeting dated 6/15/16 revealed Resident #2 was to continue on weekly weights and staff needed to encourage oral intake. Continued review of this meeting revealed the resident's family did not want [MEDICATION NAME] or other appetite stimulants given to the resident. Further review of this meeting revealed the resident was a Do Not Resuscitate and did not want a tube inserted for artificial feedings. Further review of a note dated 6/15/16 revealed Resident #2 weighed 67 pounds which was a 1.4% weight loss in 7 days. Continued review of this meeting revealed the resident was still on high calorie high protein food but the family again did not want an appetite stimulant or a Speech Therapy consult. Further review of a note dated 6/21/16 revealed Resident #2 did not like Ensure so dietary would try magic cup, cottage cheese with fruit, tuna fish sandwiches, and peanut butter. Medical record review of the Dietary Flow Sheet on which all food and fluid intake of a resident is documented to serve as a reference for the dietitian to determine ways to prevent weight loss. Continued review of the sheet for (MONTH) (YEAR) revealed amount consumed at breakfast was not documented 5 times; morning snack not documented 12 times; lunch not documented 5 times; afternoon snack not documented 11 times; supper not documented 3 times; and bedtime snack not documented 5 times. Medical record review of the Diet Flow Sheet for (MONTH) (YEAR), revealed amount consumed at breakfast was not documented 16 times; morning snack not documented 17 times; lunch not documented 17 times; afternoon snack not documented 27 times; supper not documented 13 times; and bedtime snack not documented 31 times. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE] revealed Resident #3 needed extensive assist with one person assist for transfer, ambulation, and toileting. Resident #3 had impairment on one side, upper and lower extremities, and always continent of bowel and bladder. Medical record review of the ADL FSR form dated (MONTH) (YEAR) revealed there was no documentation for bowel and bladder function or the number of voids or episodes for 3 day and 3 evening shifts. Medical record review of the ADL FSR form dated (MONTH) (YEAR) revealed there was no documentation for bowel and bladder function or the number of voids or episodes for 7 day, 16 evening, and 16 night shifts. Medical record review of the ADL FSR form dated (MONTH) (YEAR) revealed there was no documentation for bowel and bladder function or the number of voids or episodes for 4 day, 25 evening, and 11 night shifts. Medical record review of the ADL FSR form dated (MONTH) (YEAR) revealed there was no documentation for bowel and bladder function or the number of voids or episodes for 5 day, 6 evening and 7 night shifts. Interview with Nurse Supervisor #2 on 7/12/16 at 9:26 AM in her office confirmed, blank spaces on the ADL flow record form signified staff did not document the ADL function for that day or shift. Interview with ADON (Assistant Director of Nursing) on 7/12/16 at 1:36 PM at the 2nd floor East Nurse Station confirmed, blank spaces on the ADL flow record form signified staff did not document the ADL function for that day or shift. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed Resident #7 scored 3/15 on the BIMS indicating Resident #7 was severely impaired cognitively with disorganized thinking and wandering. Continued review revealed Resident #7 required limited assistance of 1 person with bed mobility, transfers, ambulation, dressing, grooming, and bathing; was independent with eating, and was continent of bowel and bladder. Medical record review of the Registered Dietitian's assessment dated [DATE] revealed the resident's weight has been stable the last few weeks. Continued review revealed .current weight 96 pounds is within ideal body weight for resident's height. PO (oral) intake of diet alone does not meet estimated nutritional needs but the additional calories and protein from supplements and snacks meets resident's needs . Medical record review of the Diet Flow Sheet for (MONTH) (YEAR) revealed no signature 6 times at breakfast, 12 times for morning snack, 6 times for lunch, 13 times for afternoon snack, and 4 for supper. Medical record review of the Diet Flow Sheet for (MONTH) (YEAR) revealed missing signatures 15 times for breakfast, 31 times for morning snack, 16 times for lunch, 31 times for afternoon snack, 21 times for supper, and 31 times for bedtime snack. Medical record review revealed Resident #8 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 #8 was dependent on 2 people for dressing and bathing; dependent on one person for eating (tube feeding) and grooming; had a Foley catheter in place, and was always incontinent of bowel. Review of the ADL FSR form for (MONTH) (YEAR) revealed no documentation as follows: 1. Bed mobility - 3 times on day and 4 times on evening shifts 2. Dressing - 1 time on night, 3 times on day, and 4 times on evening shifts 3. Grooming - 1 time on night, 4 times on day, and 3 times on evening shifts 4. Bathing - 1 time on night, 5 times on day, and 4 times on evening shifts 5. Of the Foley catheter output - 1 time on night, 6 times on day, and 5 times on evening shifts. Interview with LPN #2 on 7/12/16 at 10:15 AM on the 200 hall, and again on 7/13/16 at 12:30 PM in the anteroom, after reviewing the ADL FSR form for Resident #8 confirmed, blank spaces on the ADL FSR form meant no documentation of activity and an inability to determine if the task was completed. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #9 needed total assist with two person assist for bed mobility and toileting. Resident #9 had impairment on both sides, upper and lower extremities (quadriplegic). The resident had a Foley catheter and [MEDICAL CONDITION]. Medical record review of the ADL FSR form dated (MONTH) (YEAR) revealed no documentation for bed mobility for 1 day and 10 evening shifts. Medical record review of the ADL FSR form dated (MONTH) (YEAR) revealed no documentation for bed mobility and bowel and bladder function or the number of voids or episodes for 18 day and 23 evening shifts. Medical record review of the ADL FSR form dated (MONTH) (YEAR) revealed no documentation for bed mobility and bowel and bladder function or the number of voids or episodes for 18 day, 15 night, and 7 evening shifts. Medical record review of the ADL FSR form dated (MONTH) (YEAR) revealed no documentation for bed mobility and bowel and bladder function or the number of voids or episodes for 4 day, 3 night, and 3 evening shifts. Medical record review of the Treatment Administration Record (TAR ) dated (MONTH) (YEAR) revealed the wound treatment of [REDACTED]. Further review revealed no documentation for wound treatment for [REDACTED]. Medical record review of the TAR dated (MONTH) (YEAR) revealed the wound treatment of [REDACTED].and Clean upper left buttocks with [MEDICATION NAME], apply santyl, pack with sterile packing gauze and apply dry dressing daily at 4 PM . Further review revealed no documentation for wound treatment for [REDACTED]. Medical record review of the TAR dated (MONTH) (YEAR) revealed the wound treatment of [REDACTED].Clean upper left buttocks with [MEDICATION NAME], apply santyl, pack with sterile packing gauze and apply dry dressing daily at 4 PM . Further review revealed no documentation for wound treatment for [REDACTED]. Interview with Nurse Supervisor #2 on 7/12/16 at 9:26 AM in her office confirmed, blank spaces on the TAR signified staff did not document the treatment as ordered. Interview with ADON on 7/12/16 at 1:36 AM at the 2nd floor East Nurse Station confirmed blank spaces on the TAR signified staff did not document the treatment for [REDACTED]. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 60 day MDS dated [DATE] revealed Resident #10 scored 1/15 on the BIMS indicating he was severely impaired cognitively; was dependent on 2 staff for transfer and bed mobility; was dependent on 1 person for dressing, eating, and bathing; and was always incontinent of bowel and bladder. Medical record review of the wound care notes dated 7/8/16 revealed Resident #10 had a Stage III pressure ulcer to the sacrum measuring 1.6 cm x 1.3 cm x 0.3 cm with 65% granulation. Continued review revealed a wound of the left medial thigh measuring 2.1 cm x 2.3 cm x 0.6 cm with 60% granulation. Medical record review of the ADL FSR form revealed no documentation of bed mobility on 13 day and 15 evening shifts; no documentation of transfers, dressing, eating, grooming, bowel, and bladder on 13 day shifts for each and 15 on evening shifts for each. Medical record review of dietary notes dated 5/26/15 revealed Resident #10 had an 11 pound weight loss in 7 days while consuming 50 - 100% of meals. Continued review revealed the resident was on a puree diet with high calorie high protein added to current diet order, and he was also placed on the Red Napkin program. Medical record review of dietary notes dated 6/1/16 revealed Resident #10 had lost 5 pounds in 7 days. Continued review revealed Speech Therapy (ST) felt the wound pain was a contributing factor to the patient's inability to eat meals. Further interview revealed ST suggested 6 small meals daily, add [MEDICATION NAME] (protein powder) daily, sandwiches between meals, and house supplement between meals. Medical record review of dietary notes dated 6/8/16 revealed Resident #10 had lost 3 pounds in 7 days while eating 25 - 50% of puree diet. Continued interview revealed the house supplement was increased to 3 times daily as well as a snack three times daily. Medical record review of dietary notes dated 6/29/16 revealed Resident #10 had a 6 pound weight loss in 7 days while consuming 25 - 75% of puree high calorie high protein diet. Continued review revealed Resident #10 received snacks 3 times daily, house supplement of 240 ml 3 times daily, and food preferences were updated. Medical record review of the Diet Flow Sheet for (MONTH) (YEAR) revealed 3 signatures missing for breakfast; 11 signatures missing for morning snack, 4 for lunch, 11 for afternoon snack, 7 for supper, and 11 for bedtime snack. Medical record review of the Diet Flow Sheet for (MONTH) (YEAR) revealed 12 signatures missing for breakfast, 31 for morning snack, 16 for lunch, 31 for afternoon snack, 22 for supper, and 31 for bedtime snack. Interview with LPN #2 on 7/12/16 at 10:15 AM on the 200 hall, and again on 7/13/16 at 12:30 PM in the anteroom, after reviewing the ADL FSR form for Resident #10 confirmed, blank spaces on the ADL FSR form meant no documentation of activity and an inability to determine if the task was completed. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 day MDS dated [DATE] revealed Resident #11 was dependent on one person for transfers and grooming; required extensive assistance of one person with bed mobility, dressing, eating, bathing, and was always incontinent of bowel and bladder. Medical record review of the wound care notes dated 7/8/16 revealed Resident #11 had a Stage III pressure ulcer to the right heel, measuring 0.8 cm x 2.0 cm x 0.4 cm, with 100% granulation. Continued review revealed Resident #11 also had a wound to the left upper chin measuring 2.5 cm x 2.5 cm x 0.3 cm with 50% granulation. Medical record review of the ADL FSR form DATED???? revealed no documentation of bed mobility, transfers, dressing, grooming, bathing, and bowel and bladder on 10 day and 15 evening shifts for each of the areas. Interview with LPN #2 on 7/12/16 at 10:15 AM on the 200 hall, and again on 7/13/16 at 12:30 PM in the anteroom, after reviewing the ADL FSR form for Resident #11 confirmed, blank spaces on the ADL FSR form meant no documentation of activity and an inability to determine if the task was completed.",2019-07-01
608,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,280,D,1,0,DC3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to complete a care plan within 7 days after the completion of the comprehensive assessment and failed to revise a care plan for behaviors involving hallucinations for 1 resident (#1) of 8 residents reviewed. The findings included: Review of facility policy, Care Plans-Comprehensive, revised 10/2010 revealed .Our facility's Care Planning/Interdisciplinary Team .develops and maintains a comprehensive care plan .The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS (Minimum Data Set) .Assessments of the residents are ongoing and care plans are revised as information about the resident and the resident's condition change .The Care Planning/Interdisciplinary Team is responsible for the review and updating of the care plans . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual MDS dated [DATE] revealed Resident #1's Brief Interview for Mental Status was 12/15 indicating she was moderately cognitively impaired; had no mood, psychotic episodes or behaviors; she could hear adequately, and she could make herself understood and understood others. Medical record review revealed the care plan following the comprehensive MDS was dated 3/3/17, exceeding the 7 days after the assessment. Medical record review of the nursing notes revealed on 3/9/17 Resident #1 had experienced .hallucinations . Further review of nursing notes revealed the resident was seeing 1 or more children in her room or in her bed. Medical record review of the Social Service progress note dated 3/31/17 revealed .Res (Resident) continues to verbalize hallucinations according to nursing staff . Interview with the MDS Coordinator on 5/8/17 at 4:15 PM in the conference room confirmed Resident #1 had been experiencing visual hallucinations since 3/9/17 and the facility failed to revise the care plan until 4/3/17. Interview with the MDS Coordinator on 5/9/17 at 3:15 PM in the MDS office confirmed the MDS was completed on 2/8/17 and the facility failed to complete the care plan within 7 days of the MDS. Interview with the Administrator and the Director of Nursing on 5/9/17 at 4:05 PM in the Administrator's office, confirmed the facility failed to complete a care plan timely after a comprehensive assessment per facility policy. Further interview confirmed the facility failed to revise the care plan timely to address the hallucination per facility policy.",2020-09-01
3032,CORNERSTONE VILLAGE,445483,2012 SHERWOOD DRIVE,JOHNSON CITY,TN,37601,2017-05-17,314,D,1,1,LW9W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to complete skin assessments weekly for 1 (#133) of 3 residents reviewed for pressure ulcers, of 46 residents reviewed. The findings included: Review of the facility policy Pressure Sores, undated, revealed .A licensed nurse will complete a skin assessment weekly . Medical record review revealed Resident #133 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged on [DATE]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making, required extensive assistance of one for bed mobility, personal hygiene, and required one person physical assistance for bathing. Medical record review of the Braden Scale for Predicting Pressure Sore Risk dated 1/13/17 revealed a score of 18, indicating mild risk. Medical record review of the Care Plan dated 1/13/17 revealed .Provide extensive assist with bed mobility, transfers and toilet use as needed .Check for incontinence routinely and prn (as needed). Pericare after incontinent episodes . Medical record review of a Dietician Communication/Order Form dated 1/18/17 revealed .Recommend FeSulfate (iron) 325mg (milligrams) and Vit (Vitamin) C 500mg for [MEDICAL CONDITION] . Medical record review of a Skin Evaluation Form dated 2/5/17 revealed .Skin warm and dry to touch with good turgor .Buttocks clear with no open areas and no redness. Bilateral heels are firm and intact . Medical record review revealed the next Skin Evaluation Form in the resident's chart was dated 3/1/17 and revealed .skin has poor turgor and is dusky in color .open area noted on coccyx, foul odor noted with wet brown eschar to wound bed. Immediate surrounding skin is pink and blanchable with butterfly shape. Wound measures 3.2 (centimeters) x (by) 3.3 (centimeters) depth is unknown. Resident has refused to get out of bed past few days. Food and liquid intake has been minimal or refused. Resident is on air mattress and assisted to reposition every two hours and as needed . Medical record review of the Interdisciplinary Notes dated 3/1/17 revealed .Resident turned and repositioned every 2 hours for comfort and pressure relief. Resident noted with poor po (by mouth) intake. Will continue to encourage increased po intake . Medical record review of a Physician's Order dated 3/1/17 revealed .Clean affected area on coccyx (with) wound cleanser pat dry, apply [MEDICATION NAME] ag (antimicrobial dressing) and cover with foam dressing on M, (Monday) W, (Wednesday)F (Friday) . Medical record review of a Physician's Progress Note dated 3/2/17 revealed .pt (patient) has declined over last week (with) (decreased) po intake, (increased) somnolence. [MEDICATION NAME] decreased (and) [MEDICATION NAME] held yesterday .also now (with) Kennedy Ulcer noted by wound care . (The Kennedy Terminal Ulcer (KTU) is an unavoidable skin breakdown that occurs as part of the dying process, similar in appearance to an abrasion, and tend to occur suddenly in the sacral/coccygeal region. It appears as a discoloration of the skin in the shape of a butterfly or pear; is purple, red, blue, or black; and has a sudden onset.) Medical record review of a Physician's Progress Note dated 3/8/17 revealed .Adv (Advanced) dementia-poor appetite-eating a few bites per day. IVF (Intravenous Fluids) during the night .Kennedy ulcer worsening per wound care nurse. Discussed prognosis (with) son . Medical record review of the Dietary Notes dated 3/13/17 revealed .on comfort care at family request. She has been getting clear liquids only as of 3/10 per family wishes because she would not eat her puree diet .she began getting ensure supplements tid with meals as of 3/12. Will continue to monitor . Interview with the Director of Nursing (DON) on 5/9/17 at 3:40 PM, in the conference room, confirmed no skin assessments had been completed from 2/5/17 until 3/1/17, when the Kennedy Ulcer was identified.",2020-09-01
759,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2020-02-05,689,D,1,0,5CUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to conduct a thorough investigation of falls for 2 (Resident #1 and #3) residents of 3 residents reviewed with falls. The findings included: Review of the undated policy, Falls Management Program Guides, revealed the corporation strived to maintain a hazard free environment, mitigate fall risk factors and the implementation of preventative measures. The definition of a fall was considered to be .an unintentional coming to rest on the ground, floor, or the lower level, but not as a result of an overwhelming external force .when a resident is found on the floor, a fall is considered to have occurred . The Procedure included the fall risk assessment as part of the admission, quarterly and when a fall occurred, the identified risk factors should have been evaluated for the contribution they may have to the resident's likelihood of falling and the care plan interventions should have been implemented that addressed the resident's risk factors. Further review revealed if the event the resident fell .the attending nurse shall complete a post fall assessment .includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT to evaluate thoroughness of the investigation and the appropriateness of the interventions .nursing staff will observe and document continued resident response and effectiveness of interventions for 72 hours . Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].NON-ST ELEVATION [MEDICAL CONDITION] INFARCTION; TYPE 2 DIABETES MELLITUS; MAJOR [MEDICAL CONDITION], RECURRENT, SEVERE WITH PSYCHOTIC SYMPTOMS; UNSPECIFIED CONVULSIONS; [MEDICAL CONDITION]; [MEDICAL CONDITION]; [MEDICAL CONDITION] DISORDER, [MEDICAL CONDITION] TYPE; [MEDICAL CONDITION] DISEASE OF NERVOUS SYSTEM, and AGE-RELATED [MEDICAL CONDITION] since 2014 . Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 had adequate hearing and vision with no devices; had clear speech, and usually could make her needs known and usually understood others. The resident scored a 4 on the Brief Interview for Mental Status (BIMS), indicating she was severely cognitively impaired (severely impaired range 0 - 7). She did not have a change in mental status and exhibited no [MEDICAL CONDITION] or behaviors during the review period. She did exhibit inattentiveness which did fluctuate. She exhibited alteration in sleep and depression/feeling down for 12 - 14 days of the review period. She exhibited a change in energy for 7 - 12 days of the review period. She exhibited a change in appetite and concentration for 2 - 6 days of the review period. She was occasionally incontinent of bowel and bladder. She required limited 1 person assistance for bed mobility, transferring, walking in the room, locomotion on and off the unit, eating and toileting for her activities of daily living (ADL). Resident #1 was assessed as having no falls during the review period. Medical record review of the care plan updated in 10/28/2019, revealed Resident #1 was at risk for falls related to she required assistance with ADLs at times, received [MEDICAL CONDITION] medication, and had Actual Falls. The interventions included .Encourage resident to request assistance in ambulating, Fall Intervention: Keep personal items within reach, activities that minimize the potential for falls while providing diversion and distraction upon her visitors departure, Make sure shower chair is locked on both sides, Provide non-skid footwear as tolerated, and Therapy to provide resident with a reacher device (long handled device with pinchers on one end to grasp items) . Medical record review of the Morse Fall Scale form dated 10/29/2019, revealed Resident #1 was at a moderate risk for falls with a score of 40. Medical record review of the Nursing Progress Note, written by Licensed Practical Nurse (LPN) #1, dated 12/4/2019 at 7:00 PM, revealed .Resident (#1) was found on the floor of the room across the hall from her own room, (named CNA #1) went down the hall to start her round and saw the resident sitting on her bottom, in the floor, with blood in her hair and on the floor around her, the CNA called for a nurse, this nurse assessed the resident, discovered she had two bleeding wounds, quickly forming lumps, on her head, one on the back, right side, and one on her left side, pressure was applied with a cold towel, the other nurse called for an ambulance, which arrived and transported the resident to (named hospital) . Review of the facility investigation of the undated, Staffs 10 Questions at the Time of a Resident Fall, written by LPN #1, revealed Resident #1's head hurt, .What were you trying to do when you fell ? Walking .Position of resident when they fell ? Near wheelchair. How far from surface where they? Next to surface. What were position of their arms and legs? Arms in lap, legs in front of her .Apparel resident was wearing? Night gown .Shoes, Socks (non-skid) . Review of the facility investigation included the Supervisor Investigation of Fall, written by LPN #1, dated 12/4/2019, revealed Resident #1 had an unwitnessed fall on 12/4/2019 at 7:00 PM, in another resident's room. She possibly fell from the wheelchair, unknown. The resident's head hurt, and she had 2 hematomas to the head and was bleeding. The Immediate Intervention was to apply pressure to the wounds. The resident had not had a previous fall. CNA #1 found the resident. The resident was sent to the emergency room and neurological checks were started after the resident returned from the hospital. The physician and family were notified. Review of the Resident Event Report Worksheet, written by LPN #1, with the event date and time of 12/4/2019 at 6:55 PM, revealed the physician and family were notified. The assigned staff to Resident #1 were CNA #1 and LPN #1. The resident had an unwitnessed fall with a significant injury while in another resident's room and was found on the floor. The circumstances were unknown. The resident sustained [REDACTED]. Review of the POS [REDACTED]. Vital Signs were - Temperature 98.4; Pulse 71; Respiration 16; and Blood Pressure 147/99. The resident was found on the floor of another resident's room and she didn't know what happened, says 'I just fell .' Fall review location: in another resident's room; location prior to fall: wheelchair; Activity at time of the fall? Unknown. Footwear/device at time of fall: shoes. There were no environmental factors identified. The immediate prevention put in place was to encourage resident to ask for assistance with ADL's. Medical record review for the Morse Fall Scale form revealed there was no form for the fall on 12/4/2019 for Resident #1. Review of the undated written statement by CNA # 1 revealed .Went down 300 hall to start my round I saw (named Resident #1) on the floor with blood around her. I immediately called for help. (Named LPN #6) and (named LPN #1) came down and we grabbed towels and applied pressure. (Named LPN #6) went and called 911 and got all the paperwork together. We took her vitals and assessed her. The paramedics showed up and picked her up . Medical record review of the potential resident witnesses to the fall of Resident #1 on 12/4/2019, revealed Resident #4's Quarterly MDS dated [DATE], showed she had a BIMS of 9, indicating she was moderately cognitively impaired (moderately range 8 - 12). She had minimal difficulty hearing, adequate vision, had clear speech and could usually make herself understood and usually understood others. The investigation failed to include an interview of what the resident potentially saw and/or heard during the fall. Medical record review of potential resident witness to the fall of Resident #1 on 12/4/2019, revealed Resident #5's Annual MDS dated [DATE], showed she had a BIMS of 12, indicating she was moderately cognitively impaired. She had adequate hearing and vision, clear speech, and could make herself understood and understood others. Resident #5 had another MDS dated [DATE], which showed her BIMS was 13, indicating she was cognitively intact (intact range 13 - 15) and the other data was the same as the 9/15/2019 MDS. The investigation failed to include an interview of what the resident potentially saw and/or heard during the fall. Further review of the investigation revealed the failure to identify the room where the fall took place, failure to identify the 2 residents in the room of the fall, and failure to obtain an interview from the residents potentially witnessing the fall, if feasible, or have data to show the 2 residents where not capable of providing information. The investigation did not include a diagram of the room layout and the resident's position at the time of the fall. The investigation included 1 witness statement, by CNA #1, who named another staff member, (named LPN #6) was present in the room. There was no statement in the investigation from LPN #6. The investigation did not include a root cause. Interview with the Interim Director of Nursing (IDON) on 2/4/2020 at 8:00 AM, in the conference room stated some areas of the Post Fall Review form addressed the fall risks assessment addressed in the Falls Management Program Guidelines policy. The IDON read the Post Fall Review dated 12/4/2019 and confirmed it did not include the fall risk assessment. Further interview at 9:10 AM confirmed the investigation did not include the statement by the staff named (LPN #6) in CNA #1's statement, did not indicate when Resident #1 was last seen by staff and what she was doing, did not include how Resident #1 got into room of the fall, did not specify the room where the fall occurred, and did not identify the 2 residents who were potential witnesses and if the 2 residents were capable of providing a statement. The IDON confirmed the investigation was not complete. The IDON confirmed the Fall Risk Assessment should have been completed as part of the investigation. Medical record review revealed Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].FRACTURE OF LUMBOSACRAL SPINE AND PELVIS, REPEATED FALLS, HYPERTENSION, CHRONIC PAIN, [MEDICAL CONDITION], TYPE 2 DIABETES MELLITUS, [MEDICAL CONDITIONS] WITHOUT BEHAVIORAL DISTURBANCE, DIFFICULTY IN WALKING, MUSCLE WASTING AND ATROPHY, RETENTION OF URINE, [MEDICAL CONDITIONS], GENERALIZED ANXIETY DISORDER, POST-TRAUMATIC STRESS DISORDER, MAJOR [MEDICAL CONDITION], and ANXIETY DISORDER . Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #3 had adequate hearing; vision was impaired; her speech was unclear, she usually could make herself understood and usually understood others. She scored a 15 on the Brief Interview for Mental Status (BIMS), indicating she was cognitively intact. She had no changes in mental status, no [MEDICAL CONDITION], no [MEDICAL CONDITION] or any behaviors during the review period. The resident exhibited feeling down/depressed and a change in appetite over the past 12-14 days; a change in energy for 7-11 days, and a change in sleep and feeling bad about herself/let others down over the past 2-6 days of the review period. The resident required total 1 person assistance for bathing; extensive 2 plus (+) person assistance with bed mobility; extensive 1 person assistance with transferring, dressing, hygiene, and with toilet use. She required supervision of 1 person with locomotion on and off the unit. She resident was always incontinent of bowel and bladder. The resident had not had falls after the last MDS. Medical record review revealed the following: On 1/8/2020, of the Morse Fall Scale revealed Resident #3 score 55, indicating the resident was at high risk for falls. On 1/9/2020 at 3:41 PM, of the Health Status Note, written by Licensed Practical Nurse (LPN) #5 revealed .At around 12:50 PM on Thursday (MONTH) 9, 2020, a pt (patient) yelled down the hallway I need a nurse. This nurse came to room and found pt (Resident #3) lying face down on the floor. there was a fair amount of blood on floor with pt's glasses on floor in front of her. called another nurse into room, assessed pt then turned her over on her back, pt had blood coming from a small laceration above rt (right) eye, and redness to rt cheek. Pt was A&O x (alert and oriented times) 4, able to tell us what happened, denied any pain at this time. Picked her up and placed her back into her wheelchair. pt stated I was sitting on side of my bed, bent over to plug in my cell phone, and fell over. v/s (vital signs) (Blood Pressure (BP)) 134/78, (Respiration (R)) 18, (Pulse (P)) 80, O2 97% (percent) on room air. at this time bleeding to her head had stopped, contacted wound care nurse to asses for treatment, spoke to (named Nurse Practitioner). Had pt apply ice to right side of face/eye area. Will continue to monitor, continue on neuro checks per protocol. Call light within reach . Review of the facility investigation included the Supervisor Investigation of Fall form dated 1/9/2020, written by LPN #5, which revealed Resident #3 fell on [DATE] at 12:50 PM, in her room while bending forward trying to plug cell phone in. The roommate found the resident. The resident had an injury of a laceration above the right eye, was not sent to the emergency room , neurochecks were initiated and the physician and resident's (family member) were notified. The facility intervention was to attach the phone cord to the bedrail for easy access and the intervention was placed on the care plan. Review of the facility investigation included the undated Staff's 10 Questions at the Time of a Resident Fall form which revealed the resident stated she was 'Okay', that she was face down next to a surface and the environment was clean, dry, had no spills and the area was uncluttered. The resident was wearing pants, shirt, shoes and socks. The assistive device used was a wheelchair and she was wearing her glasses. Review of the facility investigation included the Resident Event Report Worksheet form dated 1/9/2020, written by LPN #5, revealed the date and time of the unwitnessed fall by Resident #3 was 1/9/2020 at 12:50 PM, which had occurred in Resident #3's room. The resident sustained [REDACTED]. The resident had a laceration to the right eyebrow/temple area and a red cheek. The factors related to the fall was she was reaching. The resident had no pain and the physician and family were notified. Medical record review of Resident #3's roommate, at the time of the 1/9/2020 fall, Quarterly MDS dated [DATE], revealed a BIMS score of 11, indicating she was (upper range) moderately cognitively impaired (Moderate range: 8 - 12). She had moderate difficulty with hearing, she had adequate vision and wore lenses. Medical record review of the Neurological Record form dated 1/9/2020 at 1:00 PM through 9:30 PM, and on 1/10/2020 at 1:30 AM through 5:30 AM, revealed Resident #3's results were within normal range. Medical record review of the Health Status Note dated 1/10/2020 at 9:00 AM, revealed .Nurse was called to room by (named Family Member #3). (Named Family Member #3) insisted on resident being sent to hospital for a CT (Computerized [NAME]ography) Scan due to S/P (status [REDACTED]. Noted to have bruise to right shoulder. Skin tear above right eye. No bleeding or swelling noted to site. (Named) NP (Nurse Practitioner) was called, received new orders to transport to (named hospital) for CT scan. Will continue to monitor . Interview with LPN #5 on 2/5/2020 at 8:34 AM, in the conference room revealed the LPN was working at the medicine cart when Resident #3's roommate rolled out of the room in the wheelchair and told the LPN that (Resident #3) needed help. The LPN entered the room and found Resident #3 face down with a little pool of blood under her head. The LPN called for help from other nurse. The LPN could not recall the name of the nurse helping her. The LPN reviewed her written report and confirmed she failed to write the name of the nurse on the report. The LPN stated once the other nurse was available, they assessed the resident. The LPN stated she notified the NP who was in the facility and the LPN recalled the NP went to assess the resident. The NP saw the resident, the vital signs and neurochecks were normal, the resident had complained of a sore head, but not pain, and the NP did not order a discharge to the hospital. Interview with the NP on 2/5/2020 at 9:35 AM, in the conference room revealed the NP had seen Resident #3 earlier in the day, prior to the fall on 1/9/2020. The NP stated she was notified of the fall, went to assess the resident, noted the neurocheck was normal so far, and the resident was not complaining of pain. The NP stated her intent was to continue monitoring the vital signs and neurochecks and to assess the resident for abnormalities. The NP stated the resident returned to the facility on [DATE] and she then wrote her note dated on 1/13/2020. Further review of the investigation revealed no written statements from the staff involved in the response, LPN #5, another unnamed nurse, the assigned CNA, the NP; failed to include what the resident was doing and last known location, prior to the fall; no statement from the resident; no statement from the roommate alerting staff of the fall; no diagram of the resident's room and the of the resident as found at the time of the fall, a complete set of the neurochecks, and no root cause analysis. Medical record review revealed the following: On 1/14/2020 at 10:48 AM, of the Infection Note revealed .Review of (Resident #3's) S/Sx (signs/symptoms) of infection completed using McGeer's Criteria. diagnosed infection: uti (urinary tract infection) Medication Order: [MEDICATION NAME]. Care plan revised as indicated . On 1/20/2020 at 3:20 PM, of the Health Status Note, written by LPN #3, revealed .Nurse was called to resident's room by therapy. Resident was sitting in floor on her bottom at the foot of her bed, with her back leaned up against heater. When asked resident what she was doing she said, I stood up and I was trying to reach my cell phone and I fell over. No complaints of pain voiced. No injuries noted. Intervention: Signage to be used to remind resident to ask for assistance. (Named NP) was notified. (Named Family Member #3) was notified .(Named Director of Nursing) was notified. Will continue to monitor . On 1/21/2020 at 8:53 AM, of the Health Status Note revealed the .IDT met to discuss resident's fall from (1/20/2020). Resident fell while in her room. Intervention is to provide resident with a sign to ask for staff assist . Review of the facility investigation included the Supervisor Investigation of Fall, written by LPN #3, dated 1/20/2020, revealed Resident #3 fell on Monday, 1/20/2020 at 2:30 PM, in her room when she stood up from the wheelchair and was reaching for the cell phone and fell out of the wheelchair. The therapist found the resident on the floor. The resident had no injuries or complaint of pain. The facility's immediate intervention was to assist the resident up from the floor, with 2 staff assisting, back into the wheelchair. The recent had had recent falls and the facility started neurochecks. The physician and (Family Member #3) were notified. The intervention was signage. Review of the facility investigation included the undated, Staff's 10 Questions at the Time of a Resident Fall form, written by LPN #3, revealed Resident #3 stated she was okay, and had stood up to reach for her cell phone. The resident's position after the fall was described as sitting on her bottom with her back against the heater with her legs straight out and her arms in her lap. The environment was described as clean, dry, and uncluttered with good visibility. The resident was wearing shoes and socks with proper fitting clothing. There was no one in the area when the resident fell . Review of the facility investigation included the Resident Event Report Worksheet form, written by LPN #3, dated 1/20/2020, which revealed Resident #3 had a fall in her room while reaching which resulted in no significant injury. Further review revealed LPN #2 and CNA #2 were assigned to the resident. Interview with CNA #2 on 2/4/2020 at 1:07 PM, in the conference room revealed the CNA had been assigned to the resident but she had not witnessed the fall on 1/20/2020. CNA #2 stated she had been informed of the fall by a therapist. The therapist was working with another resident in the hallway and had walked past Resident #3's room when she saw Resident #3 on the floor. The CNA stated when she entered the room the resident was seated on her bottom with her back to the heater/air conditioner, her left side was next to the window wall, her right side was on the bed side, and her legs were straight out in front of her. The CNA asked the resident to wait to get a nurse to check her over. The CNA stated LPN #4 came to the room because LPN #2, assigned to the resident, was not available. LPN #4 assessed the resident and no injury was noted and 'we got the resident into the wheelchair.' Interview with LPN #3 on 2/4/2020 at 1:34 PM, in the conference room revealed the assigned nurse, LPN #2, had gone to lunch and she had responded to CNA #2's request to help with Resident #3. The LPN did not recall a therapist being involved. LPN #3 stated LPN #4 helped her get the resident off the floor. LPN #3 stated she called the NP and Family Member #3 regarding the fall. Interview with LPN #4 on 2/4/2020 at 1:57 PM, in the conference room revealed a therapist had walked down the hall and had said something to LPN #3, then .LPN #3 yelled for me . When LPN #4 got into Resident #3's room the resident was seated on the floor with her back to the heater/air conditioner. LPN #4 stated she and LPN #3 assessed the resident, got her up into her wheelchair, and obtained vital signs. Interview with LPN #2 on 2/4/2020 at 2:55 PM, in the conference room revealed the LPN was assigned to Resident #3 on 1/20/2020. The LPN stated .a therapist got LPN #3 in the hall, then LPN #3 or CNA #2, or someone, got me. The resident was on her buttocks with her back to the heater/air conditioner and her legs were in front of her . when the LPN got into the room. The LPN stated the resident was assessed for pain and injury, while she was on the floor, and she was okay. LPN #2 stated LPN #3 was in the room with LPN #2 but LPN #2 had no recall of LPN #4 being present. LPN #2 stated this LPN notified the NP and Family Member #3 of the fall. Further review of the investigation revealed no written statements by CNA #2, LPN #2, LPN #3, LPN #4, the NP, or the therapist seeing Resident #3 on the floor. The investigation provided failed to identify all the staff involved and failed to identify the therapist. There was no diagram of the resident's room and of the resident as found at the time of the fall, and no root cause analysis. The investigation did not include the potential of the UTI contributing to the fall. Interview with the Interim Director of Nursing on 2/4/2020 at 3:05 PM, in the conference room confirmed the facility failed .to obtain interviews from staff, the therapist, anyone involved with the fall. I understand what you're saying. The information isn't there and the investigation isn't complete .",2020-09-01
3396,NASHVILLE CENTER FOR REHABILITATION AND HEALING LL,445512,832 WEDGEWOOD AVENUE,NASHVILLE,TN,37203,2018-12-20,661,D,1,0,E5NC11,"**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 3 of 11 residents reviewed (#10, #18, and #20) were provided a post discharge plan of care. Additionally, the facility failed to develop a discharge summary for Resident #18. See F622 (Discharge) and F660 (Discharge Planning), for additional information regarding Resident #10. The findings include: Review of facility policy, Discharge Planning, undated, .Development of Discharge Plan .Social Services/designee will coordinate the obtaining of the required information from the Care Plan Team members to include .Current functional status and needs (from each discipline) .Progress notes and any subsequent revisions to the Discharge Plan to be recorded by all disciplines .Social services/designee and the care plan team will make an evaluation of alternate levels of care available, outside support systems available, and factors impacting on the continuous, uninterrupted needs of the resident . The policy did not address the importance of the involvement of the resident and/or their representative in the development of a post discharge plan of care. Medical record review of the Admission Record, revealed Resident #10 was admitted to the facility on [DATE] with dianoses of Altered Mental Status, Metabolic [MEDICAL CONDITION] (abnormal levels of electrolytes, water, and vitamins that possibly affect brain function), muscle weakness, and difficulty walking. Review of the 14 day Admission (MDS) data set [DATE] revealed a Brief Interview for Mental Status score 3 of 15 indicating she was severely cognitively impaired. A comprehensive review of the medical records revealed there was no documented evidence Resident #10, or her representative was provided a post discharge plan of care that was developed with the resident and/or her representative. Interview with the Administrator, Director of Social Services, Rehabilitation Director #109 and the Physical Therapist #112) revealed Director of Social Services stated there was a baseline care plan for Resident #10 and he/she would need to check with nursing if there was a post discharge plan of care for this resident. No further documents reflecting a discharge plan were ever provided to the SSA prior to exit from the facility. Medical record review of the Admission Record revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a social Servicces evaluation completed on 10/9/18 noted Resident #18's Brief Interview for Mental Status score was 6 out of 15 which indicated he was severely cognitively impaired. Interview with the interim Director of Nursing (DON) #11 on 12/20/18 at 4:02 PM confirmed there was no discharge summary completed by nursing for Resident #18, no documentation from the medical provider to address the stay of the resident and no post discharge plan of care for the resident. Interview with the interim DON #11 on 12/20/18 at 4:23 PM, revealed she stated an agency nurse was the person who opened the discharge summary and did not complete it for Resident #18. She confirmed there was no discharge summary, or a post discharge plan of care developed for this resident. Resident #20 was admitted on [DATE] with [DIAGNOSES REDACTED]. She was discharged on [DATE]. Medical record review of a care plan, last revised on 8/24/18, revealed Resident #20's placement in the facility was short term. The interventions included Assist with obtaining DME (durable medical equipment) and medical supplies prior to discharge. Educate resident and/or designated representatives about community resources. Facilitate discharge planning with all disciplines via CCP {Coordinated Care Plan) meeting. Identify resident support in community. Make appropriate referrals as needed i.e.(including) homecare. Provide resident and/or designated representatives with teachings as needed i.e. (including) medications, diet, wound care, adaptive equipment. Provide support and counseling re: (regarding) discharge concerns. Social Worker will meet resident and/or designated representatives to identify needs for discharge. Medical record review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #20's Brief Interview for Mental Status (BIMS) was 6 out of 15, indicating she had severe cognitive impairment. She required extensive assistance with bed mobility, transfers, dressing, eating, hygiene and toilet use. She required total assistance with bathing. Medical recod review of Resident #20's Discharge Summary, dated 9/19/18, revealed the resident was discharged home and [NAME] Discharge Instructions: 1. Discharge Instructions Provided. Medical record review of a Progress Note dated 9/19/18, revealed Resident #20 was discharged home with her daughter, no documentation the resident/family had been adequately prepared for discharge back to the community, and no documentation of referrals to home health services as recommended by physical therapy. Review of the Physical Therapy Discharge Summary, signed on 9/21/18, revealed the discharge recommendations included home health and assistive device for safe functional mobility and assistance with activities of daily living. Medical record review revealed there was no post-discharge plan of care or discharge instructions. There were no social work progress notes to indicate the social worker had met with the resident and/or family to identify needs for discharge. Interview with the Administrator on 12/20/18 at 5:40 PM, confirmed there was no post-discharge plan of care or discharge instructions given for Resident #20. Interview with Registered Nurse Manager #23 on 12/20/18 at 5:48 PM, revealed she was familiar with the resident and family. She stated she had provided discharge instructions and referrals to home care and confirmed she was unable to provide a copy of the post-discharge plan of care or discharge instructions.",2020-09-01
2193,HARRIMAN CARE & REHAB CENTER,445368,240 HANNAH ROAD,HARRIMAN,TN,37748,2018-04-11,609,D,1,0,IG0J11,"**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 an allegation of abuse was reported timely for 1 resident (#2) of 8 residents reviewed for abuse. The findings included: Review of facility policy Abuse, Neglect and Misappropriation of Property dated 11/16/17 revealed .(facility) policy .ensure that all alleged violations of federal or state laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident's property are investigated and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with the Federal and State laws .All alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than 2 hours after the allegation is made .all allegations and incidents of abuse or neglect, as defined in this policy, will be reported immediately . Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] for [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set Assessment ((MDS) dated [DATE] revealed Resident #2 scored a 9 (moderately cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive two staff assist for bed mobility, transfers, dressing, toileting, and personal hygiene. Continued review revealed the resident was frequently incontinent of bladder and always incontinent of bowel. Medical record review of a Nursing Note dated 3/1/18 at 7:14 PM revealed .Late Entry-Spoke with resident (Resident #2) RE (regarding) allegation that a staff member had treated (Resident #2) in an inappropriate manner yesterday .resident unable to recall any happenings . Interview with the Director of Nursing (DON) on 4/11/18 at 7:58 AM, in the conference room, confirmed the two Certified Nursing Assistants failed to report alleged abuse timely. Further interview revealed the incident occurred on 2/28/18 between 7:00 PM and 9:00 PM and the incident was not reported until 3/1/18 around 9:00 AM or 10:00 AM (approximately 12-14 hours later).",2020-09-01
4432,CREEKSIDE CENTER FOR REHABILITATION AND HEALING,445516,306 W DUE WEST AVENUE,MADISON,TN,37115,2016-10-24,514,L,1,0,CT4U11,"**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 medical records were complete and accurate for 7 (Resident #2, #3, #5, #6, #7,#8, #18) residents of 14 residents reviewed by failing to document physician notification of blood glucose results greater than 400; failing to document recheck of abnormal blood glucose values in 15 minutes; failing to document blood glucose monitoring and tube feedings as ordered by the physician; and failing to document tube feedings administered when a resident's meal intake was decreased. These failures 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 all facility residents. The Administrator (NHA) was notified of the Immediate Jeopardy on 10/24/16 at 3:25 PM in the Conference Room. The findings included: Review of facility policy, Change in a Resident's Condition or Status, undated, revealed, .To insure the proper and timely .documentation of any changes in a resident's condition or status .The nurse will record in the resident's medical record any changes in the resident's medical condition or status . Review of facility policy, Diabetes, Nursing Care of the Adult Diabetes Mellitus Resident, undated, revealed, .The purpose of this guideline is .Prevent recurrence of [MEDICAL CONDITION]/[DIAGNOSES REDACTED] (high and low blood sugars) .document the treatment of [REDACTED]. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].ACCUCHECKS (finger stick for blood sugar) BEFORE BOLUS FEEDINGS AND SSI (sliding scale insulin) AS FOLLOWS: 0-59 = CALL MD(Medical Doctor) .351-400 = 10u .NOTIFY MD AND RECHECK IN 15 MINUTES . Medical record review of the 6/2016 Medication Administration Record [REDACTED] 591 on 6/4 at 7:30 AM 432 on 6/6 at 6:00 AM 401 on 6/7 at 12:00 AM High on 6/9 at 12:00 PM 456 on 6/12 at 6:00 AM 429 on 6/18 at 6:00 AM Medical record review revealed no documentation the MD or Nurse Practitioner (NP) were notified regarding the elevated blood sugars, and no documentation the blood sugars were re-checked in 15 minutes. Medical record review of the 7/2016 MAR indicated [REDACTED] 564 on 7/1 at 6:00 AM 441 on 7/1 at 12:00 PM 503 on 7/6 at 12:00 AM 489 on 7/9 at 12:00 PM 518 on 7/10 at 12:00 AM 511 on 7/10 at 12:00 PM 405 on 7/12 at 12:00 AM 466 on 7/25 at 6:00 AM 459 on 7/27 at 12:00 AM 436 on 7/31 at 6:00 PM Medical record review revealed no documentation the MD or NP were notified of Resident #2's elevated blood sugars, and no documentation the blood sugars were re-checked in 15 minutes. Medical record review of the 8/2016 MAR indicated [REDACTED] 475 on 8/1 at 12:00 AM 492 on 8/7 at 6:00 PM 456 on 8/20 at 6:00 PM 432 on 8/21 at 6:00 PM 493 on 8/25 at 6:00 PM Medical record review revealed no documentation the MD or NP were notified regarding the elevated blood sugars, and no documentation the blood sugars were re-checked in 15 minutes for Resident #2. Medical record review of the 9/2016 MAR indicated [REDACTED] 423 on 9/3 at 12:00 PM 487 on 9/4 at 6:00 PM 47 on 9/7 at 12:00 PM 452 on 9/10 at 12:00 PM 482 on 9/16 at 12:00 AM 434 on 9/17 at 6:00 AM 491 on 9/17 at 12:00 PM 501 on 9/22 at 12:00 PM 560 on 9/23 at 6:00 AM 474 on 9/23 at 12:00 PM 420 on 9/26 at 12:00 AM Medical record review revealed no documentation the MD or NP were notified regarding the elevated blood sugars, and no documentation Resident #2's blood sugars were re-checked in 15 minutes. Interview with LPN #6 on 10/19/16 at 7:15 AM in the conference room confirmed Resident #2's blood sugar was 47 on 9/7/16 and she failed to document the results of the blood sugar after rechecking it, and failed to document the physician was notified. Medical record review of the 10/16 MAR indicated [REDACTED]. Medical record review revealed no documentation the MD or NP was notified regarding Resident #2's elevated blood sugars, and no documentation the blood sugar was re-checked in 15 minutes. Interview with the Director of Nursing (DON) on 10/19/16 at 4:05 PM, in the conference room confirmed the facility failed to document the MD or NP were notified of the elevated blood sugars, and failed to document the blood sugar was re-checked 15 minutes after identifying it was greater than 400. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's telephone order dated 9/12/16 revealed, .[MEDICATION NAME] HCL (used to treat low blood pressure) 5 mg tab (tablet) give one tab PT (per tube) before meals; BP (blood pressure) to be checked prior to administration, Hold for BP (systolic greater than 120 or diastolic greater than 80) . The order was written by LPN #4 and signed by NP #1. Medical record review of the MAR indicated [REDACTED]. Interview with the DON on 10/19/16 at 4:05 PM, in the conference room confirmed the facility failed to follow their policy for documentation and failed to document blood sugar and/or blood pressure results per physician orders [REDACTED].#3. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's admission orders [REDACTED]. Continued review revealed if the blood glucose was greater than 400 the nurse was to notify the physician. Medical record review of the blood glucose monitoring record and the MAR indicated [REDACTED]. continued review revealed no documentation the blood glucose was rechecked in 15 minutes per physician orders [REDACTED]. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's admission orders [REDACTED]. Continued review revealed the order stated if the resident's blood glucose was greater than 400 the nurse was to administer 10 units of insulin and notify the physician. Medical record review of the blood glucose monitoring sheets and the MAR indicated [REDACTED] a. 9/20/16 blood glucose 593 at 9:00 PM b. 9/24/16 blood glucose 405 at 9:00 PM c. 9/29/16 blood glucose 421 at 1:00 PM d. 9/29/16 blood glucose 423 at 5:00 PM e. 10/4/16 blood glucose 405 at 6:15 PM Continued review revealed no documentation the physician was notified of any of these abnormal blood glucose results. Further review revealed no documentation the blood glucose was repeated in 15 minutes per physician order [REDACTED]. Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's admission orders [REDACTED]. If BS (blood sugar) > (greater than) 400 notify MD and recheck in 15 minutes . Medical record review of the blood glucose monitoring record and the MAR indicated [REDACTED]. Continued review revealed no documentation the physician was notified of the abnormal blood glucose result. Further review revealed no documentation the blood glucose was rechecked in 15 minutes per physician order [REDACTED]. Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's admission orders [REDACTED]. Continued review revealed if the blood glucose was greater than 400 the nurse was to notify the physician and recheck the blood glucose in 15 minutes. Medical record review of the blood glucose monitoring record and the MAR indicated [REDACTED]. Continued review revealed there was no documentation the physician was notified of the abnormal blood glucose result. Further review revealed no documentation the blood glucose was rechecked in 15 minutes per physician order [REDACTED]. Medical record review of physician's orders [REDACTED].Please give 8 ounces [MEDICATION NAME] (liquid feeding given via tube for residents who are unable to swallow) 1.5 per tube as needed if meal intake is less than 50% . Continued review of physician orders [REDACTED].[MEDICATION NAME] 1.5 cal liquid, Give 8 ounces per tube BID (twice daily) between meals with 120 ml (milliliters) H2O flush before and after each bolus . Medical record review of the Medication Administration Record [REDACTED]. Continued review revealed the 8 ounces to be given with food intake less than 50% was scheduled for 9:00 AM, 1:00 PM, and 7:00 PM. Further review of the MAR indicated [REDACTED]. Medical record review of nursing notes for 10/2016 revealed no documentation the [MEDICATION NAME] was given between meals as ordered. Interview with Licensed Practical Nurse (LPN) #7 on 10/17/16 at 3:05 PM in the conference room, revealed she documented the amount the resident ate and put a check mark to indicate she was aware of the amount the resident ate. continued interview revealed if the resident ate less than 50% of the meal the nurse would administer [MEDICATION NAME] to the resident. Interview with LPN #3 on 10/17/16 at 3:11 PM in the conference room revealed nurses place a check mark on the MAR indicated [REDACTED]. Continued interview revealed if the resident ate less than 50% the staff would give [MEDICATION NAME] because that was the order. Further interview revealed LPN #3 was not aware of any place to document the [MEDICATION NAME] when it it given. Continued interview revealed .If the amount the resident eats is less than 50% we assume the nurse administered the [MEDICATION NAME] . Review of facility policy, Negative Pressure Wound Therapy (NPWT), undated revealed, .Inspect condition of wound on ongoing basis; note drainage and odor .verify airtight dressing seal and correct negative pressure setting. Measure wound drainage output in canister .Chart in the nurses's notes the appearance of wound, color, characteristics of any drainage .NPWT pressure setting, dressing change, and resident response to dressing change . Medical record review revealed Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] revealed the resident was severely cognitively impaired, always incontinent of bowel and bladder and had a Stage IV pressure ulcer to the sacrum. Medical record review of a physician's telephone order dated 10/10/16 prescribed by NP #3 revealed, .Coccyx pressure area - NPWT to pack/fill woundbed & drape to seal .Continue AG Collagen to cover coccyx wound bed each Vac (change) . Observation of Resident #18 on 10/18/16 at 10:20 AM, in the resident's room revealed the resident was in bed, eyes closed. A wound vac was present to the side rail with serous drainage noted. Interview with the Wound Nurse on 10/19/16 at 11:30 AM in Hermitage Hall when asked when the resident's wound vac was placed stated, Friday. (10/14). Continued interview revealed when asked what the treatment order dated 10/10 meant the Wound Nurse stated, that the wound vac was there. Continued interview revealed the Wound Nurse confirmed she documented care of the resident and the wound vac on 10/13, 10/14, 10/17, 10/18, and 10/19. Further review revealed there was no additional documentation of when the wound vac was placed, the negative pressure setting, how often it was to be changed, amount and color of drainage or how the resident was tolerating it. The Wound Nurse stated, I should have documented all of that. Interview with the DON on 10/19/16 at 4:05 PM in the conference room confirmed the Wound Nurse should have clarified the 10/10/16 treatment order for the wound vac to Resident #18 on 10/10/16, and most certainly when the wound vac was placed. Continued interview with the DON confirmed there should have been documentation of the amount, color and odor of drainage, how the resident was tolerating the wound vac, the amount of negative pressure the wound vac was set on, and the type of wound vac machine and there was not. Interview with LPN #8 on 10/20/16 at 1:00 PM in the conference room confirmed she had cared for the resident on 10/15/16 and had documented on the TAR she had followed the treatment order dated 10/10/16. When asked what the protocol was for care of a resident with a wound vac she stated, It is changed every Monday, Wednesday, and Friday and it is done by the Treatment (Wound) Nurse. When asked what her documentation of the order meant, she stated, I've never changed a wound vac before. I checked that it was there. Continued interview with the LPN confirmed she did not provide any care, or documentation of the wound, or wound vac for Resident #18. Telephone interview with LPN #11 on 10/20/16 at 4:50 PM confirmed she had cared for the resident on 10/16/16. When asked what care she provided to the resident she stated, He had a wound vac to his sacrum. I changed the tape. The wound was exposed and I secured the dressing with tape. Continued interview with the LPN confirmed she did not change the dressing, or document the status of the wound, wound vac settings, drainage type and amount, or how the resident was tolerating the care. Refer to F157 K, F224 L SQC, F281 L, F332 L SQC, F333 L SQC, F353 L, F490 L, F493 L, F501 [MI]",2019-10-01
2501,"NHC HEALTHCARE, FARRAGUT",445415,120 CAVETT HILL LANE,KNOXVILLE,TN,37922,2017-10-25,323,D,1,1,1WES11,"**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 safety of 1 resident (#366) of 3 residents reviewed for accidents. The findings included: Review of the Facility Policy Falls revised 7/14/17, revealed, .Assessment and Recognition .As part of the initial assessment .identify individuals with history of falls and risk factors for subsequent falling .based on preceding assessment .identify pertinent interventions to try to prevent subsequent falls . Medical record review revealed Resident #366 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) 5 Day Scheduled assessment dated [DATE], revealed Resident #366 required extensive assistance with activities of daily living (ADLs) and 2 person physical assist for transfers. Medical record review of Resident #366's Completed Care Plan dated 8/30/17, revealed no documentation the resident required 2 person physical assist with transfers. Medical record review of the MDS 30 Day Scheduled assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, meaning the resident was cognitively intact. Continued review revealed Resident #366 required extensive assistance with ADLs and 2 person physical assist for transfers. Medical Record review of the MDS Unscheduled assessment dated [DATE] revealed Resident #366 required 2 person physical assist for transfers. Medical record review of the Post Falls assessment dated [DATE] at 10:00 PM, revealed, .transfer from recliner to wheelchair and patient was facing recliner with wheelchair behind her when patients knees seemed to buckle. Patient's legs gave out and patient started going down .gently lower patient to knees on the floor . Continued review revealed, .immediate interventions .2 person assist for all transfers . Further review revealed one staff person was present to assist during the transfer. Medical Record review of the Daily Skilled Nursing Notes dated 9/30/17 at 10:00 PM, revealed, .fall/let down to floor .(no) injuries noted .new intervention to have assist (times 2) for all transfers . Interview with Registered Nurse #1 on 10/24/17 at 3:55 PM, in the conference room, confirmed the MDS assessment was accurate and the resident was assessed as requiring 2 persons for transfers. Interview with the Director of Nursing on 10/24/17 at 4:39 PM, in the conference room confirmed, the failed to provide a safe transfer for Resident #366 as indicated by the resident's comprehensive assessment.",2020-09-01
1825,WYNDRIDGE HEALTH AND REHAB CTR,445304,456 WAYNE AVENUE,CROSSVILLE,TN,38555,2018-08-29,689,G,1,1,6O4N11,"**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 safety of 2 residents (#19, #4) of 6 residents reviewed for accidents, of 31 sampled residents. The facility's failure to ensure a safe transfer resulted in actual Harm to Resident #19 when the resident received a fractured femur from an improper transfer. The findings include: Review of the Facility Policy, Falls Management, undated, revealed, .Policy: Residents at risk for falls are identified to prevent future falls and maintain maximum level of function through use of interventions, as appropriate. Procedures: 1. A fall assessment will be completed on admission, quarterly (following the MDS (Minimum Data Set) schedule) and as needed. 2. The Care Plan will reflect measures implemented to prevent falls as appropriate. 3.) The Committee members will maintain/monitor as indicated .New interventions to Care Plan . Medical record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #19's Significant Change of Status, MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating the resident was moderately cognitively impaired with decisions of daily care. Continued review revealed the resident required extensive assistance with activities of daily living (ADLs), and 2 person assist for transfers and toileting. Medical record review of Resident #19's care plan initiated 1/26/16 and revised 10/4/17, revealed an intervention for assistance for the resident of 1-2 persons with transfers as needed and the use of a gait belt. (A gait belt is a device used by caregivers to transfer care receivers with mobility issues from one position to another, from one location to another or while assistively ambulating patients who have problems with balance.) Medical record review of a Fall Risk assessment dated [DATE] revealed Resident #19 was a high risk for falls. Medical record review of the Nurses Note dated 1/5/18, timed 12:50 PM, revealed, Called to room by staff. Res (resident) found in bathroom, bullfrog legged on floor. CNA had attempted to transfer res back to wc (wheelchair) when res fell to floor .therapy transferred resident back to wc. Res c/o (complained of) pain to right leg. When back to bed, attempted to reposition res when she began to cry with pain to right leg/hip .(physician notified) .new order noted to transfer res to .ER (emergency room ) for eval (evaluation) and tx (treatment). Review of a facility fall investigation dated 1/5/18 at 12:50 PM revealed .CNA (Certified Nursing Assistant) was attempting to assist resident back to w/c (wheelchair) when legs went out & (and) resident fell to floor, resident sitting bullfrog legged on floor in bathroom. No gait belt was used. Medical Director and family notified . Interventions were implemented to include staff education on the use of gait belts, and all transfers to be 2 person assist. Medical record review of a discharge note from Erlanger Hospital 1/10/18 revealed .Primary discharge Diagnoses: [REDACTED].brought in by EMS (emergency management system) to the emergency room complaining of right thigh/leg pain status [REDACTED].initially taken to .(name of hospital) where x-ray showed fractured so she was transferred here .(a larger hospital) for orthopedic surgery consult .ortho .now stable . Interview with MDS Licensed Practical Nurse (LPN) #1 on 8/29/18, at 8:56 AM in the conference room revealed the LPN had cared for the resident in the past and although Resident #19's care plan stated the resident was a 1-2 person assist for transfers, she would have asked for help transferring the resident and would consider the resident a 2 person assist for transfers. Interview with LPN #2 on 8/29/18, at 9:24 AM, in the conference room confirmed LPN #2 had been working on Resident #19's hall on 1/5/18 when the fall occurred. The LPN stated to safely transfer Resident #19, you would need the assistance of 2 persons. Further interview revealed the Nurse Aide (NA) who transferred the resident in the bathroom on 1/5/18 was in training, and the CNA training her was on break at the time of the fall. Interview with Risk Management LPN #3 on 8/29/18, at 9:40 AM, in the conference room, revealed LPN #3 was in charge of investigating falls and completing reports on falls. The LPN stated Resident #19 required 2 persons to ensure a safe transfer on the day of the fall, and only had the assistance of 1 person for the transfer, a newly employed Nurse Aide, still in training with a CNA who was on a break at the time of the fall, which resulted in a fractured femur. Interview with the Director of Nursing (DON) on 8/29/18, at 10:20 AM, in the conference room confirmed the Nurse Aide trainee should not have been transferring the resident by herself on the day of the resident's fall. Continued interview confirmed the resident should have been transferred with 2 persons for a safe transfer. The DON confirmed the facility's failure to ensure a safe transfer for Resident #19 resulted in a fall with Harm on 1/5/18. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #4's 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 of the MDS revealed the resident had a [DIAGNOSES REDACTED]. Medical record review of Resident #4's Fall Risk assessment dated [DATE] revealed a score of 6, with a 10 or above indicating high risk for falls. Medical record review of Resident #4's care plan dated 11/8/17 with revision date 6/6/18 revealed .Assist (Resident #4) with transfers .use assist of 1-2 . Review of a facility fall investigation dated 6/6/18 revealed .Resident (#4)being transferred to w/c (wheelchair) by staff became unstable et (and) fell to floor . Interview with Certified Nurse Assistant (CNA) #1 on 8/28/18 at 2:12 PM in the Conference Room revealed she went to the resident's room on 6/6/18 and observed CNA #2 and Resident #4 on the floor in the resident's room. Further interview with CNA #1 revealed the resident required a 2 person assist with transfers, and only CNA #2 was present for the transfer at the time of the fall. Interview with MDS Nurse #1 on 8/28/18 at 3:35 PM in the Conference Room confirmed the Resident (#4) required a 2 person assist to ensure a safe transfer.",2020-09-01
3389,NASHVILLE CENTER FOR REHABILITATION AND HEALING LL,445512,832 WEDGEWOOD AVENUE,NASHVILLE,TN,37203,2017-09-27,281,D,1,0,9IDG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to follow Physician order [REDACTED].#3) of 8 residents reviewed for medication administration. The findings included: Review of facility policy, Medication Administration, revealed .Nursing Care Center Pharmacy and Procedure Manual .Medications are administered in accordance with written orders of the prescriber . Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a physician's orders [REDACTED].[DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Medical record review of the Narcotic Sheet dated 5/15/17 revealed [MEDICATION NAME]-[MEDICATION NAME] 10-325, 1 tablet every 6 hours for pain were not signed out on 5/15/17 for the 12:00 AM dose or the 6:00 AM dose. Telephone interview on 9/27/17 at 2:00 PM with Licensed Practical Nurse (LPN) #15 revealed the resident had left the faciity on [DATE] with family and returned around 11:00 PM that night. Further interview revealed the day shift nurse had given the resident her night medication (which included her pain medication) to take with her because she wouldn't be back in the facility until later that night. Continued interview revealed the resident requested her night medication when she returned at 11:00 PM and LPN #15 told her she couldn't give her the night medication again because she had taken it with her when she left the facility and this would over medicate her. Further interview revealed the resident was told if she had any pain to let her know and she would ask her supervisor what she could do. Continued interview revealed she helped the resident use the bedside commode and get into bed and never heard anything else from the resident that night. Further interview revealed LPN #15 did not give the12:00 AM dose of her pain medication because she did not know when the resident had taken her pain medication that night before coming back to the facility at 11:00 PM. Continued interview with LPN #15 revealed she did not give the 6:00 AM scheduled dose of pain medication to the resident and could not remember why. Interview on 9/27/17 with the Assistant Director of Nursing (ADON) at 3:00 PM in the Director of Nurse's office revealed she expected nurses administrating medications to follow physician's orders [REDACTED].",2020-09-01
1806,LIFE CARE CENTER OF ELIZABETHTON,445302,1641 HIGHWAY 19E,ELIZABETHTON,TN,37643,2017-11-01,309,D,1,1,VBW711,"**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 a physician's order for [MEDICAL CONDITION] care and failed to process a physician's order for an antibiotic for 1 resident (Resident #138) of 25 residents reviewed. The findings included: Review of the facility policy, Administration of Medication not dated revealed, .medications are administered safely .appropriately .initial each medication in the correct box on the MAR (medication administration record) after the medication is given .circle initials on MAR indicated [REDACTED].check .drawers .if it was placed in the wrong drawer .call the pharmacy or supervisor to obtain the medication . Review of the facility policy [MEDICAL CONDITIONS], or [MEDICATION NAME], revised 11/28/16 revealed, .procedure developed to provide a safe standard method for the care and maintenance of a patient with a [MEDICAL CONDITION] .physician's order will be obtained for ostomy care .regarding appliance .barrier .skin care .documentation .time .initials of person doing treatment .develop the comprehensive person-centered careplan . Review of the facility policy Physician's Orders/Transcription revised 10/2004 revealed .proper channels of communication are used to ensure accurate delivery of medications and treatments .receiving an order .physician .must write order on order sheet .each time .nurse charts .physician orders section should be checked for new orders .sign .order sheet .indicating orders have been transcribed .draw line on order sheet below the order .send copy to pharmacy . Resident #138 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #138 had a Brief Interview of Mental Status (BIMS) score of 12, indicating Resident #138 had moderate cognitive impairment. Continued review revealed Resident #138 required limited assistance of one person physical assist for personal hygiene. Further review revealed Resident #138 used an ostomy for bowel continence. Medical record review of the Physician Orders dated 11/2016 revealed .change ostomy wafer and bag weekly .start date 9/9/16 . Medical record review of the Progress Notes dated 11/11/16 revealed .Resident's daughter .in facility on 11/10/16 .noted .ostomy bag/wafer .not been changed as ordered . Medical record review of the MAR indicated [REDACTED]. Medical record review of the Physician/Prescriber Telephone orders dated 11/23/16 revealed .[MEDICATION NAME] (antibiotic) 1gm (gram) IV (intravenous) Q (every) day x (times) 10 days . Medical record review of the MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 10/31/17 at 3:26 PM, in the DON's office, confirmed the [MEDICAL CONDITION] care was not done on 11/2/17, and the [MEDICATION NAME] was not administered until 11/24/17.",2020-09-01
4223,CREEKSIDE CENTER FOR REHABILITATION AND HEALING,445516,306 W DUE WEST AVENUE,MADISON,TN,37115,2016-12-14,281,E,1,0,0GRH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to follow physician's orders for medication administration for four residents (#15, #22, #25, #36) of 37 residents reviewed for medication administration, and failed to follow physician's orders for administration of tube feeding for 1 resident (#13) of 3 residents reviewed for tube feeding. The findings included: Review of facility policy, Identifying and Managing Medication Errors and Adverse Consequences, revised (MONTH) 2007, revealed .The staff and practitioner shall try to prevent medication errors and adverse medication consequences, and shall strive to identify and manage them appropriately when they occur. The staff and practitioner shall strive to minimize adverse consequences by: (a) following relevant clinical guidelines and manufacturer's specifications for use. (b) defining appropriate indications for use . Medical record review revealed Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #15 was moderately impaired cognitively. Continued review of the MDS revealed Resident #15 required extensive assistance with transfers, dressing, and grooming; was dependent for feeding and bathing; and was always incontinent of bowel and bladder. Medical record review of physician's orders dated 12/6/16 revealed an order for [REDACTED]. which was documented as administered. Further review of physician's orders revealed Resident #15 was also being treated for [REDACTED]. Continued review of orders dated 12/7/16 revealed orders for .[MEDICATION NAME] 40 mg IM x1 . and .[MEDICATION NAME] 20 mg po (orally) daily for [MEDICAL CONDITIONS] . Medical record review of the Medication Administration Record (MAR) revealed one sheet with the [MEDICATION NAME] 40 mg IM documented as administered on 12/8/16 at 3:00 PM. Continued review revealed [MEDICATION NAME] 20 mg one tab by mouth daily was documented on the MAR and scheduled for 9:00 AM but no doses were signed off. Further review revealed a second MAR, undated, with [MEDICATION NAME] 20 mg PT (per tube) daily scheduled for 9:00 AM and documented as administered on 12/8/16, 12/9/16, 12/11/16, and 12/12/16. Medical record review of nursing notes dated 12/13/16 revealed .Noted resident not getting [MEDICATION NAME] 20 mg PT daily ordered on 12-7-16, (named physician) made aware and new order to start [MEDICATION NAME] 20 mg PT daily x 5 days . Medical record review of the MAR for (MONTH) (YEAR) revealed an undated entry for [MEDICATION NAME] 20 mg PT daily x5 days with a start date of 12/13/16 and initialed as administered on 12/13/16 then D/C'd (discontinued). Medical record review of nursing notes dated 12/13/16 at 5:53 PM revealed .In reviewing MAR [MEDICATION NAME] found to be administered per order . Continued review of notes dated 12/14/16 of a note from the Unit Manager, revealed .This writer notified MD of [MEDICATION NAME] administration and number of days medication given. Received order to D/C [MEDICATION NAME] . Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 3 indicating the resident was severely impaired cognitively. Medical record review of physician's orders dated 1/27/15 revealed an order for [REDACTED]. Medical record review of the MAR for (MONTH) (YEAR) revealed on 11/25/16 Resident #22's blood pressure was 104/50. Continued review revealed there was no documentation on the MAR the medication was held. Further review revealed no circle around the initials of the nurse administering the medication as is the standard when a medication is held. Continued review of nursing notes revealed no documentation the medication was held. During interview on 12/13/16 at 1:27 PM in the conference room, the Director of Nursing (DON) confirmed the DBP was Medical record review of a [MEDICAL CONDITION] consult dated 11/15/16 revealed .Doppler shows occlusion of left posterior tibial artery. American Heart Association recommends [MEDICATION NAME] as alternative to Aspirin in reducing risk of [MEDICAL CONDITION], Vascular Death, and [MEDICAL CONDITION] Infarction in [MEDICAL CONDITION] patients . Medical record review of physician's orders dated 11/2/16 revealed an order for [REDACTED]. Medical record review of nursing notes dated 11/29/16 revealed .Physician .notified of med error r/t (related to) [MEDICATION NAME] order. Resident assessed with [REDACTED]. NO (new order) written to begin [MEDICATION NAME] 75 mg QD (daily). During interview on 12/14/16 at 12:00 noon in the conference room, the DON confirmed the nurses failed to follow physician's orders for the [MEDICATION NAME] and failed to administer the [MEDICATION NAME] from 11/17/16 - 11/29/16. Medical record review revealed Resident #25 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 #25 scored 15 on the BIMS indicating she was alert and oriented. Continued review revealed Resident #25 required extensive assistance with transfers, dressing, grooming, and bathing; assistance with eating; and was always continent of bowel and bladder. Medical record review of physician's orders dated 11/30/16 revealed Resident #25 was ordered [MEDICATION NAME] 50 mg daily. Medical record review of nursing notes dated 12/13/16 for a late entry on 12/12/16 revealed .Discovered scheduled 9pm [MEDICATION NAME] doses for 12/10/16 and 12/11/16 were inadvertently omitted. Daughter & MD notified of med errors . Review of the Narcotic Administration Record for the resident's [MEDICATION NAME] revealed no doses signed out for 12/10/16 and 12/17/16. During interview on 12/14/16 at 10:47 AM in the conference room, the DON confirmed 2 doses of [MEDICATION NAME] were not signed out or documented as being administered on 12/10/16 and 12/11/16. Medical record review revealed Resident #36 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a physician's order dated 9/9/16 for [MEDICATION NAME] (antidepressant) 15 mg (milligram) tablet give 1/2 tablet (7.5 mg) by mouth at bedtime daily. Observation of Licensed Practical Nurse (LPN) #1 on 12/12/16 at 11:10 PM in the resident's room revealed the LPN administered 2 (two) 7.5 mg tablets to the resident. Interview with LPN #1 on 12/13/16 at 12:10 AM at the Hermitage Nurse Station and medication cart confirmed she had given 2 (two) 7.5mg tablets instead of 1 (one) 7.5mg tablet to Resident #36. Interview with the Director of Nursing (DON) on 12/14/16 at 3:10 PM in the conference room confirmed LPN #1 gave the wrong dosage of [MEDICATION NAME] to Resident #36 on 12/12/16, and failed to follow the physician's order. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS revealed Resident #13 was severely impaired cognitively; required extensive assistance with transfers, dressing, grooming, and bathing; required tube feedings; and was always incontinent of bowel and bladder. Medical record review of physician's orders dated 10/28/16 revealed Resident #13 was ordered [MEDICATION NAME] 1.5 cal at 60 ml/hr for 22 hours as tube feeding. Medical record review of nursing notes dated 11/30/16 at 7:33 AM revealed .Noted upon making rounds resident has [MEDICATION NAME] 1.2 cal infusing via peg (feeding tube). Order on MAR is [MEDICATION NAME] 1.5 cal. [MEDICATION NAME] 1.2 stopped; resident's peg tube flushed; placement verified; residual checked; and correct tube feeding started . During interview on 12/14/16 at 12:01 PM in the conference room, the DON confirmed one strength tube feeding was ordered and another strength tube feeding was hanging. Continued interview revealed the tube feeding bottles are stored in the storage room on the first floor by the nurses' station and nurses will go into the room to obtain the next bottle.",2019-11-01
4812,GRACE HEALTHCARE OF WHITES CREEK,445281,3425 KNIGHT DRIVE,WHITES CREEK,TN,37189,2016-07-08,281,E,1,0,TQUZ11,"**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 facility policy on Intake and Output for 3 (Resident #1, 3, 4) of 3 residents reviewed; failed to document the use of [MEDICAL CONDITION] (Continuous Positive Airway Pressure) on the Medication Administration Record [REDACTED]. The findings included: Review of the facility policy entitled Intake and Output, Conditions Requiring, revealed .Recording of Intake and Output will be done with the goal of providing continuing assessment information, therefore the Physician and or the Director of Nursing/Nurse Managers may place a resident on Intake and Output or discontinue Intake and Output if the resident's clinical condition deems appropriate . 2. Residents with the following conditions and [DIAGNOSES REDACTED]. Residents with a Foley catheter .d. Residents on fluid restriction .3. Nursing staff will record Intake and Output per facility documentation protocols . Review of the facility policy entitled Fluids, Restricted revealed . It is the policy of this facility to safely provide to the resident the amounts of fluids indicated by the physician's order .Fluids will be provided upon request and at times designated . Fluids consumed by the resident are to be accurately measured and recorded. Intake record should be maintained during the time the resident is on restricted fluids . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored 8 on the Brief Interview for Mental Status (BIMS) indicating she was moderately cognitively impaired. Continued review of the MDS revealed Resident #1 required extensive assist with transfers; was independent with eating; was incontinent of bowel; and had a Foley catheter in place. Medical record review revealed Resident #1 was admitted to the hospital on [DATE] due to shortness of breath which occurred during a physician's appointment. Medical record review of transfer orders dated 11/25/15 revealed Resident #1 was continued on [MEDICATION NAME] (diuretic medication) 80 mg (milligrams) daily and .Fluid restriction 1500 milliliters (ml) . was added to the recapitulation orders after being signed by the physician. Continued review of the orders revealed Resident #1 was readmitted to the facility with a Foley catheter in place. Medical record review of an undated fluid restriction form, which the Director of Nursing (DON) confirmed was applicable to the resident when she returned from the hospital on [DATE], revealed Resident #1 was on a 1500 ml fluid restriction with dietary providing 720 ml at breakfast, 240 ml at lunch, and 240 ml at dinner. Continued review revealed nursing was to give the resident 150 ml fluid during the day and 150 ml fluid during the evening. Medical record review of the Counted Intake and/or Output Roster completed by the Certified Nursing Aides (CNA) revealed documentation of the fluid amounts sent up on each tray by dietary as well as the Foley catheter output. Continued review revealed no documentation of the 300 ml fluids nursing was allowed to give the resident or the amount of fluids administered along with medications. Further review of the form revealed Resident #1 should have received 31,500 ml of fluid from 11/26/15 - 12/16/15 but only received 25,740 ml. Continued review revealed the resident had no fluid intake on 19 occasions when she refused a meal. Medical record review of physician's admission orders [REDACTED]. Continued review revealed an order for [REDACTED]. Interview with the DON on 6/30/16 at 10:45 AM in the conference room, confirmed the [MEDICAL CONDITION] was not reordered when Resident #1 was readmitted to the facility on [DATE]. Medical record review revealed Resident #3 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 #3 scored 8 on the BIMS, indicating she was moderately cognitively impaired. Continued review of the MDS revealed Resident #3 required extensive assistance of 3 people for transfers; required set up assistance for eating; and was occasionally incontinent of bowel and bladder. Medical record review of physician's orders dated 1/11/16 revealed Resident #3 was placed on a fluid restriction of 2000 ml daily. Medical record review of nursing notes dated 1/11/16 revealed dietary would provide the resident with 720 ml with breakfast; 240 ml with lunch; and 240 ml with dinner. Further review revealed there were 800 ml which nursing could administer but there was no documentation in the medical record of fluids administered to the resident by nursing; no documentation of fluids administered with medications; and no record of intake and output. Continued review revealed Resident #3 received [MEDICATION NAME] 80 mg daily. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #4 scored 12 on the BIMS indicating slight cognitive deficit. Continued review of the MDS revealed Resident #4 required assistance of 1 person with transfers; and had occasional bladder incontinence and frequent bowel incontinence. Medical record review of physician's orders dated 4/12/16 revealed Resident #4 was placed on a fluid restriction of 1500 ml daily. Continued review revealed dietary would provide the resident 720 ml for breakfast, 240 ml at lunch, and 240 ml at dinner. Further review revealed nursing could provide 300 ml to the resident over 24 hours. Continued review revealed Resident #4 received [MEDICATION NAME] 80 mg daily. Medical record review of nursing notes revealed no documentation of the amount of fluids administered to the resident with medications; no documentation of fluids administered by nursing; and no documentation the resident was on a fluid restriction. Interview with the DON on 7/6/16 at 8:20 AM in the DON's office confirmed the facility does not keep intake and output on any residents unless the physician orders it for a special case in spite of the fact the facility policy states MD/DON/Nurse Manager may order Intake and Output. Further interview confirmed there was no documentation of resident intake of fluids allotted to nursing and no documentation of the amount of fluids administered with medications. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders dated 11/20/15 revealed an order for [REDACTED].>Medical record review of the MAR for (MONTH) and (MONTH) (YEAR) revealed no documentation the resident was on [MEDICAL CONDITION] and there was no order to discontinue the [MEDICAL CONDITION]. Interview with the DON on 6/30/16 at 10:45 AM in the conference room, confirmed the [MEDICAL CONDITION] was not reordered when Resident #6 returned to the facility on [DATE] and the use of the [MEDICAL CONDITION] was not reflected on the MAR for (MONTH) or December. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the hospital medication discharge orders dated 5/20/16 and the facility admission (MONTH) (YEAR) Physician Orders recapitulation form, signed by the facility physician on 5/24/16, included the diabetic medication [MEDICATION NAME] ER (extended release) 500 mg (milligrams) 2 tablets by mouth twice a day for 5 days; then increase to 1000 mg twice daily. Further review revealed the hospital discharge orders and the facility recapitulation form included Polyethylene [MEDICATION NAME] 3350 (for constipation) 17 gm (grams) orally every 24 hours. Medical record review of telephone physician orders revealed no changes regarding the [MEDICATION NAME] or the Polyethylene [MEDICATION NAME] medications from admission to 5/23/16. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED].administration .except on Mondays and Thursdays . Interview with Licensed Practical Nurse #1 on 6/30/16 at 12:55 PM at the back nursing station confirmed, the Polyethylene [MEDICATION NAME] was not administered as ordered daily after 5/23/16 when the MAR indicated [REDACTED].administer .except on Mondays and Thursdays . Interview with ADON #1 on 6/30/16 at 2:30 PM in the ADON's office confirmed, the ADON had incorrectly changed the [MEDICATION NAME] and Polyethylene [MEDICATION NAME] data entry in the MAR indicated [REDACTED].except on Mondays and Thursdays .and the facility had failed to follow the physician order to administer the [MEDICATION NAME] twice daily and the Polyethylene [MEDICATION NAME] daily.",2019-07-01
4715,OVERTON COUNTY HEALTH AND REHAB CENTER,445419,318 BILBREY STREET,LIVINGSTON,TN,38570,2016-08-18,281,D,1,0,HM2S11,"**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 their policy to obtain urine cultures for residents with cloudy urine for 1 (Resident #4) of 6 residents reviewed. The findings included: Review of policy entitled Culture tests and confirmed by the DON on 8/16/16 at 3:30 PM as being the policy the facility currently follows, revealed .Urine cultures may be obtained by the Charge Nurse if a resident develops cloudy urine or other signs of urinary tract infection. An order from the physician must be obtained before the specimen is sent to the laboratory . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 scored 4/15 on the Brief Interview for Mental Status indicating she was severely impaired cognitively. Continued review of the MDS revealed Resident #4 was totally dependent on 2 staff for transfers and bathing; was totally dependent on 1 person for eating; required extensive assistance of 2 people for dressing and grooming; had a Foley catheter in place; and was frequently incontinent of bowel. Medical record review of a communication with the physician dated 12/29/15 revealed .Family noted dark colored urine which they verbalized was indicative of a UTI (urinary tract infection). (MONTH) we obtain UA (urinalysis) to verify? . Continued review revealed the physician responded on 1/2/16 to obtain one by an in and out catheterization. Further review revealed a note from the physician's office dated 1/4/16 stating .do not obtain UA D/T (due to) ABT (antibiotics) in use . Medical record review of nursing notes dated 1/13/16 revealed Resident #4 had a Foley catheter which was draining cloudy urine with sediment. Continued review of notes dated 1/15/16 revealed the Foley catheter was draining cloudy yellow urine with moderate amount of sediment. Further review of nursing notes dated 1/19/16 revealed the Foley was draining cloudy yellow urine with sediment. Continued review of nursing notes dated 1/23/16 revealed Foley catheter was patent draining cloudy yellow urine. Further review of nursing notes dated 1/24/16 revealed the Foley was draining light yellow urine. Review of physician communications revealed no documentation the physician was notified of the cloudy urine with sediment. Further review revealed no nursing orders for a urinalysis as per policy. Continued review of the History and Physical from the hospital revealed one of the admitting [DIAGNOSES REDACTED]. Interview with the DON on 8/16/16 at 2:20 PM in the Administrator's office, revealed Resident #4 was receiving [MEDICATION NAME] 250 milligrams four times daily for [MEDICAL CONDITION] infection from admission and it was discontinued on 1/22/16. In continued interview the DON confirmed a urine culture should have been sent 3 days after completion of the antibiotics which was facility policy and would have been 1/25/16 but a culture was not sent. In further interview the DON confirmed the policy on Culture Tests was the one currently in use in the facility and there was a statement the charge Nurse could order a urinalysis if a resident had cloudy urine and no culture was ordered.",2019-08-01
4843,NORTHSIDE HEALTH CARE NURSING AND REHABILITATION C,445373,202 EAST MTCS ROAD,MURFREESBORO,TN,37130,2016-07-26,514,D,1,0,AK2Z11,"**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 neurological assessments readily accessible for review during the survey for 1 (Resident #3) of 3 residents reviewed for falls. The findings included: Review of the facility policy Neurological Assessment, dated 9/2014, revealed .Falls that occur and a patient hits their head or if the fall is unobserved and the possibility is there that a patient may have hit their head, a neurological assessment must be conducted to evaluate for possible impairment . Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility Monthly Falls Tracking Form, the facility documentation of the event and/or the investigation, and review of the medical record of the physician orders and progress notes revealed Resident #3 had the following: 1.) On 1/6/16 at 7:30 AM had an unobserved fall, was an unassisted self transfer from the wheelchair and was found on the floor next to the wheel chair. Review of the facility investigation revealed neuro checks were to be initiated. Medical record review of the physician order dated 1/6/16 revealed an order for [REDACTED]. 2.) On 1/15/16 at 9:00 AM had an unobserved fall, was found lying on the floor mat next to the resident's bed. Review of the facility investigation revealed neuro checks were to be initiated. Medical record review of the physician order dated 1/15/16 revealed an order for [REDACTED]. 3.) On 1/29/16 at 7:00 AM had a witnessed fall from the wheelchair to the floor hitting her head. Review of the facility investigation revealed neuro checks were to be initiated. Medical record review of the physician order dated 2/1/16 revealed an order for [REDACTED].F/U (follow-up) fall/laceration Fore head/ .neurochecks 4.) On 6/6/16 at 1:15 AM had an unwitnessed fall from the wheelchair to the floor. Review of the facility investigation revealed neuro checks were to be initiated. Medical record review of the physician order dated 6/7/16 revealed an order for [REDACTED]. Medical record review revealed no documentation presented to the surveyors during the survey, of neuro checks for the falls on 1/6/16, 1/15/16, 1/29/16 and 6/6/16 . Interview with the Director of Nursing (DON) on 7/20/16 at 10:05 AM in the DON's office, when asked if the neuro check documentation was available stated .No, I didn't find documentation . per facility policy. Interview with the Assistant Director of Nursing on 7/20/16 at 10:35 AM in the conference room confirmed the facility failed to have documentation of neuro checks, after the falls of 1/6/16, 1/15/16, 1/29/16 and 6/6/16, accessible for review during the survey.",2019-07-01
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
3309,NEWPORT HEALTH AND REHABILITATION CENTER,445504,135 GENERATION DRIVE,NEWPORT,TN,37821,2017-05-24,205,F,1,1,8GYB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to issue a written bed-hold policy to the resident and responsible party for 10 of 10 residents (#162, #142, #121, #85, #63, #54, #33, #30, #28 and #27) reviewed for admission, transfer, and discharge rights of 27 residents reviewed. The findings included: Review of Bed Hold/Leave of Absence policy revision date: (MONTH) (YEAR) '' .Upon admission or Leave of Absence, a facility designee will provide the resident and/or responsible party written information concerning the option to exercise the Bed Hold/Leave of Absence Policy .Upon leave of absence, a Bed Hold Authorization form is distributed to the resident and/or responsible party .'' Medical record review revealed resident #162 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) discharge records dated 11/23/16 and 1/17/17, revealed the resident was transferred to the hospital on [DATE] and on 1/17/17. Medical record review continued and revealed a written notice of the bed-hold policy was not issued. Medical record review revealed the following 9 residents were hospitalized without documentation of a bed-hold policy being issued: Resident #142 was hospitalized [DATE]-4/5/17; Resident #121 was hospitalized [DATE]-2/28/17; Resident #85 was hospitalized [DATE]-2/18/17; Resident #63 was hospitalized [DATE]-4/11/17; Resident #54 was hospitalized [DATE]-4/11/17; Resident #33 was hospitalized [DATE]-4/28/17; Resident #30 was hospitalized [DATE]-3/31/17; Resident #28 was hospitalized [DATE]-2/2/17; and Resident #27 was hospitalized [DATE]-1/24/17. Interview with the Director of Nursing (DON) on 5/24/17 at 10:40 AM, in the conference room, confirmed the facility had not provided written information concerning the bed-hold policy the 2 times Resident #162 was transferred to the hospital. Continued interview revealed, .I could not find anything to show that the 9 residents on the list you gave me received a bed-hold policy . Interview continued and confirmed the facility failed to implement the bed-hold policy.",2020-09-01
4813,GRACE HEALTHCARE OF WHITES CREEK,445281,3425 KNIGHT DRIVE,WHITES CREEK,TN,37189,2016-07-08,514,E,1,0,TQUZ11,"**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 a complete and accurate medical record for [MEDICAL CONDITION] (Continuous Positive Airway Pressure) use for 2 (Resident #1, 6) of 3 residents reviewed for [MEDICAL CONDITION] use; for fluid restriction for 3 (Resident #1, 3, 4) of 3 residents reviewed for fluid restriction; for physician orders for 1 (Resident #2) of 9 residents reviewed; and for transcription error for 1 (Resident #7) of 9 residents reviewed. The findings included: Review of the facility policy entitled [MEDICAL CONDITION]/[MEDICAL CONDITION] Support revealed .Documentation .General Assessment (including vital signs, oxygen saturation, respiratory, circulatory and gastrointestinal status) prior to procedure; Time [MEDICAL CONDITION] was started; duration of the therapy; Mode and setting for the [MEDICAL CONDITION]/ .Oxygen concentration and flow, if used; How the resident tolerated the procedure; Oxygen saturation during therapy . Review of the facility policy entitled Intake and Output, Conditions Requiring, revealed .Recording of Intake and Output will be done with the goal of providing continuing assessment information . 2. Residents with the following conditions and [DIAGNOSES REDACTED]. Residents with a Foley catheter .d. Residents on fluid restriction .3. Nursing staff will record Intake and Output per facility documentation protocols . Review of the facility policy entitled Fluids, Restricted revealed . It is the policy of this facility to safely provide to the resident the amounts of fluids indicated by the physician's order .Fluids will be provided upon request and at times designated . Fluids consumed by the resident are to be accurately measured and recorded. Intake record should be maintained during the time the resident is on restricted fluids . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #1 was admitted to the hospital on [DATE] due to shortness of breath which occurred during a physician's appointment. Medical record review of transfer orders dated 11/25/15 revealed Resident #1 was continued on [MEDICATION NAME] 80 mg daily and .Fluid restriction 1500 milliliters (ml) . was added to the recapitulation orders after being signed by the physician. Continued review of the orders revealed Resident #1 was readmitted to the facility with a Foley catheter in place. Medical record review of an undated fluid restriction form, which the DON confirmed was applicable to the resident when she returned from the hospital on [DATE], revealed Resident #1 was on a 1500 ml fluid restriction with dietary providing 720 ml at breakfast, 240 ml at lunch, and 240 ml at dinner. Continued review revealed nursing was to give the resident 150 ml fluid during the day and 150 ml fluid during the evening. Medical record review of the Counted Intake and/or Output Roster completed by the Certified Nursing Aides (CNA) revealed documentation of the fluid amounts sent up on each tray by dietary as well as the Foley catheter output. Continued review revealed no documentation of the 300 ml fluids nursing was allowed to give the resident or the amount of fluids administered along with medications. Further review of the form revealed Resident #1 should have received 31,500 ml of fluid from 11/26/15 - 12/16/15 but only received 25,740 ml. Continued review revealed the resident had no fluid intake on 19 occasions when she refused a meal. Medical record review of physician's admission orders [REDACTED]. Continued review revealed an order for [REDACTED]. Interview with the DON on 6/30/16 at 10:45 AM in the conference room, confirmed the [MEDICAL CONDITION] was not reordered when Resident #1 was readmitted to the facility on [DATE]. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders dated 11/20/15 revealed an order for [REDACTED].>Medical record review of the Medication Administration Record [REDACTED]. Interview with the DON on 6/30/16 at 10:45 AM in the conference room, confirmed the [MEDICAL CONDITION] was not reordered when Resident #6 returned to the facility on [DATE] and the use of the [MEDICAL CONDITION] was not reflected on the MAR for (MONTH) or December. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of physician's orders dated 1/11/16 revealed Resident #3 was placed on a fluid restriction of 2000 ml daily. Medical record review of nursing notes dated 1/11/16 revealed dietary would provide the resident with 720 ml with breakfast; 240 ml with lunch; and 240 ml with dinner. Further review revealed there were 800 ml which nursing could administer but there was no documentation in the medical record of fluids administered to the resident by nursing; no documentation of fluids administered with medications; and no record of intake and output. Continued review revealed Resident #3 received [MEDICATION NAME] 80 mg daily. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders dated 4/12/16 revealed Resident #4 was placed on a fluid restriction of 1500 ml daily. Continued review revealed dietary would provide the resident 720 ml for breakfast, 240 ml at lunch, and 240 ml at dinner. Further review revealed nursing could provide 300 ml to the resident over 24 hours. Continued review revealed Resident #4 received [MEDICATION NAME] 80 mg daily. Medical record review of nursing notes revealed no documentation of the amount of fluids administered to the resident with medications; no documentation of fluids administered by nursing; and no documentation the resident was on a fluid restriction. Interview with the DON on 7/6/16 at 8:20 AM in the DON's office confirmed the facility does not keep intake and output on any resident unless the physician orders it for a special case in spite of the fact the facility policy states MD/DON/Nurse Manager may order Intake and Output. Further interview confirmed the medical record was incomplete as there was no documentation of resident intake of fluids allotted to nursing and no documentation of the amount of fluids administered with medications. Review of the undated facility policy entitled Medication Orders and Review revealed .A current list of orders must be maintained in the clinical record of each resident .Orders must be written and maintained .All medication administration to the resident must be ordered in writing by the resident's attending physician .Medications .or any other treatment may not be administered to the resident without the written approval from the attending physician . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed the medical record failed to contain the facility admission physician orders transcribed from the hospital discharge orders. Medical record review of the (MONTH) (YEAR) Physician Orders recapitulation form, signed by the reviewing nurse on 4/14/16 (8 days after the admission) and signed but undated by the physician, revealed Resident #2 was to receive medications via the Gastrosotomy tube and also included the hand written order dated 4/20/16 for a change in medication. Medical record review of the (MONTH) (YEAR) Physician Orders recapitulation form, signed by the physician on 5/6/16, revealed each entry of the medication administration included a hand written change from per tube to po (by mouth) and one entry with the date 5/11 (5 days after the physician had signed the recapitulation form). Further review of physician telephone orders for (MONTH) (YEAR) revealed no order to change the medication administration from per tube to by mouth. Medical record review of the facility 4/7/16 through 5/11/16 Medication Administration Records (MAR) revealed Resident #2 was provided medication via the Gastrosotomy tube. Further review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Medical record review of telephone physician orders dated 4/14/16, 4/27/16, and 6/22/16 for laboratory tests including ammonia levels revealed the medical record failed to include the laboratory results. Interview with Medical Record Staff #1 and the Director of Nursing (DON) on 6/29/16 at 1:00 PM in the conference room, when asked why the physician did not date the (MONTH) (YEAR) Physician Order recapitulation form stated think the physician signed the order (form) on 4/8/16 when he did the History and Physical. During further interview the DON was asked if it was acceptable to alter recapitulation forms after the physician signed the recapitulation form stated .No . Interview with the DON on 6/29/16 at 2:30 PM in the conference room, confirmed the facility failed to have the ordered laboratory test results in the medical record for the tests ordered on [DATE], 4/27/16 and 6/22/16. Interview with the DON on 6/30/16 at 2:00 PM in the conference room, confirmed the medical record was not complete and the facility failed to follow their policy by the failure to include the admission facility physician orders, and the failure to include the phone order changing the medication administration from per tube to by mouth. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the hospital medication discharge orders dated 5/20/16 and the facility admission (MONTH) (YEAR) Physician Orders recapitulation form, signed by the facility physician on 5/24/16, included the diabetic medication [MEDICATION NAME] ER (extended release) 500 mg (milligrams) 2 tablets by mouth twice a day for 5 days; then increase to 1000 mg twice daily. Further review revealed the hospital discharge orders and the facility recapitulation form included Polyethylene [MEDICATION NAME] 3350 (for constipation) 17 gm (grams) orally every 24 hours. Medical record review of telephone physician orders revealed no changes regarding the [MEDICATION NAME] or the Polyethylene [MEDICATION NAME] medications from admission to 5/23/16. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED].administration .except on Mondays and Thursdays . Interview with Licensed Practical Nurse #1 on 6/30/16 at 12:55 PM at the back nursing station confirmed, the Polyethylene [MEDICATION NAME] was not administered as ordered daily after 5/23/16 when the MAR indicated [REDACTED].administer .except on Mondays and Thursdays . Interview with ADON #1 on 6/30/16 at 2:30 PM in the ADON's office confirmed, the ADON had incorrectly changed the [MEDICATION NAME] and Polyethylene [MEDICATION NAME] data entry in the MAR indicated [REDACTED].except on Mondays and Thursdays . and the facility had failed to maintain an accurate medical record per the physician order and facility policy.",2019-07-01
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
3326,LIFE CARE CENTER OF HICKORY WOODS,445507,4200 MURFREESBORO PIKE,ANTIOCH,TN,37013,2019-05-21,842,D,1,0,T9UH11,"**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 medication administration record for 1 of 3 residents (#1) reviewed. The findings include: Review of the facility policy revised 2/2018, Protection of Residents: Reducing the Threat of Abuse and Neglect revealed .Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone .It is the policy of this facility to screen staff (as defined in this policy) for a history of abuse, neglect, exploitation, or misappropriation of resident property in order to prohibit abuse, neglect, and exploitation of resident property .The deliberate misplacement, exploitation or wrongful temporary or permanent use of a resident's belongs or money without the resident's consent. Residents' property includes all residents' possessions, regardless of their apparent value to others since they may hold [MEDICATION NAME]'s value to the resident . Review of the facility policy revised 1/1/13, Inventory of Controlled Substances revealed .The facility should routinely reconcile the number of doses remaining in the packages to the number of remaining doses recorded on the controlled Substances Verification/Shift Count Sheet, to medication administration record . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment Medical record review of the care plan dated 4/26/19 revealed .Resident at risk of pain. Risk factors include: Pancreatitis (inflammation of the pancreas), pancreatic CA (cancer), kidney stones . Medical record review of the Discharge Patient Medication Report dated 4/25/19 revealed .[MEDICATION NAME]/apap ([MEDICATION NAME]) (pain medication) 7.5/325 mg (milligrams) every 6 hours as needed . Review of the facility investigation revealed a copy of the Controlled Drug Record dated 4/26/19 which revealed 11 [MEDICATION NAME]-Acet 7.5-325 mg were signed out by staff. Medical record review of the Medication Administration Record (MAR) dated (MONTH) 2019 revealed the [MEDICATION NAME]-[MEDICATION NAME] Tablet 7.5-325 mg by mouth every 6 hours was signed out 3 times on the MAR. Telephone interview with the Pharmacy Consultant on 5/20/19 at 3:05 PM revealed the consultant comes to the building every month and audits and gets a a sampling of residents on narcotics. Continued interview confirmed documentation should be completed at all times. If it is a PRN (as needed) it should be documented in front and the MAR and back of the MAR for effectiveness. Interview with the Administrator on 5/21/19 at 11:03 AM in the conference room revealed the Unit Manger reported to her Resident #1 had not received pain medication. They could not find the medication nor the Controlled Drug Record. Continued interview revealed the Administrator called Licensed Practical Nurse (LPN) #6 and she stated she administered the med's and the card was empty. Continued interview revealed the Administrator asked about the MAR and LPN #6 stated she forgot to record it on the MAR. Continued interview with the Administrator confirmed the MAR and the Controlled Drug Record sheet were not identical in showing if the resident received the pain medication.",2020-09-01
757,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2020-02-05,580,D,1,0,5CUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to notify the Resident's Representative of a fall for 1 resident (Resident #3) of 3 residents reviewed for falls. The findings included: Review of the undated policy, Falls Management Program Guides, revealed .the responsible party should be notified . Medical record review revealed Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].FRACTURE OF LUMBOSACRAL SPINE AND PELVIS, REPEATED FALLS, [MEDICAL CONDITIONS] WITHOUT BEHAVIORAL DISTURBANCE, DIFFICULTY IN WALKING, MUSCLE WASTING [MEDICAL CONDITION], GENERALIZED ANXIETY DISORDER, POST-TRAUMATIC STRESS DISORDER, and MAJOR [MEDICAL CONDITION]. Medical record review of the Face Sheet for Resident #3 revealed Family Member #3 was listed as the Contact/Emergency Contact #1. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #3 had adequate hearing; vision was impaired; her speech was unclear, she usually could make herself understood and usually understood others. She scored a 15 on the Brief Interview for Mental Status (BIMS), indicating she was cognitively intact. Medical record review revealed the following: On 1/9/2020 at 3:41 PM, of the Health Status Note, written by Licensed Practical Nurse (LPN) #5, revealed .At around 12:50 PM on Thursday (MONTH) 9, 2020, a pt (patient) yelled down the hallway I need a nurse. This nurse came to room and found pt (patient - (Resident #3) lying face down on the floor. there was a fair amount of blood on floor .pt had blood coming from a small laceration above rt (right) eye, and redness to rt cheek . On 1/10/2020, of the Post Fall Review, written by LPN #5, revealed Resident #3 had an unwitnessed fall on 1/9/2020 at 12:50 PM. Further review revealed the .Family/Responsible Party was notified on 1/9/2020 at 2:00 PM and named the specific family member. Further review revealed the specified family member notified was not Family Member #3. Review of the facility investigation included the Supervisor Investigation of Fall form dated 1/9/2020, written by LPN #5, which revealed Resident #3 fell on [DATE] at 12:50 PM, in her room. The form revealed the resident's family member, specifying the relationship to the resident, was notified on 1/9/2020 at 1:15 PM. Further review revealed the family member notified was not family Member #3. Interview with LPN #5 on 2/5/2020 at 8:34 AM, in the conference room revealed the LPN was working at the medicine cart when Resident #3's roommate rolled out of the room in the wheelchair and told the LPN that (Resident #3) needed help. The LPN entered the room and found Resident #3 face down with a little pool of blood under her head. The LPN stated she went to the nursing station and was checking the resident's chart to initiate the notifications when the nursing station telephone rang. The LPN answered the telephone and Resident #3's relative was asking to speak to the resident. The LPN stated she noticed this family members name was listed as an emergency contact and proceeded to inform the individual of the fall and then took the telephone to the resident for the family member to talk with the resident. The LPN stated she saw the name on the list and did not recall if there was a designation of which to notify first. The LPN stated several hours later, (Named Family Member #3) called the facility and 'was yelling at me why didn't I notify her first.' The LPN stated she tried to apologize and explained what had happened regarding the telephone ringing right when she was ready to call and it was Resident #3's family on the telephone and on the emergency contact list. Interview with the Interim Director of Nursing on 2/4/2020 at 3:05 PM, in the conference room confirmed the facility failed to notify the appropriate Family Member, #3. Further interview revealed the Face Sheet used at the time of the 1/9/2020 fall included the name of the the family member which called the facility but there was no evidence of the information in the current medical record or in the fall investigation documentation.",2020-09-01
5033,CREEKSIDE CENTER FOR REHABILITATION AND HEALING,445516,306 W DUE WEST AVENUE,MADISON,TN,37115,2016-06-16,157,G,1,0,GZPX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to notify the physician of a pressure ulcer for 1 (Resident #1) resident of 12 residents reviewed for pressure ulcers. The facility's failure to notify the physician of the pressure ulcer resulted in Actual Harm to Resident #1. The findings included: Facility policy review titled Wound Care Management, dated 3/13/15 revealed, .Notify the .physician .of the presence of the wound and if the resident .has a negative change in the wound appearance . Medical record review revealed Resident #1 was admitted to the facility on [DATE], discharged on [DATE], readmitted on [DATE] and discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 15/15 indicating the resident was cognitively intact. Continued review of the MDS revealed the resident had no pressure ulcers and was always incontinent of urine and bowel. Medical record Review of the POS [REDACTED]. Medical record review of the Nursing Admission assessment dated [DATE] at 4:27 AM by Licensed Practical Nurse (LPN) #1, revealed documentation of the presence of a Pressure Ulcer in the skin portion of the assessment for Resident #1. Medical record review of the Departmental Notes dated 3/17/16 at 10:39 AM, by LPN #2, documented .late entry for 3/16/16: resident also has noted open area on coccyx . Medical record review of the Skin Concerns Roster dated 3/17/16 at 5:27 PM by RN #1 revealed, Yes skin concern-nurse notified. Medical record review of the Skin Inspection Report for Resident #1 dated 2/15/16 through 5/4/16 revealed the following: 3/17/16 Skin Not Intact-Existing by LPN #3 4/22/16 Skin Not Intact-New by RN #2 4/27/16 Skin Not Intact-Existing by LPN #4 5/4/16 Skin Not Intact-Existing by LPN #4 Medical record review of the Wound Assessment Report by LPN #5 dated 4/19/16 revealed Resident #1 had an abrasion to the coccyx that was identified on 4/19/16. There was no drainage; the wound measured 1.50 cm (centimeters) in length, 2.70 cm in width, and had a depth of 0.10 cm. Medical record review of the Wound Assessment Report completed by the Wound Nurse dated 5/4/16 revealed the wound type was an abrasion; wound location was coccyx; wound status was deteriorated; a small amount of serosanguinous (yellowish with small amounts of blood) drainage was present; the wound measured 4.00 cm in length, 4.50 cm in width and 0.10 cm in depth; description of the skin irritation/excoriation was documented as Red or darker pink, moderate irritation. Medical record review of the Wound Assessment Report completed by the Wound Nurse, dated 5/9/16, revealed the wound status was unchanged; the wound type was an abrasion; wound location was the coccyx; a small amount of serosanguinous drainage and was documented as to have no infection or pain. The measurements remained unchanged from the previous assessment on 5/4/16. Medical record review revealed no documentation in the physician progress notes [REDACTED].#1 by the physician or nurse practitioner. Telephone interview with the Medical Director (MD) on 5/19/16 at 7:54 AM revealed the MD was unaware of any type of wound for Resident #1. The MD was asked if the Wound Nurse had contacted him on 4/19, 4/27, 5/4 and 5/9 regarding a wound to the coccyx with an increase in size and drainage for Resident #1. The MD stated, No, I definitely was not called 4 times. I was not aware of any problems until the Director of Nursing (DON) called me yesterday to ask me if I knew anything about a shearing problem for (named Resident #1). I told her no, this is the first I've heard of it. Interview with Nurse Practitioner (NP) #2 on 5/19/16 at 9:45 AM, in the Physician's Office at the facility, revealed the NP was present in the facility 5 days a week. The NP stated, I never knew of any wound to (named Resident #1) and I work very closely with (named MD) and I can attest that he never knew anything either. (Named MD) and I rounded on Sunday 5/8/16 and (named Resident #1) was somnolent but arousable over 5/7/16 and 5/8/16. She had a gradual decline over the last week. I absolutely did not know about this. Interview with NP #3 on 5/19/16 at 10:00 AM in the Physician's Office at the facility revealed NP #3 had no knowledge of an abrasion, wound or pressure ulcer to Resident #1. Telephone interview with NP #1 on 5/19/16 at 11:40 AM revealed the NP was nationally certified as a Wound Care and Ostomy Specialist. The NP denied having any knowledge of an abrasion, wound, or pressure ulcer to the coccyx of Resident #1. The NP referred to her notes and stated she had treated the resident for leg pain but no other problems were brought to her attention. The NP was asked if she was notified on 5/4/16 by the Wound Nurse regarding the increase in size and drainage to the wound on the resident, the NP stated, No, I knew nothing about it. I received a list on 5/6/16 with (named resident) name on it to round on for Tuesday 5/10/16 but it is circled because I never saw her, and I thought she was at [MEDICAL TREATMENT]. The NP continued to state she was present at the facility on Monday 5/2/16, Friday 5/6/16, and on Monday 5/9/16 and nothing was ever communicated to her about a wound or any other concern with the resident. The NP stated, I only know if the staff communicate to me or another NP, but I had no knowledge of this. Further interview with NP #1 on 5/24/16 at 7:37 AM revealed the NP stated, I depend on the nurses to let me know there is a problem. There is a Communication Book for the NP's that the nurses can write their problems or concerns, but (named Resident #1) wasn't listed and I never got anything on her. Review of the Hermitage Nurse Station Communication Book dated 3/16/16-5/9/16 revealed no skin concerns were documented for Resident #1. Interview with the Wound Nurse on 6/14/16 at 8:40 AM in the Conference Room, when asked if the MD or NP were notified of a wound for Resident #1 at any time the resident was in the facility, revealed the Wound Nurse stated, No, not from me. The facility's failure to notify the physician of a pressure ulcer resulted in Actual Harm to Resident #1.",2019-06-01
4422,CREEKSIDE CENTER FOR REHABILITATION AND HEALING,445516,306 W DUE WEST AVENUE,MADISON,TN,37115,2016-10-24,157,K,1,0,CT4U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to notify the physician of residents with a blood glucose greater than 400 for 5 (Resident #2, #6,#5, #7, #8) of 12 residents reviewed for Diabetes Mellitus. These failures placed all diabetic residents 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 or a resident). The Administrator (NHA) was informed of the Immediate Jeopardy on 10/24/16 at 3:15 PM in the Conference Room. The findings included: Review of facility policy, Change in Resident's Condition or Status, undated, revealed, .To insure the proper and timely reporting and documentation of any changes in a resident's condition or status .Nursing services will notify the resident's attending physician when .there is a significant change in the resident's physical, mental or psychosocial status .there is a need to alter the resident's treatment .Deemed necessary or appropriate in the best interest of the resident . Review of facility policy, Diabetes, Nursing Care of the Adult Diabetes Mellitus Resident, undated revealed, .The physician should be notified when the blood sugar falls above his/her specified blood sugar range and/or above 400 mg/dL (milligrams per deciliter). The Medical Director of the facility is the physician of record for all the residents. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].ACCUCHECKS (finger stick for blood sugar) BEFORE BOLUS FEEDINGS AND SSI (sliding scale insulin) AS FOLLOWS: 0-59 = CALL MD (Medical Doctor) .351-400 = 10u .NOTIFY MD AND RECHECK IN 15 MINUTES . Medical record review of the 6/2016 Medication Administration Record [REDACTED] 591 on 6/4 at 7:30 AM 432 on 6/6 at 6:00 AM 401 on 6/7 at 12:00 AM High on 6/9 at 12:00 PM 456 on 6/12 at 6:00 AM 429 on 6/18 at 6:00 AM Medical record review revealed no notification of the MD or Nurse Practitioner (NP) regarding the elevated blood sugars. Medical record review of the 7/16 MAR indicated [REDACTED] 564 on 7/1 at 6:00 AM 441 on 7/1 at 12:00 PM 503 on 7/6 at 12:00 AM 489 on 7/9 at 12:00 PM 518 on 7/10 at 12:00 AM 511 on 7/10 at 12:00 PM 405 on 7/12 at 12:00 AM 466 on 7/25 at 6:00 AM 459 on 7/27 at 12:00 AM 436 on 7/31 at 6:00 PM Medical record review revealed no notification of the MD or NP regarding the elevated blood sugars. Medical record review of the 8/16 MAR indicated [REDACTED] 475 on 8/1 at 12:00 AM 492 on 8/7 at 6:00 PM 456 on 8/20 at 6:00 PM 432 on 8/21 at 6:00 PM 493 on 8/25 at 6:00 PM Medical record review revealed no notification of the MD or NP regarding the elevated blood sugars. Medical record review of the 9/16 MAR indicated [REDACTED] 423 on 9/3 at 12:00 PM 487 on 9/4 at 6:00 PM 47 on 9/7 at 12:00 PM 452 on 9/10 at 12:00 PM 482 on 9/16 at 12:00 AM 434 on 9/17 at 6:00 AM 491 on 9/17 at 12:00 PM 501 on 9/22 at 12:00 PM 560 on 9/23 at 6:00 AM 474 on 9/23 at 12:00 PM 420 on 9/26 at 12:00 AM Medical record review revealed no notification of the MD or NP regarding the elevated blood sugars or the low blood sugar on 9/7/16. Telephone interview with Licensed Practical Nurse (LPN) #5 on 10/18/16 at 4:00 PM revealed, I did not call the Doctor when the sugar was 560 on 9/23/16. Interview with LPN #6 on 10/19/16 at 7:15 AM, in the conference room confirmed Resident #2's blood sugar was 47 on 9/7/16 and she failed to notify the physician. Medical record review of the 10/2016 MAR indicated [REDACTED]. Medical record review revealed no notification of the MD or NP regarding the elevated blood sugar. Interview with the Director of Nursing (DON) on 10/19/16 at 4:05 PM, in the conference room confirmed the facility policy was to notify the physician if a blood sugar was less than 60 or greater than 400. Continued interview with the DON confirmed the facility failed to follow the policy and notify the physician of the elevated blood sugars for Resident #2. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's admission orders [REDACTED]. Continued review revealed the order stated if the resident's blood glucose was greater than 400 the nurse was to administer 10 units of insulin and notify the physician. Medical record review of a History and Physical from the hospital dated 9/14/16 revealed Resident #6 was admitted for a blood sugar which was .measurable high . Continued review revealed the blood glucose in the Emergency Department was 500 and significant ketosis was present. Medical record review of the blood glucose monitoring sheets and the Medication Administration Record [REDACTED] a. 9/20/16 blood glucose 593 at 9:00 PM b. 9/24/16 blood glucose 405 at 9:00 PM c. 9/29/16 blood glucose 421 at 1:00 PM d. 9/29/16 blood glucose 423 at 5:00 PM e. 10/4/16 blood glucose 405 at 6:15 PM Continued review revealed no documentation the physician was notified of any of these abnormal blood glucose results. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's admission orders [REDACTED]. Continued review revealed if the blood glucose was greater than 400 the nurse was to notify the physician. Medical record review of the blood glucose monitoring record and the MAR indicated [REDACTED]. Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's admission orders [REDACTED]. If BS (blood sugar) > (greater than) 400 notify MD and recheck in 15 minutes . Medical record review of the blood glucose monitoring record and the MAR indicated [REDACTED]. Continued review revealed no documentation the physician was notified of the abnormal blood glucose result. Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's admission orders [REDACTED]. Continued review revealed if the blood glucose was greater than 400 the nurse was to notify the physician and recheck the blood glucose in 15 minutes. Medical record review of the blood glucose monitoring record and the MAR indicated [REDACTED]. Continued review revealed there was no documentation the physician was notified of the abnormal blood glucose result. Interview with the Administrator and new Director of Nursing (DON) on 10/24/16 at 11:15 AM, in the Conference Room revealed they had been working on this tag since the last survey with continued education about notification. Continued interview revealed the DON stated she could not say why nurses were still not documenting physician notification. Interview with Nurse Practitioner (NP) #2 on 10/24/16 at 12:20 PM in the conference room revealed she had never been notified of any medications being administered late. Continued interview revealed NP #2 stated if a blood glucose was greater than 400 she would expect the nurse to recheck in 15 to 30 minutes and notify her if it was still elevated.",2019-10-01
604,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,157,D,1,0,DC3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to notify the physician the ordered urine analysis (U/A) and culture was not obtained for 1 resident (#1) of 8 residents reviewed. The findings included: Review of facility policy, Policy for MD/RP (Medical Doctor/Responsible Party) Notifications, undated revealed .PURPOSE: To keep the physician, who is in charge of the medical care .informed of the resident's medical condition .STANDARD: Notification of the physician .should occur promptly, according to federal regulations, when there is a change in the resident's condition . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Telephone Physician order [REDACTED].U/A + (and) culture . Medical record review of the Lab Log, with Licensed Practical Nurses (LPN's) #2 and #3 present, revealed the 3/23/17 U/A order was documented in the Lab Log to be obtained on 3/24/17. Further review revealed a written notation .Unable to Obtain . Interview with LPN's #2 and #3 on 5/9/17 at 3:00 PM at the 1 East nursing station confirmed the 3/23/17 U/A and culture order had been documented in the Lab Log and the facility was not able to obtain a specimen. When the LPN's were asked if the physician had been notified the U/A had not been obtained, the LPN's confirmed the facility failed to notify the physician until 5/8/17. Interview with the Administrator and the Director of Nursing on 5/9/17 at 4:25 PM in the Administrator's office confirmed the facility failed to notify the physician the U/A had not been obtained and seek further instructions.",2020-09-01
609,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,281,D,1,0,DC3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to obtain a physician order [REDACTED]. The findings included: Review of facility policy, Medication and Treatment Orders, revised 2/2014 revealed .Orders for medications and treatments will be consistent with principles of safe and effective order writing .shall be administered only upon the written order . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Telephone Physician order [REDACTED].DC (discontinue) zinc oxide cream (ointment for skin treatment) to buttock and groin q (every) shift and as needed . Further review revealed no physician signed telephone order or physician signed computerized order to initiate the the zinc oxide treatment. Medical record review of the 2/2017 and 3/2017 Treatment Administration Records revealed the zinc oxide treatment was administered from 2/15/17 to 3/13/17. Interview with Licensed Practical Nurse (LPN) #2 on 5/10/17 at 9:30 AM at 1 East nursing station confirmed she had written the 3/13/17 discontinuation of zinc oxide order. LPN #2 reviewed the telephone and computerized physician orders [REDACTED]. Interview with the Administrator on 5/10/17 at 10:45 AM in the conference room confirmed the facility failed to follow the facility policy to only administer medications and treatments after a physician order [REDACTED].",2020-09-01
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
2634,WOODBURY HEALTH AND REHABILITATION CENTER,445435,119 WEST HIGH STREET,WOODBURY,TN,37190,2018-05-31,689,D,1,1,SLTY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to prevent a fall for 1 resident (#68) of 3 residents reviewed for falls. The findings included: Resident #68 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #68 was discharged to an Assisted Living facility on 11/21/17. Review of the facility policy, Falls (and) Incident Management, undated revealed .Quality Indicator .Decrease in preventable falls/incidents .All residents shall benefit from a safe environment . Medical record review of Resident #68's care plan dated 6/7/17 revealed .Problem .The resident is at risk of injury from falls .Approaches .Lock wheels on bed/wheelchair . Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #68 had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Medical record review of the facility'sFall Scene Investigation Report, dated 9/12/17, revealed .Resident was styling her hair, painting her nails (and) watching television. She used her walker to assist in her ambulation to her bed. She began to sit down and the bed (wheels unlocked per housekeeping) slid out from under her, causing the fall .Summary . It is unlikely this fall would've happened if wheels to bed were in locked position .skin tear evaluated by treatment nurse .no dressing needed .area closed .left open to air . Interview with the Director of Nursing on 5/31/18 at 3:38 PM, in the conference room, confirmed the facility's failure to lock the bed wheels resulted in Resident #68 falling, nodding her head .yes . Continued interview confirmed the facility failed to prevent a fall for Resident #68 on 9/12/17.",2020-09-01
3261,WEST HILLS HEALTH AND REHAB,445501,6801 MIDDLEBROOK PIKE,KNOXVILLE,TN,37919,2019-03-20,689,G,1,1,VPMF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to prevent a fall resulting in actual Harm for 1 resident (#9) of 5 residents reviewed for falls of 24 sampled residents. The findings include: Review of the facility policy Falls Management, undated, revealed .Residents are assessed for the fall risk factors. The interdisciplinary team works .to identify and implement appropriate interventions to reduce the risk of falls or injuries . Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #9 scored a 2 on the Brief Interview for Mental Status (BIMS) indicating the resident had severe cognitive impairment. Continued review revealed Resident #9 required extensive assistance of 2 staff with bed mobility, and total dependence of 2 staff for transfers, toileting, and hygiene. Medical record review of Resident #9's comprehensive care plan dated 12/11/18 revealed .Ensure fall precautions are in place . Continued review revealed the resident required 2 staff assistance for bed mobility. Medical record review of the untitled Certified Nursing Assistant (CNA) care guide dated 2/28/19 revealed Resident #9 required assistance of 2 staff for bed mobility. Medical record review of a Fall Scene Investigation form revealed on 3/2/19 at 5:45 AM, .Rolled out of bed while being assisted by one CNA . Medical record review of a nurse's note dated 3/2/19 at 6:43 AM, revealed .Nurse was alerted of a fall .Patient was on the floor parralel (parallel) to her bed, laying on her right side. CNA stated that she rooled (rolled) out of bed while .the CNA was trying to do peri-care (perineal care) .no s/s (signs/symptoms) of pain noted . Medical record review of a late entry nurse's note dated 3/2/19 at 5:41 PM, revealed .0700am .O2 (oxygen) sat (saturation) 82-88 on room air, res (resident) having difficulty breathing, neb (nebulizer) tx (treamtment) administered as per prn (as needed) orders, O2 sat improved to 90-93% (percent) on room air, res continues grunting noise and is continuing to be nonverbal, asking res about pain discomfort res still not answering questions. 0745am called on call doctor left voicemail requesting call back .continues to be having changes with resp (respiratory) status . Medical record review of a Physician's Telephone Order dated 3/2/19 revealed .Send to ER for eval /(evaluation) & (and) tx (treatment) due to fall .Resp. status . Medical record review of a hospital History and Physical Report dated 3/2/19 revealed .Chest x-ray reveals subcutaneous [MEDICAL CONDITION] with rib fractures on the left 2 through 7. Pneumothorax (collapsed lung) . Continued review revealed acute [MEDICAL CONDITION] associated with [MEDICAL CONDITION] and multiple left sided rib fractures .Pneumothorax .Fall from bed .Patient has a history of multiple [MEDICAL CONDITIONS] (stroke) with dense left [MEDICAL CONDITION] (paralized or weakness to one side of the body) . Further review revealed a CT (computed tomography) scan of the chest revealed enlarging pneumothorax .chest tube placed . Continued review revealed, .I (the ER physician) have spoken to the patient's sister at bedside and the patient's daughter by telephone .end of life issues were discussed. Prognosis is very poor . Review of a Personnel Consultation form dated 3/6/19 revealed CNA #1's employment was terminated from the facility. Continued review revealed .associate was providing patient care, alone, on a person who required the assist (assistance) of 2 (staff). The patient (Resident #9) fell from the bed and sustained injury. Associate (CNA #1) did not adhere to the ADL (Activities of Daily Living) care guide . Telephone interview with CNA #3 on 3/19/19 at 5:15 AM revealed CNA #3 was sitting at the nurse's station and heard CNA #1 hollered out to me from the resident's (Resident #9's) room door . Further interview revealed CNA #1 had .not asked for help all night . Telephone interview with CNA #1 on 3/19/19 at 12:55 PM, revealed CNA #1 was providing care to the resident on 3/2/19 at 5:45 AM .changed her by myself .I always changed her (alone) . Continued interview revealed Resident #9 was rolled onto the right side to provide peri-care, the left leg shifted .and threw her off the bed before I could catch her . Interview with CNA #5 on 3/19/19 at 2:46 PM, in the conference room, revealed the CNA had worked in the facility for 7 months. Continued interview revealed the CNA was aware Resident #9 required the assistance of 2 staff for bed mobility, and had always required the assistance of 2 staff since he had been employed in the facility. Interview with CNA #4 on 3/20/19 at 2:20 PM, in the conference room, revealed .we knew she was a 2 person assist by the care guide and by looking at her .she was obese, not active, non-verbal, just needed assistance with everything . Interview with Registered Nurse (RN) #4 on 3/20/19 at 2:50 PM, on the 400 Hall, revealed CNA care guides are updated daily and printed and left in a folder at the nurse's station daily for the CNAs which clearly document the level of assitance Resident #9 required. Interview with the Director of Nursing (DON) and the Administrator, on 3/19/19 at 4:05 PM, in the DON's office, confirmed Resident #9 required 2 person assistance with bed mobility, Resident #9 sustained multiple rib fractures, and the facility failed to provide the required 2 person assistance which resulted in a fall and actual harm to Resident #9. In summary, Resident #9 had been assessed as requiring the assistance of 2 staff members for bed mobility. Resident #9's MDS assessment, Care Plan, and CNA Care Guide all documented Resident #9 needed the assistance of 2 staff members for bed mobility. During interviews conducted with multiple CNAs during the survey, all were aware of the level of assistance Resident #9 required. Interviews confirmed other CNAs were available and nearby when CNA #1 assisted Resident #9, and interviews confirmed CNA #1 only asked for help after Resident #9 had already fallen from the bed.",2020-09-01
1106,RENAISSANCE TERRACE,445223,257 PATTON LANE,HARRIMAN,TN,37748,2019-12-04,600,D,1,1,3W9311,"**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 1 resident (#7) of 14 residents reviewed for abuse. The findings include: Review of the facility policy, Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Policy, undated, revealed .resident has the right to be free from abuse .Resident's must not be subjected to abuse by anyone .including, but is not limited to .other residents .the facility's goal is to protect the resident from abuse .The facility has developed and implemented written policies and procedures designed to prohibit and prevent mistreatment .and abuse of residents . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #7's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 14 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Continued review revealed the resident had delusions and had behaviors of wandering. Medical record review of Resident #7's Comprehensive Care Plan revealed .has potential to be verbally aggressive .ineffective coping skills, Mental/Emotional illness, Poor impulse control .potential to be physically aggressive . Medical record review revealed Resident #157 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #157's Admission MDS assessment dated [DATE] revealed the resident scored a 0 on the BIMS, indicating the resident had severe cognitive impairment. Further review revealed the resident exhibited verbal and physical behaviors, rejection of care, wandering, and intrusive behaviors daily. Medical record review of Resident #157's Comprehensive Care Plan revealed .behavior problem .reject care, verbal abusive, threatening, screaming, cursing, pushing, hitting, grabbing . wanderer .Impaired safety awareness, resident wanders aimlessly, significantly intrudes . Medical record review of the facility investigation report dated 10/2/19 revealed .found this resident (#157) in floor exchanging contact with another resident (#7) .This resident (#157) was assisted away .a skin tear to left knuckles treated . Medical record review of the facility investigation report witness statement from Registered Nurse (RN) #1 dated 10/2/19 revealed .heard noise in hallway .saw the two residents (Residents #7 and #157) on the floor with one resident hitting the other resident in the face with his fist .separate (separated) them to maintain their safety-the other nurse assisted with keeping residents apart .assessed residents skin for injuries and provided first aid to some skin tears . Medical record review of the Psychiatric Progress note dated 10/7/19, revealed .He (Resident #7) has had a recent resident to resident physical altercation with another resident here. (Resident #7) becomes extremely agitated when someone gets into his personal space .no significant injury to any party . Interview with RN #1 on 12/3/19 at 12:35 PM, in the conference room confirmed Resident #7 was hitting Resident #157 while on the floor and the residents were separated. RN #1 confirmed Resident #157 had a skin tear to the left hand and complained of rib pain. The x-ray was negative for any fractures. RN #1 confirmed Resident #157 had a history of [REDACTED]. Interview with the Director of Nursing (DON) on 12/4/19 at 8:50 AM, in the DON's office, revealed Resident #7 liked personal space and Resident #157 had no concept of personal space. The DON stated .can't always predict behaviors with dementia. I do not believe the incident could have been prevented if staff were in front of them .",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
1006,SPRING CITY CARE AND REHABILITATION CENTER,445209,331 HINCH STREET,SPRING CITY,TN,37381,2018-06-13,600,D,1,0,ZR5S11,"**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 residents (#4125 and #3936), of 5 residents reviewed for abuse. The findings included: Review of the facility's policy Abuse, Neglect and Misappropriation of Property no date, revealed the facility had a system in place for prevention of Abuse and Misappropriation, including orientation and training of employees, pre-employment screening of potential employees, identification, investigation and reporting of abuse, and protection of residents. Further review of the policy revealed the Policy Statement .It is . policy to prevent the occurrence of abuse .Definitions; Abuse is the willful infliction of injury .resulting in physical .pain or mental anguish . Medical record review revealed Resident # 4125 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) was 9, indicating the resident was moderately cognitively impaired. The resident's functional status for self-performance of activities of daily living (ADLs) for bed mobility, transfers, dressing, toilet use, and personal hygiene was extensive assistance with 2+ persons support provided. Medical record review of a psychotherapy note dated 5/15/18, revealed .staff reports periods of tremors and possible [MEDICAL CONDITION] activity .PCP (primary care Physician) added PRN (as needed) [MEDICATION NAME] (an antianxiety medication) .staff reports no tremor recently .it is thought at times an attention seeking behavior .review of systems .delusions, mild irritability/anger, decreased attention/concentration, and moderate executive dysfunction . plan of care: continue current medications . may consider a GDR (gradual dose reduction) at next visit, will continue to monitor . Medical record review of the resident's Care Plan dated 10/3/17, revealed .I have behaviors such as verbal/physical towards staff. I wander when up .I also have delusions and hallucinations. I have an [MEDICAL CONDITION]. MR and [MEDICAL CONDITION] and I like to get into dirty trays with food on them and pilfer through them and eat what I want. I also go into others rooms and take their stuff and eat it and drink their drinks; Goal: I will not harm themselves or others secondary to their behaviors through 9/7/18 .approach supervise activities during the day/redirect as needed .discourage me from taking .eating off dirty trays . Medical record review revealed Resident # 3936 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) was 15, indicating the resident was cognitively intact. The resident's functional status for self-performance of activities of daily living (ADLs) for bed mobility, transfers, dressing, toilet use, and personal hygiene was extensive assistance with 2+ persons support provided. Medical record review of a psychotherapy note dated 4/24/18, revealed the resident mild geriatric depression and anxiety about her future, willingly participated in the psychotherapy sessions and had no behavioral aggressive issues. Review of the facility investigation of the abuse incident between Resident #4125 an Resident #3936,dated 5/16/18, revealed the facility notified all parties and the State Agency promptly, assessments were completed on Resident #4125 and Resident #3936 and no injuries were found. The facility performed skin assessments for residents with a BIMS of less than 8 (moderate to cognitively impaired) and interviews with residents with a BIMS of 8 (moderate to cognitively intact) or greater were completed with no other findings of abuse. The Dietary staff was educated on placing all open food tray trolleys in the dish washing area in order to prevent any resident from eating off returned trays. The Nursing staff was educated on making sure the involved residents were returned to their rooms after meals. Observation of the tray carts after dinner on 6/11/18, after breakfast and lunch on 6/12/18, and after breakfast and lunch on 6/13/18 revealed no open tray carts had been left in the dining room available for residents, all open tray carts had been stored in the dish washing area of the kitchen. Interview with Resident #3936 on 6/12/18, at 9:45 AM, in the resident's room revealed the resident recalled the incident with Resident #4125 in the dining room on 5/16/17 and stated Resident #4125 had hit her on her shoulder lightly after she told her to stop eating that garbage from the trays. The resident then stated she hit Resident #4125 back on her shoulder .she said I slapped her face but I hit her shoulder because anybody that hits me is going to get hit back . Interview with the Dietary Aide on 6/12/18, at 2:30 PM, in the conference room revealed she overheard, did not see, the altercation between Resident #4125 and Resident #3936 on 5/16/18 at approximately 6:30 PM. The Dietary Aide went into the dining room and separated the 2 residents and moved the open tray cart into the kitchen out of the way. The Dietary Aide stated the residents went back to their rooms after the incident and she saw Licensed Practical Nurse (LPN) #1 in the hall and told her what had happened between the residents. Interview with Resident #4125 on 6/13/18, at 8:10 AM, at the Nurses' station revealed the facility was giving her good care and she had no complaints. The resident appeared well groomed and clean and her skin was clear. The resident did not remember the incident with Resident # on 5/17/18. Interview with the Director of Nursing (DON) on 6/13/18, at 12:20 PM, in the conference room revealed LPN #2 had called the DON and the Administrator on 5/16/18,about the incident and the investigation was initiated. The DON stated she had interviewed Resident #4125 and the resident told her Resident #3936 had hit her, the DON questioned the resident if she had hit the other resident first and she replied she had. The DON stated the Assistant DON interviewed Resident #3936 about hitting Resident #4125 and she immediately affirmed she had hit her back. Interview with the DON and the Administrator on 6/13/18, at 12:30 PM, confirmed the facility had failed to prevent the abuse between Resident #4125 and Resident #3936.",2020-09-01
3122,MCKENDREE VILLAGE,445491,4347 LEBANON ROAD,HERMITAGE,TN,37076,2019-06-19,689,D,1,1,VV4U11,"**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 an accident for 1 of 58 residents (#73) reviewed related to not having 2 staff members operating a lift during a transfer. The findings include: Review of the facility policy Lifting and Machine, Using a Mechanical revised (YEAR) revealed .At least two (2) nursing assistants are needed to safely move a resident with mechanical lift . Medical record review revealed Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the undated bed side care plan revealed Resident #73 required 2 persons for assist with transfers. Medical record review of the care plan dated 11/7/18 revealed .Assist x 2 with Transfers . Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #73 required extensive assistance with 2 staff members for transfers. Medical record review of the Fall Documentation dated 12/5/18 revealed .The tech was trying to get the Resident up in the stand uplift to change his briefs, the Resident slipped down the floor from the recliner . Medical record Review of the POS [REDACTED].I (Certified Nurse Technician (CNT) #7) was in the patients room using the Sara Lift to stand .up to change brief .I hooked .up on the L (left) side and attempted to hook the R (right) side of the sling .slid off .recliner and I lowered .to the floor . Interview with CNT #7 on 6/18/19 at 4:43 PM in the conference room revealed the CNT could not recall who assisted her with Resident #73 when operating the lift stand. Interview with the Unit Manager on 6/18/19 at 5:23 PM at the nurse station revealed the Unit Manager could not remember the staff who assisted Resident #73 with the lift on 12/5/18. Continued interview revealed if there were 2 CNT members assisting Resident #73 .there should be another statement for the other CNT . Continued interview confirmed .if CNT #7 was using the lift then there should have been 2 people . Telephone interview with Registered Nurse (RN) #6 on 6/18/19 at 7:19 PM revealed RN #6 could not remember if CNT #7 had another CNT with her at the time of Resident #73's fall. Continued interview with RN #6 revealed when she arrived to Resident #73's room to assess the resident there were 2 CNT's in the room. Interview with the Administrator on 6/19/19 at 7:34 PM in the conference room confirmed the staff were to follow the care plan when caring for Resident #73.",2020-09-01
2237,NORTHSIDE HEALTH CARE NURSING AND REHABILITATION C,445373,202 EAST MTCS ROAD,MURFREESBORO,TN,37130,2017-11-30,602,D,1,1,Z9P511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to prevent misappropriation of controlled medications for 1 resident (#37) of 37 residents reviewed. The findings included: Review of facility policy, Abuse, Neglect, Exploitation, dated 11/27/16, revealed .Misappropriation of resident property means deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent .When a suspicion occurs an investigation is immediately warranted .Ensure alleged violations are reported immediately . Review of facility policy, Controlled Medication Policy, effective 11/28/17 revealed .The facility will have safeguards in place to prevent loss, diversion, or accidental exposure .Any discrepancies that cannot be resolved must be reported immediately: notify the DON immediately and the Pharmacy; complete an investigation detailing the discrepancy; steps taken to resolve it; and names of all licensed staff working when the discrepancy was noted .Staff may not leave the area until discrepancies are resolved or reported as unresolved discrepancies . Medical record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #37 was moderately impaired cognitively. Medical record review of the (MONTH) Medication Administration Record [REDACTED]. Review of the facility investigation revealed the narcotic sign-out sheet for [MEDICATION NAME] for Resident #37 had the signature of Licensed Practical Nurse (LPN) #4 as administering the medication but also had the signature of Registered Nurse (RN) #2 as observing/confirming the wasting of 0.25 mg of [MEDICATION NAME] on 10/30/17 and 10/31/17. Continued review revealed the signature did not appear to be that of RN #2 and when questioned she denied it was her signature. Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 11/30/17 at 1:50 PM in their office revealed LPN #4 signed out [MEDICATION NAME] on 10/30/17 and again on 10/31/17. Continued interview revealed the dose of [MEDICATION NAME] signed out was 0.5 mg and the order was for 0.25 mg so 0.25 mg was wasted each night. Further interview revealed the signature of the nurse observing and confirming the wastage appeared to be RN #2 but the DON and ADON said it was not her regular signature. Continued interview revealed RN #2 was interviewed and categorically denied it was her signature. Further interview the DON confirmed the facility failed to prevent misappropriation of medications.",2020-09-01
761,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2017-08-02,224,D,1,1,RHGV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to prevent misappropriation of medications for 1 resident (#79) of 7 residents reviewed for abuse. The findings included: Review of facility policy, Abuse, released 10/20/16, revealed .Verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, and neglect of the patient as well as mistreatment, injuries of unknown source, and misappropriation of patient property are strictly prohibited .Misappropriation is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent . Review of facility policy, Drug Diversion, released 6/1/16, revealed .Oncoming and offgoing nurses complete a shift to shift count on medication cards or containers containing controlled substance medication; controlled substance medication sheets; controlled substance medications in E-kits (Emergency medications) when the E-kit has been opened .Nurses report any discrepancy in controlled substance medication counts to the Director of Nursing Service (DNS) immediately .Facility management should investigate and make every reasonable effort to reconcile reported discrepancies. Investigation included interview, medical record reviews, observation of facility practices related to handling of controlled substances; evaluate if loss is associated with or attributed to specific individuals; identify any potential negative impact on patient's condition or safety .Notify the Executive Director, pharmacy manager, and consultant pharmacist immediately .Potential theft of controlled substance is reportable to the local law enforcement agency, appropriate professional licensing board; and state agency . Medical record review revealed Resident #79 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED].#79 was ordered [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) 7.5/325 mg (milligrams) 1 tablet QID (four times daily). Review of the Pharmacy Delivery Invoice revealed 30 tablets of [MEDICATION NAME]/[MEDICATION NAME] 7.5/325 mg were delivered to the facility on [DATE] and signed for by the two nurses on duty. Review of the facility investigation revealed: 1/3/17 -card of 7.5/325 mg [MEDICATION NAME] and its narcotic sheet missing -all medication carts were checked -pharmacy was called to verify delivery 1/4/17 - complete MAR (Medication Administration Records) to cart audits were done on on all carts - pharmacy was requested to do a complete audit of delivery - part of the (MONTH) narcotic shift-to-shift tracking log was also missing - interviews were completed with licensed nurses who had access to the carts - Executive Director and corporate office were notified 1/5/17 - inservices for licensed nurses on counts and drug diversion were held - police were notified - suspect nurse was terminated - suspect nurse did not show for her shift 1/4/17 at 6:00 PM - 6:30 AM nor any subsequent shifts - suspect was unable to be reached by telephone The DNS interviewed all nurses who had access to the medication cart during the period of the diversion including Licensed Practical Nurses (LPN) #5, #6, #7, #8, #9 and Registered Nurse (RN #1). Questions asked included did they count; how many medication cards did they see; did they see the card count sheet; who received the drug delivery; and what was done with the drugs after delivery. Review of the Root Cause Analysis Summary revealed the delivery of the [MEDICATION NAME] on 12/31/16. On 1/3/17 the supervisor was doing a verification of narcotics when she noted a card of [MEDICATION NAME] and its narcotic sign sheet were missing. The narcotics were signed in on delivery by 2 licensed nurses and delivered to medication carts to be locked in the narcotic drawer. The carts were kept locked and only the nurse working that hall has the key to the cart. The cards were logged onto the card count sheet. When cards were taken out of the cart they were logged on the card count sheet and nurses signed for them. Reports from pharmacy were sent to the DNS to verify narcotic deliveries and the presence of narcotics. Narcotics were delivered; accepted; and stored correctly. The nurse signed on the narcotic sheet/card count sheet as 29 vs 30 as it should have been. The nurse was made aware of the missing drug and she began to question fell ow nurses as to how it was found out. The suspected nurse became a no call no show for scheduled shifts. The suspected nurse was unable to be reached by telephone and did not return calls. The facility was unable to say definitively she was guilty but she had keys to the cart and access to the narcotics. Resident #79 had multiple cards of drugs in the cart and by changing the card count sheet with next day being a new month, the count would be correct. Interview with the DNS, on 8/2/17 at 9:25 AM in her office confirmed a card of 30 tablets of [MEDICATION NAME] as well as the accompanying sign out sheet were missing and unable to be located. The DNS also confirmed the accused nurse refused to return telephone calls so was unable to be interviewed",2020-09-01
4600,LIFE CARE CENTER OF OLD HICKORY VILLAGE,445509,1250 ROBINSON ROAD,OLD HICKORY,TN,37138,2016-09-28,224,E,1,0,O3DK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to prevent misappropriation of medications for 3 residents (#1, #2, # 3) of 7 residents reviewed for misappropriation. The findings included: Review of facility policy, Abuse Policy and Procedure, revealed .Any form of patient/resident abuse shall not be tolerated. Responsibility for reporting patient/resident abuse, mistreatment, or neglect directly to the Director of Nursing and/or Executive Director or their designees, lies with all associated .Facility will analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences . Review of facility policy, Protection from Abuse, revealed .Investigation and documentation for allegations of abuse include the following: 1. Who allegedly committed the abuse act 2. Who was abused. 3. What type of abuse was involved. 4. When and where it occurred. 5. Results of the investigation. 6. The corrective action taken . Review of the policy, Inventory Control of Controlled Substances, revised 1/1/13 revealed .Facility should maintain separate individual controlled substances records on any Schedule II medications and any medication with a potential for abuse or diversion in the form of declining inventory .Facility should ensure that staff IMMEDIATELY reports suspected theft or loss of controlled substances to their supervisor/manager for appropriate documentation, investigation, and timely follow-up .Facility should ensure the appropriate Facility personnel confirm the discrepancy .Facility should also conduct an investigation to determine whether a dose was in fact administered and, if so, the reason the administration was not charted, and whether a dose was refused . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Admission Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 was alert and oriented. Medical record review of physician's orders [REDACTED]. Review of the Medication Administration Record (MAR) revealed on 7/25/16 it was documented the resident received [MEDICATION NAME] at 2:00 AM and 6:00 AM but at no other times. Continued review of the MAR dated 7/26/16 revealed [MEDICATION NAME] was administered at 6:00 AM and 12:00 PM but at no other times. Review of the Controlled Drug Record revealed the medication was received at the facility on 7/25/16 and 2 tablets were signed out at 6:00 PM, 10:00 PM, 2:00 AM, and 6:00 AM by Licensed Practical Nurse (LPN #1) Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE], revealed Resident #2 was alert and oriented and able to make his needs known. Medical record review of physician's admission orders [REDACTED]. Medical record review of the MAR dated 7/25/16 revealed no documentation of any [MEDICATION NAME] administered. Review of the Controlled Drug Record revealed 1 [MEDICATION NAME] was signed out at 11:25 PM on 7/25/16 by LPN #1. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE], revealed Resident #3 was alert and oriented and able to make her needs known. Medical record review of physician's admission orders [REDACTED]. Medical record review of the MAR revealed no [MEDICATION NAME] documented as being administered on 7/25/16. Medical record review of the Controlled Drug Record revealed 1 [MEDICATION NAME] 5/325 mg was signed out at 7:00 PM on 7/25/16. Review of the facility investigation dated 7/26/16 revealed at 5:46 AM the Director of Nursing (DON) was notified by the Staff Educator that LPN #1 was scheduled to work 7:00 PM - 11:00 PM the night of 7/25/16 and signed out [MEDICATION NAME] (pain medication) IR 10 milligrams (mg) 4 times, including 3 times she was not at work. Continued review revealed on 7/26/16 at 6:00 AM the Interim Administrator was notified. Further review revealed on 7/26/16 at 7:00 AM, the Staff Educator and the Unit Manager called LPN #1 into the office and questioned her about the medication being signed out during hours she was not at work. Continued review revealed LPN #1 stated she signed them out between the hours of 7:00 PM and 11:00 PM and gave them to the resident during those hours. Further review revealed on 7/26/16 Human Resources conducted a drug test on LPN #1 at 7:30 AM which was positive and at 8:00 AM the Police were notified. Continued review revealed on 7/26/16 at 8:15 AM, the DON and Administrator interviewed LPN #1 and she stated she gave all the medications between 7:00 PM and 11:00 PM. Further review revealed the DON stated she would have to send Resident #1 to the emergency room (ER) for evaluation due to the amount of medication LPN #1 stated she had administered to the resident. Continued review revealed the DON assessed Resident #1 who stated he did not receive any pain medication until 6:00 AM. Further review revealed the DON returned to the office and LPN #1 had told the Administrator and Human Resources that she took the medications. Further review revealed on 7/26/16 at 10:30 AM, the DON reviewed the controlled drug logs on all 3 halls assessing for trends. Continued review revealed she identified 3 residents who stated they did not take any pain medication which had been signed out for them. Further review revealed on 7/28/16 LPN #1 was terminated from employment. Interview with the Administrator and DON on 9/7/16 at 3:27 PM in the conference room revealed the nurse educator was orientating a Certified Nursing Aide the night of 7/25/16 when the night nurse went to her with the sign-out sheet for narcotics showing [MEDICATION NAME] for Resident #1 signed out for 2:00 AM and 6:00 AM by LPN #1 when she only worked 7:00 PM - 11:00 PM. Continued interview revealed the nurse educator checked the MAR and notified the DON. Further interview revealed the Administrator and DON interviewed LPN #1 who had slurred speech. LPN #1 stated she gave Resident #1 all 8 doses of [MEDICATION NAME] in 4 hours. Continued interview revealed the DON told LPN #1 that Resident #1 and possibly all the residents she had cared for the previous evening would have to go to the ER for evaluation. Further interview revealed LPN #1 then admitted taking the medications. Continued interview with the Administrator and DON confirmed narcotics were signed out by LPN #1 and documented as being administered by LPN #1 but the residents to whom the medications were documented stated they did not receive any medications during the shift worked by LPN #1. Further interview with the Administrator and DON confirmed LPN #1 misappropriated medications belonging to residents at the facility.",2019-09-01
2141,"LAKEBRIDGE, A WATERS COMMUNITY, LLC",445358,115 WOODLAWN DRIVE,JOHNSON CITY,TN,37604,2017-10-25,224,D,1,1,OMO511,"**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 the misappropriation of medication for one resident (#55) of 3 residents reviewed for medication management. The findings included: Review of the facility policy, Controlled Substances, dated (MONTH) (YEAR), revealed .b. All .controlled substances .will be counted each shift .both nurses will count the number of packages of controlled substances that are being reconciled during shift to shift count . Medical record review revealed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued medical record review revealed the resident was discharged home on[DATE]. Review of a controlled medication receipt, dated 8/26/17, revealed the facility had received a 30 count of the medication [MEDICATION NAME] (anxiety medication), the day after the resident had been discharged . Interview with the Director of Nursing on 10/25/17 at 10:22 AM, in the conference room, revealed the Assistant Director of Nursing (ADON) discovered the empty medication card in the facility's Sharps container (a hard plastic container used to store needles and other sharp instruments safely) on 9/1/17. Continued interview revealed the medications from the card (30 [MEDICATION NAME] tablets) could not be accounted for. Continued interview with the DON and review of the facility's investigation dated 9/1/17, revealed the charge nurses had failed to count the number of controlled substance cards at the change of shift. Continued interview confirmed the facility's policy for the management of controlled substances had not been followed.",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
2189,HARRIMAN CARE & REHAB CENTER,445368,240 HANNAH ROAD,HARRIMAN,TN,37748,2020-01-15,625,D,1,0,JJIZ11,"**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 policy for 1 of 5 (Resident #3) reviewed for transfer, admission, and discharge. The findings include: Review of the facility policy, Facility Bedhold, last revised 11/12/2018, showed .The Facility will notify the resident/responsible party of the facility's bed hold and re-admission policies at admission and anytime a resident is transferred to the hospital .The Facility will also notify the resident/responsible party in writing of the reason for transfer/discharge to another legally responsible institutional .setting and about the residents right to appeal the transfer/discharge .The facility's Bedhold (Bed hold) and Re-admission policies will be discussed with the resident/responsible party and the facility will provide written notice of the bed hold and re-admission policies .Before a resident's transfer to the hospital .The facility's Social Worker or Licensed Nurse will document verbal and written notification in the medical record . Review of the medical record, showed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #3 had a Brief Interview of Mental Status Score (BIMS) of 15 indicating the resident was cognitively intact. Review of the medical record showed Resident #3 was transferred to a local hospital for evaluation and treatment after a change in mental status on 11/24/2019. The resident was evaluated in the emergency department and admitted to the hospital for further treatment. Review of the Discharge MDS dated [DATE], showed the resident's return to the facility after hospitalization was anticipated. During an interview on 1/15/2020 at 9:48 AM, the MDS Coordinator confirmed Resident #3 was discharged on [DATE] to the hospital and her return to the nursing home was anticipated at the time. During an interview on 1/15/2020 at 11:15 AM, Registered Nurse #1 confirmed she transferred Resident #3 to the hospital on [DATE]. Further interview confirmed she failed to provide the resident/family the bed hold policy when the resident was transferred to the hospital. During an interview on 1/15/2020 at 3:12 PM, the Director of Nursing (DON) confirmed the facility failed to provide Resident #3 and the resident's family with the written bed hold policy when the resident was transferred to the hospital on [DATE].",2020-09-01
1458,AHC CUMBERLAND,445262,4343 ASHLAND CITY HIGHWAY,NASHVILLE,TN,37218,2019-03-14,684,D,1,0,Z3RS11,"**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 care in accordance with professional standards of practice and failed to follow its policy on wastage of narcotics for 3 (Resident #2, #11, and #12) of 8 residents reviewed for narcotic administration. The findings included: Review of facility policy, Controlled Medication Policy, revised 11/2017, revealed .The facility will have safeguards in place to prevent loss, diversion, or accidental exposure .The charge nurse conducts a daily visual audit of the required documentation of controlled substances .Controlled substances are stored under double lock until administered to the patient .Two licensed staff must witness any disposal or destruction of a controlled substance and document same on the Controlled Drug Receipt/Record/Disposition form .Two licensed nurses account for all controlled substances and access keys at the end of each shift .Any discrepancies which cannot be resolved nurse must notify DON and pharmacy immediately .Complete an investigation detailing the discrepancy, steps taken to resolve it, and the names of all licensed staff working when the discrepancy was noted .Staff may not leave the area until discrepancies are resolved or reported as unresolved . Medical record review revealed Resident #2 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED].#2 was ordered Buprenorphin 8 mg SL, give 3/4 tab (6 mg) BID. On 2/7/19 at 6:00 AM, 2/9/19 at 6:00 AM, 2/10/19 at 6:00 AM and 6:00 PM, and 2/16/19 at 6:00 AM there was not a second nurses' signature attesting to the wastage of 1/4 tablet each time. Although there is no order found and no change on the narcotic sheet, for 2/20/19, 2/21/19, and 2/22/19 the medications is signed out as 1 tablet given with no second signatures on any of the dates of a second nurse witnessing the wastage. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED].#11 was ordered [MEDICATION NAME] 0.5 mg give 1/2 tab 2 times daily. Review of the narcotic sign out sheet on 1/25/19 at 6:00 AM, 1/26/19 at 6:00 AM and 6:00 PM, 1/27/19 at 6:00 PM, 1/28/19 at 6:00 PM, 1/29/19 at 6:00 AM, 1/30/19 at 6:00 AM; 1/31/19 at 6:00 AM and 6:00 PM; 2/2/19 at 6:00 AM and 6:00 PM; 2/3/19 at 6:00 AM and 6:00 PM; 2/4/19 at 6:00 AM; 2/5/19 at 6:00 AM; 2/6/19 at 6:00 PM; 2/8/19 at 6:00 AM; 2/9/19 at 6:00 AM; 2/13/19 at 6:00 AM; 1/224/19 at 6:00 AM; 2/15/19 at 6:00 PM; 2/16/19 at 8:00 am and 9:00 PM; 2/17/19 at 8:00 AM and 9:00 PM revealed a second nurses' signature was not present on the sheet to indicate a second nurse had witnessed the wastage. During this time sometimes the amount given was documented as 1 tablet and other times it was documented as 1/2 tablet. From 2/16/19 - 2/23/19 it was consistently documented 1 tablet was given and there were no second signatures. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED]. 1/2 tablet 2 times daily on 10/11/17. Review of the narcotic sign out sheet revealed on 2/1/19 at 8:00 am; 2/6/19 at 8:00 AM; 2/7/19 at 8:00 AM; 2/9/19 at 8:00 AM; 2/10/19 at 8:00 AM; 2/11/19 at 8:00 AM and 9:00 PM; 2/12/19 at 9:00 AM; 2/14/19 at 8:00 AM revealed a second nurses' signature was not present on the sheet to indicate a second nurse had witnessed the wastage. During interview on 3/14/19 at 2:00 PM in the conference room the Administrator confirmed the signature of the second nurse witnessing the wastage was missing from the three narcotic records.",2020-09-01
4425,CREEKSIDE CENTER FOR REHABILITATION AND HEALING,445516,306 W DUE WEST AVENUE,MADISON,TN,37115,2016-10-24,282,L,1,0,CT4U11,"**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 care in accordance with the resident's Plan of Care by failing to complete blood glucose testing as outlined in the care plan for 9 residents (#2, #3, #4, #5, #6, #7, #8, #9, #10) of 9 diabetic residents reviewed; failed to administer insulin as outlined in the care plan for 7 residents (#2, #3, #5, #6, #7, #8, #9) of 7 residents receiving insulin; failed to administer cardiac and blood pressure medications as outlined in the care plan for 3 residents (#3, #6, #7) of 3 residents reviewed for cardiac and blood pressure medications; failed to administer antidepressant and antianxiety medications as outlined in the care plan for 3 residents (#8, #9, #10) of 3 residents receiving antidepressants; and failed to follow guidelines for care of a resident with a wound vac for 1 resident (#18) of 1 resident with a wound vac. These failures placed all residents in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator (NHA) was informed of the Immediate Jeopardy on 10/24/16 at 3:25 PM, in the Conference Room. The findings included: Review of facility policy, Medication Administration, revised 3/16/15 revealed, .Administer medications within 60 minutes of the scheduled time . Review of facility policy, Diabetes, Nursing Care of the Adult Diabetes Mellitus Resident, undated, revealed, .The purpose of this guideline is .Prevent recurrence of [MEDICAL CONDITION]/[DIAGNOSES REDACTED] (high and low blood sugars). Recognize, assist and document the treatment of [REDACTED].obtain pre-meal fingerstick blood glucose within 60 minutes (maximum) of anticipated meal .The physician should be notified when the blood sugar falls above his/her specified blood sugar range and/or above 400 mg/dL (milligrams per deciliter) . Review of facility policy, Negative Pressure Wound Therapy (NPWT), undated, revealed, .Review health care provider's orders for frequency of dressing change, type of foam to use, amount of negative pressure and cycle (intermittent or continuous) .Routinely check that the vacuum level is set as prescribed and the dressing is properly sealed .Inspect condition of wound on ongoing basis; note drainage and odor .verify airtight dressing seal and correct negative pressure setting. Measure wound drainage output in canister .Chart in the nurses's notes the appearance of wound, color, characteristics of any drainage .NPWT pressure setting, dressing change, and resident response to dressing change . The Medical Director of the facility is the physician of record for all the 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 the resident had a Brief Interview for Mental Status (BIMS) of 4 indicating the resident was severely cognitively impaired. She had continuous behaviors of inattention that did not change and had rejected care 1-3 days of the previous 7 days. Continued review revealed the resident received 51% or more of her calories, 500 cc (cubic centimeters) or more of fluid through a feeding tube, and received 7 injections of insulin during the previous 7 days. The resident was impaired to her bilateral lower extremities, and impaired on her left upper extremity. She used a wheelchair for ambulation. Medical record review of a comprehensive care plan for Resident #2 dated 6/8/16 revealed a problem of a PEG tube (Percutaneous Endoscopic Gastrostomy - feeding tube) for adequate nutritional intake. Interventions included: .Check placement before initiating my tube feedings; Check for residual before initiating my feeding; Tube feeding and flushes per order . Observation on 10/11/16 at 1:15 PM, in Resident #2's room revealed Licensed Practical Nurse (LPN) #1 was preparing to administer a bolus tube feeding to the resident. Continued observation revealed the LPN administered 300 cc of Glucerna 1.5 and 240 cc of water through the PEG tube without first checking placement, or checking for residual. Interview with LPN #1 on 10/11/16 at 1:25 PM at the medication cart outside room [ROOM NUMBER]B confirmed she did not check placement or residual prior to administering 300 cc of Glucerna 1.5 tube feeding or 240 cc of water. The LPN confirmed she did not follow the care plan as directed for Resident #2. Medical record review of a comprehensive care plan dated 6/7/16 revealed a problem of medical management for Diabetes Mellitus Type II. Interventions included, .Administer my scheduled insulin as ordered; Obtain my finger stick blood sugars as ordered . Medical record review of Physician's Orders dated 9/22/16 revealed an order for [REDACTED]. The scheduled administration time was 9:00 PM. Medical record review of the 9/2016 and 10/2016 Medication Administration Record [REDACTED]. Interview with Registered Nurse (RN) #2 by phone on 10/12/16 at 3:20 PM confirmed 21 Units of [MEDICATION NAME] was not administered to Resident #2 on 9/22/16 at 9:00 PM as ordered. Medical record review of a Physician's Order dated 6/4/16 revealed, .ACCUCHECKS (finger stick for blood sugar) BEFORE BOLUS FEEDINGS AND SSI (sliding scale insulin) AS FOLLOWS: 0-59 = CALL MD 60-150=0, 151-200=2u (units), 201-250=4u, 251-300=6u, 301-350=8u, 351-400 = 10u .NOTIFY MD AND RECHECK IN 15 MINUTES . The scheduled time was 6 AM, 12 PM, 6 PM, and 12 AM daily. Medical record review of Residnet #2's 6/2016 Medication Administration Record [REDACTED]. Continued review revealed blood sugars were checked 1-4 hours late 2 times for the month of 6/2016. Interview with Licensed Practical Nurse (LPN) #3 on 10/18/16 at 2:20 PM, in the conference room revealed he called Nurse Practitioner (NP) #2 on 6/4/16 regarding Resident's #2's blood sugar of 211 and was told to hold the SSI dose of 4 units. Continued interview with the LPN confirmed he did not write an order to hold the 4 units of insulin and he did not administer the dose per the sliding scale protocol. Medical record review of the 6/2016 Medication Administration Record [REDACTED] 591 on 6/4 at 7:30 AM 432 on 6/6 at 6:00 AM 401 on 6/7 at 12:00 AM High on 6/9 at 12:00 PM 456 on 6/12 at 6:00 AM 429 on 6/18 at 6:00 AM Medical record review revealed no notification of the MD or Nurse Practitioner (NP) regarding Resident #2's elevated blood sugars. Medical record review of the 7/2016 MAR indicated [REDACTED]. The time frame excludes the 60 minute window of time (60 minutes before and 60 minutes after the scheduled time) which is allowable to administer medication before or after the scheduled time. Medical record review of Resident #2's 7/2016 MAR indicated [REDACTED] 564 on 7/1 at 6:00 AM 441 on 7/1 at 12:00 PM 503 on 7/6 at 12:00 AM 489 on 7/9 at 12:00 PM 518 on 7/10 at 12:00 AM 511 on 7/10 at 12:00 PM 405 on 7/12 at 12:00 AM 466 on 7/25 at 6:00 AM 459 on 7/27 at 12:00 AM 436 on 7/31 at 6:00 PM Medical record review revealed no notification of the MD or NP regarding Resident #2's elevated blood sugars. Medical record review of the 8/16 MAR indicated [REDACTED] 475 on 8/1 at 12:00 AM 492 on 8/7 at 6:00 PM 456 on 8/20 at 6:00 PM 432 on 8/21 at 6:00 PM 493 on 8/25 at 6:00 PM Medical record review revealed no notification to the MD or NP regarding Resident #2's elevated blood sugars. Medical record review of the 9/2016 MAR indicated [REDACTED]. Continued medical record review of the 9/2016 MAR indicated [REDACTED]. There was no documentation the blood sugar was re-checked in 15 minutes after administration of the 10 units of SSI. Resident #2's blood sugar was not checked at 6:00 PM per order. The blood sugar was 327 at 12:00 AM on 9/23 and no SSI was administered; the blood sugar was 560 at 6:00 AM and no SSI was administered, the blood sugar was not re-checked in 15 minutes, and the physician was not notified. Continued review revealed no physician orders to hold accuchecks, or SSI in Resident #2's medical record. Telephone interview with LPN #5 on 10/18/16 at 4:00 PM revealed, (RN #2) gave me report to hold the insulin for lab work in the morning. I should have looked to see the order myself, and I did not call the Doctor when the sugar was 560. I was just going on what I was told. Interview with LPN #6 on 10/19/16 at 7:15 AM, in the conference room confirmed Resident #2's blood sugar was 47 on 9/7/16 and she failed to notify the physician. Medical record review of the 10/2016 MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 10/19/16 at 4:05 PM, in the conference room confirmed the facility policy was to notify the physician if a blood sugar was less than 60 or greater than 400. Continued interview revealed the DON was unaware accuchecks were up to 5 hours late. Further interview with the DON revealed I knew they were a little late but I had no idea they were 2 1/2-3 hours late. Continued interview with the DON confirmed the facility failed to check blood sugars as ordered, failed to follow the facility policy, and failed to notify the physician of Resident #2's elevated blood sugars. Interview with the DON on 10/19/16 at 4:05 PM, in the conference room confirmed not administering [MEDICATION NAME] as ordered on [DATE] and administering the insulin at 11:25 PM instead of 9:00 PM were medication errors. Continued interview with the DON confirmed the facility failed to follow physician orders. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission MDS dated [DATE] revealed the resident was severely cognitively impaired, had impairments to all extremities, received insulin 1 time over the previous 7 days and received 51% or greater of his calories and 501 cc per day of fluid through a feeding tube. Medical record review of the comprehensive care plan dated 7/19/16 revealed a problem of insulin dependent diabetes. Interventions included, .Administer my insulin according to my physician's orders; Monitor my blood sugars per my physician's orders . Medical record review of a physician's telephone order dated 9/22/16 revealed, .Accuchecks before meals and at bedtime . The scheduled time of administration was 7:30 AM, 12:00 PM, 5:00 PM, and 9:00 PM. The order did not include sliding scale insulin (SSI) orders. Medical record review of the 9/2016 MAR indicated [REDACTED]. Medical record review revealed no physician's telephone orders regarding accuchecks, SSI, or administration time changes. Medical record review of the Physician's Recapitulation Orders for 9/2016 revealed an order dated 9/23/16 for accuchecks with SSI. The scheduled times were 10:00 AM, 2:00 PM, 6:00 PM and 10:00 PM. Medical record review of the 9/2016 and 10/2016 MAR indicated [REDACTED] 9/24 scheduled at 10:00 AM checked at 3:05 PM 9/24 scheduled at 2:00 PM checked at 4:20 PM 9/25 scheduled at 10:00 AM checked at 3:38 PM 9/25 scheduled at 2:00 PM checked at 5:33 PM 9/25 scheduled at 10:00 PM checked at 11:23 PM 9/26 scheduled at 10:00 AM checked at 12:39 PM 9/26 scheduled at 2:00 PM checked at 3:28 PM 9/26 scheduled at 10:00 PM checked at 5:20 AM on 9/27 9/28 scheduled at 10:00 AM checked at 11:19 AM 9/28 scheduled at 2:00 PM checked at 4:04 PM 9/28 scheduled at 10:00 PM checked at 11:36 PM 9/29 scheduled at 10:00 AM checked at 3:19 PM 9/29 scheduled at 2:00 PM checked at 3:20 PM 10/4 scheduled at 2:00 PM checked at 6:08 PM Medical record review of the comprehensive care plan dated 7/19/16 revealed a problem of signs of [MEDICAL CONDITION]. Interventions included: .Administer my cardiac .meds (medications) as ordered . Medical record review of a physician's telephone order dated 9/12/16 revealed, .[MEDICATION NAME] HCL (used to treat low blood pressure) 5 mg tab (tablet) give one tab PT (per tube) before meals; BP (blood pressure) to be checked prior to administration, Hold for BP (systolic greater than 120 or diastolic greater than 80) . The order was written by LPN #4 and signed by NP #1. Medical record review of the Electronic Physician's Order dated 9/12/16 for [MEDICATION NAME] 5 mg revealed it was entered into the computer by LPN #4 at 7:00 PM. The electronic order contained a special requirement to check the blood pressure prior to administration and to hold if the systolic blood pressure was less than 120. Medical record review of 9/2016 MAR indicated [REDACTED].[MEDICATION NAME] HCL 5 MG TABLET give one tablet per tube before meals. CHECK BP (blood pressure) . There were no blood pressure parameters transcribed onto the MAR. Medical record review of the 9/2016 MAR indicated [REDACTED]. 9/12 at 10:00 PM. BP 149/90 9/13 at 10:00 AM. BP 152/82 9/13 at 2:00 PM. BP 125/64 9/13 at 6:00 PM BP 122/80 9/13 at 10:00 PM. BP 124/53 9/14 at 10:00 AM. BP 134/70 9/14 at 2:00 PM. BP 130/70 9/14 at 6:00 PM. BP 134/70 9/14 at 10:00 PM. BP 129/82 9/15 at 10:00 AM. BP 126/75 9/15 at 2:00 PM. BP 128/75 9/16 at 10:00 AM. BP 120/100 9/16 at 2:00 PM. BP 118/88 Continued review of an Electronic Physician's Order dated 9/16/16 revealed LPN #3 removed the parameter to hold the [MEDICATION NAME] 5mg if the systolic blood pressure was less than 120 on 9/16/16 at 5:01 PM. The original parameters from the 9/12/16 order to hold the medication if the systolic BP was greater than 120 or the diastolic BP was greater than 80 was not entered into the computer or transcribed onto the MAR. Medical record review of the MAR indicated [REDACTED]. Interview with the Regional Nurse on 10/24/16 at 2:00 PM in the conference room confirmed the facility failed to follow physician orders for Resident's #2 and #3. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders dated 7/26/16 revealed .Please give 8 ounces [MEDICATION NAME] 1.5 per tube as needed if meal intake is less than 50% . Continued review of physician orders dated 9/20/16 revealed .[MEDICATION NAME] 1.5 cal liquid, Give 8 ounces per tube BID (twice daily) between meals with 120 ml (milliliters) H2O flush before and after each bolus . Medical record review of the MAR for (MONTH) (YEAR), revealed the 8 ounces of [MEDICATION NAME] were administered at 10:00 AM and 10:00 PM. Continued review revealed the 8 ounces to be given with food intake less than 50% was scheduled for 9:00 AM, 1:00 PM, and 7:00 PM. Further review of the MAR indicated [REDACTED]. Medical record review of nursing notes for (MONTH) (YEAR) revealed no documentation the [MEDICATION NAME] was given between meals as ordered. Interview with LPN #7 on 10/17/16 at 3:05 PM, in the conference room revealed she documented the amount the resident ate and put a check mark to indicate she was aware of the amount the resident ate. Continued interview revealed if the resident ate less than 50% of the meal the nurse would administer [MEDICATION NAME] to the resident. Interview with LPN #3 on 10/17/16 at 3:11 PM, in the conference room revealed nurses place a check mark on the MAR indicated [REDACTED]. Continued interview revealed if the resident ate less than 50% the staff would give [MEDICATION NAME] because that was the order. Further interview revealed LPN #3 was not aware of any place to document the [MEDICATION NAME] when it was given. Continued interview revealed .If the amount the resident eats is less than 50% we assume the nurse administered the [MEDICATION NAME] . Medical record review of the care plan for Resident #4, revised 9/22/16 revealed a problem of I have labile blood sugars related to Type II Diabetes Mellitus. Continued review revealed Approaches included: a. Monitor my nutritional intake. b. Obtain my finger stick blood sugars as ordered. c. Administer my oral hypoglycemic agents as ordered. Medical record review of the MAR for (MONTH) (YEAR) revealed: a. on 21 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Interim Care Plan initiated 10/9/16 revealed a problem of Resident required insulin injections to manager Diabetes. Continued review revealed Approaches included: a. Administer routine and sliding scale insulin as per physician's orders. b. Administer finger sticks as ordered and give sliding scale insulin as per physician's orders c. Observe for signs/symptoms of hypo/[MEDICAL CONDITION] and report to physician as per parameters. Medical record review of the MAR for 10/2016 revealed: a. on 7 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window b. on 4 occasions insulin was administered 1 1/2 - 2 hours past the scheduled window c. on 6 occasions [MEDICATION NAME] was administered 1 1/2 - 3 hours past the scheduled window. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan with a problem onset dated 9/30/16 of I am insulin dependent diabetic. Continued review of the care plan revealed Approaches included: a. Administer my insulin according to my physician's orders. b. Monitor my blood sugars per my physician's orders. c. Observe me for signs/ symptoms of hypo/[MEDICAL CONDITION] and report any noted to physician. Medical record review of the Care Plan revealed a problem onset of 5/19/14 of I am at risk for side effects from [MEDICAL CONDITION] drug use. Continued review revealed Approaches included: a. Administer my medication as ordered by physician. b. Observe me for adverse side effects, document, and report to my physician. Medical record review of the Medication Administration Record [REDACTED] a. on 22 occasions blood glucose monitoring was completed from 1 1/2 - 7 hours past the scheduled window b. on 12 occasions insulin was administered 1 1/2 - 7 hours past the scheduled window c. on 7 occasions [MEDICATION NAME] (antibiotic) was administered 2 - 8 1/2 hours past the scheduled window. Medical record review of the MAR for (MONTH) (YEAR) revealed: a. on 33 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window b. on 2 occasions insulin was administered 1/2 - 1 1/2 hours past the scheduled window c. on 4 occasions [MEDICATION NAME] (antidepressant) was administered 2 - 3 hours past the scheduled window d. on 4 occasions [MEDICATION NAME] (antidepressant) was administered 1/2 - 3 hours past the scheduled window e. on 9 occasions [MEDICATION NAME] (anti-anxiety) was administered 1 1/2 - 4 hours past the scheduled window Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan revealed a problem onset of 10/12/16 of I am insulin dependent diabetic. Continued review revealed Approaches included: a. Administer my insulin according to my physician's orders. b. Monitor my blood sugars per my physician's orders. c. Observe me for signs/symptoms of hypo/[MEDICAL CONDITION] and report any noted to my physician. Medical record review revealed a problem onset of 10/12/16 of I am at risk for altered cardiac status related to Cor Pulmonale, Hypertension, and [MEDICAL CONDITION]. Continued review revealed Approaches of: a. Medication as ordered. b. Report signs/symptoms of side effects. Medical record review of the MAR for (MONTH) (YEAR) revealed: a. on 18 occasions blood glucose monitoring was completed 1 1/2 - 3 hours past the scheduled window b. on 16 occasions insulin was administered 2 1/2 - 8 hours past the scheduled window c. on 5 occasions [MEDICATION NAME] (cardiac) was administered 3 1/2 - 6 hours past the scheduled window d. on 9 occasions [MEDICATION NAME] (blood pressure) was administered 1 1/2 - 3 hours past the scheduled window e. on 5 occasions [MEDICATION NAME] (blood pressure) was administered 1 1/2 - 3 hours past the scheduled window f. on 3 occasions [MEDICATION NAME] (antianxiety) was administered 1 1/2 - 2 1/2 hours past the scheduled window Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan revealed a problem onset of 8/4/16 of I am an insulin dependent diabetic. Continued review revealed Approaches included: a. Administer my insulin according to my physician's orders. b. Monitor my blood sugars per my physician's orders. c. Observe me for signs/symptoms of hypo/[MEDICAL CONDITION] and report any noted to my physician. Medical record review of the Care Plan revealed a problem onset of 8/4/16 of I am at risk for side effects from antidepressant drug use. Continued review revealed Approaches of: a. Administer my medication as ordered by physician. Medical record review of the MAR for 9/2016 revealed: a. on 54 occasions blood glucose monitoring was completed 1 1/2 - 8 1/2 hours past the scheduled window b. on 18 occasions [MEDICATION NAME] (blood pressure) was administered 1 1/2 - 5 hours past the scheduled window c. on 13 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 5 1/2 hours past the scheduled window d. on 14 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 4 1/2 hours past the scheduled window e. on 3 occasions [MEDICATION NAME] (cardiac) was administered 1 1/2 - 2 1/2 hours past the scheduled window f. on 1 occasion [MEDICATION NAME] ([MEDICAL CONDITION]) and [MEDICATION NAME] (antacid) were administered 10 1/2 hours past the scheduled window Medical record review of the MAR for 10/2016 revealed: a. on 31 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window b. on 4 occasions insulin was administered 2 - 5 hours past the scheduled window c. on 20 occasions [MEDICATION NAME] was administered 1 1/2 - 7 /12 hours past the scheduled window d. on 11 occasions [MEDICATION NAME] was administered 2 - 3 hours past the scheduled window e. on 13 occasions [MEDICATION NAME] was administered 1 1/2 - 5 hours past the scheduled window. Medical record review revealed Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan revealed a problem onset of 5/4/16 of I am an insulin dependent diabetic. Continued review revealed Approaches included: a. Administer my insulin according to my physician's orders. b. Monitor my blood sugars per my physician's orders. c. Observe me for signs/symptoms of hypo/[MEDICAL CONDITION] and report any noted to my physician. Medical record review of the Care Plan revealed a problem onset of 5/4/16 of I am at risk for side effects from [MEDICAL CONDITION] drug use related to antidepressant and antianxiety medication. Continued review revealed approaches of: a. Administer my medications as ordered by physician. Medical record review of the MAR for 9/2016 revealed: a. on 30 occasions blood glucose monitoring was completed 1 1/2 - 7 hours past the scheduled window b. on 20 occasions insulin was administered 1 1/2 - 7 hours past the scheduled window. c. on 43 occasions [MEDICATION NAME] (antianxiety) was administered 1 1/2 - 5 hours past the scheduled window d. on 16 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 5 hours past the scheduled window e. on 16 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 5 hours past the scheduled window. Medical record review of the MAR for 10/2016 revealed: a. on 13 occasions blood glucose monitoring was completed 1 1/2 - 4 hours past the scheduled window b. on 6 occasions insulin was administered 1 1/2 - 3 1/2 hours past the scheduled window c. on 19 occasions [MEDICATION NAME] was administered 1 1/2 - 2 1/2 hours past the scheduled window d. on 8 occasions [MEDICATION NAME] was administered 1 1/2 - 3 1/2 hours past the scheduled window e. on 8 occasions [MEDICATION NAME] was administered 1 1/2 hours - 3 1/2 hours past the scheduled window Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for 9/2016 revealed: a. on 47 occasions blood glucose monitoring was completed 1 1/2 - 7 hours past the scheduled window Medical record review of the MAR for 10/2016 revealed: a. on 34 occasions blood glucose monitoring was completed 1 1/2 - 7 1/2 hours past the scheduled window. Interview with the Director of Nursing (DON) on 10/20/16 at 4:40 PM, in the Conference Room confirmed medications were administered outside the window of 60 minutes before and 60 minutes after the scheduled time. Continued interview confirmed blood glucose monitoring and insulin administration occurred outside the window. Medical record review revealed Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] revealed the resident was severely cognitively impaired, always incontinent of bowel and bladder and had a Stage IV pressure ulcer to the sacrum. Medical record review of a telephone physician's order dated 10/10/16 prescribed by NP #3 revealed, .Coccyx pressure area - NPWT to pack/fill woundbed & drape to seal .Continue AG Collagen to cover coccyx wound bed each Vac (change) . Medical record review of the Treatment Administration Record (TAR) for 10/16 revealed the order was not followed on 10/11 or 10/12. Observation of Resident #18 on 10/18/16 at 10:20 AM in the resident's room revealed the resident was in bed, eyes closed. A wound vac was present to the side rail with serous drainage noted. Interview with the Wound Nurse on 10/19/16 at 11:30 AM, in Hermitage Hall when asked when the resident's wound vac was placed stated, Friday. (10/14). Continued interview revealed when asked what the treatment order dated 10/10 meant the Wound Nurse stated, that the wound vac was there. Continued interview revealed the Wound Nurse confirmed she documented care of the resident and the wound vac on 10/13, 10/14, 10/17, 10/18, and 10/19. Further review revealed there was no additional documentation of when the wound vac was placed, the negative pressure setting, how often it was to be changed, amount and color of drainage or how the resident was tolerating it. The Wound Nurse stated, I should have documented all of that. Interview with the DON on 10/19/16 at 4:05 PM, in the conference room confirmed the Wound Nurse should have clarified the 10/10/16 treatment order for the wound vac to Resident #18 on 10/10/16, and most certainly when the wound vac was placed. Continued interview with the DON confirmed there should have been documentation of the amount, color and odor of drainage, how the resident was tolerating the wound vac, the amount of negative pressure the wound vac was set on, and the type of wound vac machine and there was not. Interview with LPN #8 on 10/20/16 at 1:00 PM, in the conference room confirmed she had cared for the resident on 10/15/16 and had documented on the TAR she had followed the treatment order dated 10/10/16. When asked what the protocol was for care of a resident with a wound vac she stated, It is changed every Monday, Wednesday, and Friday and it is done by the Treatment (Wound) Nurse. When asked what her documentation of the order meant, she stated, I've never changed a wound vac before. I checked that it was there. The LPN confirmed she did not provide any care, or documentation of the wound, or wound vac for Resident #18. Telephone interview with LPN #11 on 10/20/16 at 4:50 PM confirmed she had cared for the resident on 10/16/16. When asked what care she provided to the resident she stated, He had a wound vac to his sacrum. I changed the tape. The wound was exposed and I secured the dressing with tape. The LPN confirmed she did not change the dressing, or document the status of the wound, wound vac settings, drainage type and amount, or how the resident was tolerating the care. Refer to F157 K, F224 L SQC, F281 [MI]",2019-10-01
1476,AHC CUMBERLAND,445262,4343 ASHLAND CITY HIGHWAY,NASHVILLE,TN,37218,2018-11-07,658,D,1,0,Y07M11,"**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 services according to accepted standards of clinical practice for 21 (Residents #3 - #23) of 24 residents reviewed for scabies. The findings include: Review of facility policy, Scabies, effective 12/11/17, revealed .Scabies is an itchy, highly contagious skin disease caused by an infestation of the itch mite .Scabies is characterized by an intense pruritic [DIAGNOSES REDACTED]tous popular eruption caused by burrowing of adult female mites in upper layers of the epidermis, creating wavy burrows .Scabies most commonly appears between the fingers, folds of the wrist, elbow or knee, around the waistline and navel, on the breasts or genitals .Transmission occurs through prolonged close personal contact .Place the resident on contact isolation .Treat with topical [MEDICATION NAME] 5% cream removed by bathing after 8 - 14 hours or oral ivermectin, given as 2 doses 1 week apart .Bed linens and clothes should be washed separately using hot water and hot dryer cycles .If the resident has stuffed animals or other items that are not washable they should be sealed in a plastic bag for a minimum of 3 days .A 100% skin audit should be conducted and documented on all residents who live in close proximity to the affected resident .All staff assigned to the hall of the affected resident should have a documented skin audit and be treated, if warranted .All new residents should be screened for scabies . Medical record review revealed Resident #3 - #23 were determined to have scabies. Continued review revealed no documentation of skin audits of residents in close proximity to the affected residents as stated in the facility policy. Further review revealed there was also no documentation of the characteristics or location of the rash for each resident. Review of employee records revealed no documentation of skin audits for those employees assigned to the floors where the residents with scabies were residing as stated in the facility policy. Interview with the Administrator on 11/7/`18 at 3:00 PM in the conference room confirmed the facility did not follow its policy for resident and staff assessment when residents are [DIAGNOSES REDACTED].",2020-09-01
3276,"THE WATERS OF SMYRNA, LLC",445502,202 ENON SPRINGS ROAD EAST,SMYRNA,TN,37167,2018-01-16,623,D,1,0,POU411,"**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 written discharge notice as soon as practicable for 3 residents (#6 #19, #23) of 5 residents reviewed for transfer/discharge requirements. The findings included: Review of facility policy Transfer and Discharge Policy and Procedure, dated 1/11/17, revealed .Non-emergency transfers or discharges not within the same certified facility will receive notice 30 days before transfer or discharge. Notice will be given the resident/responsible party .Before the facility transfers or discharges a resident, the facility must notify the resident and, if known, the legal representative or family member of the resident of the impending transfer/discharge .The Ombudsman must be notified in writing as well .Except when immediate transfer is required, written notice of a transfer or discharge must be made by the facility at least 30 days before the resident is to be transferred or discharged .When immediate transfer or discharge is required, a notice may be made as soon as practicable for the transfer or discharge . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed there was no active discharge planning and the resident expects to remain in this facility. Contined review of the MDS revealed Resident #6 scored 3 on the Brief Interview for MEntal Status, indicating she was severely cognitively impaired. FDurther reive wof the MDS revealed she had delusions and trouble with sleep. Medical record review of a Progress Note dated 10/31/17 revealed the facility informed the family a new placement would have to be found for the resident, as she was not a good fit for the facility due to safety concerns. Review of MDS tracking forms revealed the resident was discharged from the facility on 11/13/17. Medical record review revealed no evidence the resident and her responsible party/family member were provided a written notice of discharge, which included all required information such as date of discharge, location to which the resident was being discharged , and reason for the discharge, as well as information about how to appeal the discharge, if desired. The facility could not locate or provide the resident's hard copy closed record for review. Interview with the Social Services Director (SSD), on 1/10/18 at 9:56 AM in the conference room, confirmed on 10/31/17, the facility had contacted the resident's daughter and told her the resident, who had eloped from the building, was not a good fit for the facility. Continued interview revealed the SSD stated she told the family they would need to find alternate placement for the resident, and offered to help her find another facility with a locked unit. Further interview with the SSD revealed the facility did not provide a written discharge notice when the facility made the decision to discharge the resident due to safety concerns. Continued interview revealed she stated after the family was informed the resident could no longer stay in the facility, the Ombudsman called and talked to her and the Director of Nursing (DON) and informed them that, We had to give at least a 7-day notice. Further interview revealed the SSD stated I did not give a written notice. I don't have that authority, I can't make that decision. Continued interview revealed she stated I was told to get her out as soon as possible by the DON. Further interview revealed the SSD confirmed no written notice of discharge was ever provided to the resident and/or her family member prior to her discharge to another facility on 11/13/17. Interview on the Administrator on 1/10/18 at 11:05 AM in his office, revealed the SSD was the staff responsible for issuing discharge notices when the facility made the decision to initiate a discharge. Interview with the DON, on 1/10/18 at 12:15 PM in the conference room, confirmed the facility failed to give Resident #6 a written discharge notice. Continued interview revealed the DON indicated she was not aware of the requirement a written discharge notice be provided, or of the time frames in which the notice was to be given. Medical record review revealed Resident #19 was admitted to the facility on [DATE]. Medical record review of the Admission MDS dated [DATE] revealed there was no active discharge planning and the resident expects to remain in this facility. Medical record review of Progress Notes dated 11/1/17 at 6:29 PM revealed a nurse entered the resident's room and found the resident in bed, passing a cigarette to a visitor who then put the cigarette out on the window inside the room. Continued review revealed the note stated the DON and Administrator were called. Further review of the note revealed, .Called POA (power of attorney) friend (name) to inform him he would need to be discharged in am . Continued review of a Progress Notes dated at 11/2/17 at 1:14 PM revealed .Due to not adhering to the smoking rules and smoking in room multiple times, resident will be discharging the facility due to being a danger to self and others . Review of an additional Progress Note dated 11/2/17 at 3:32 PM revealed the resident was discharged to (name) facility this afternoon . Further medical record review and hard copy clinical record revealed no evidence Resident #19 and/or his responsible party/family member were provided a written notice of discharge, which included all required information such as date of discharge, location to which the resident was being discharged , and reason for the discharge, as well as information about how to appeal the discharge, if desired. Interview with the SSD on 1/10/18 at 11:08 AM in the DON's office confirmed the facility initiated discharge of Resident #19 after he was caught smoking in his room. Continued interview with the SSD confirmed the facility had not issued a written discharge notice after they made the decision to discharge the resident. Further interview revealed the SSD could provide no explanation as to why a written discharge notice was not issued, stating, I just didn't. Medical record review revealed Resident #23 was admitted to the facility on [DATE] for short-term rehabilitation. Continued medical record review revealed the facility issued a Notice of Medicare Non-coverage (also known as an Advance Beneficiary Notice - ABN) to the resident on 12/29/17, telling him the effective date of coverage of his current skilled services would end on was 1/3/18. Further review of the clinical record revealed no evidence the resident had initiated this discharge. Continued review of the record revealed no evidence the resident had been provided a written notice of discharge which included all required information. Further review revealed the resident's closed record did include a piece of paper titled, Discharge Notice stating the resident would be discharged on [DATE] and which provided instructions to staff to make sure his belongings were packed, orders were followed, prescriptions were faxed, and gave the name of his Home Health services. Continued review revealed this Discharge Notice did not include the location to which the resident was being discharged , rationale for discharge, appeal rights, or any other information required by federal regulations. Interview with the SSD on 1/11/18 at 9:52 AM in her office, revealed the Discharge Notice was not a written notice given to the resident, but rather, was her working instructions to facility staff to prepare the resident for his discharge. Continued interview revealed she stated the facility had initiated the discharge when Medicare informed them they would no longer pay for services due to an improvement in the resident's condition. Further interview revealed the SSD related she had provided the ABN on 12/29/17 and confirmed the facility had not issued a written discharge notice to the resident and/or his family/responsible party. Continued review revealed she stated she thought all required information was contained on the ABN and, as a result, had never given a separate written discharge notice when a resident was being discharged from the facility due to the end of therapy. Further interview revealed a review of the ABN with the SSD confirmed it did not contain all information required by regulation to be in a written discharge notice, including the date of discharge, location of discharge, and which of the 6 allowable reasons were the rationale for the discharge. Continued interview revealed although the ABN provided information on how to appeal the termination of skilled Medicare coverage, it did not provide information on how to appeal the discharge from the facility. Further interview revealed the SSD then provided a form which she stated the facility used if they did provide written notice of discharge. Continued interview revealed it was titled, Nursing Home Notice of Involuntary Transfer or Discharge revised 3/17. Further interview revealed the SSD stated a written discharge notice was required for all facility-initiated discharges and she stated she understood a written discharge notice was only given when the discharge was involuntary such as in the care of non-payment or the resident did not want to leave when the facility said they must go. Continued interview with the SSD confirmed appropriate discharge notices were not given to the resident.",2020-09-01
5201,SERENE MANOR MEDICAL CTR.,4.4e+252,970 WRAY ST,KNOXVILLE,TN,37917,2016-05-11,225,D,1,0,ABWK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to report an allegation of abuse to the State Agency and failed to complete a thorough investigation for an allegation of abuse for one Resident (#1) of three residents reviewed for abuse. The finding included: Review of the facility policy Resident Abuse with a revision date of (MONTH) (YEAR), revealed, .When a person witnesses or suspects abuse, neglect or mistreatment of [REDACTED].(the facility) is committed to protecting residents from abuse and will thoroughly investigate and promptly report to proper authorities all allegations or incidents or resident abuse .Procedure / Process .Investigation: Alleged violations will be thoroughly investigated by the director of nursing (or designee) and the results of that investigation reported to the Administrator or his/her designated representative .An incident report will be completed for incidents of unusual nature such as .suspected abuse by an employee, another patient, or any other person, injuries of an unknown source or an accident that causes injury to a resident .The incident and investigative report will be retained by the facility and will be available for review by federal, State, or local authorities . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status score of 4 indicating the resident was severely cognitively impaired. Medical record review of a Social Service Director (SSD) note dated 4/28/16 revealed the Administrative Assistant brought the SSD a message Resident #1's son had called and stated staff had physically abused his father. Continued review revealed the MDS Coordinator, Quality Assurance Nurse (QA)/3rd Floor Unit Manager, Administrative Assistant, and the SSD had a conference call with Resident #1's son regarding the accusation of abuse, and the son stated Resident #1's arm was hurting and he felt staff had abused Resident #1. Further review revealed the facility ordered an x-ray (results were negative). Medical record review of a Care Planning Meeting dated 4/28/16 from 3:40 PM - 4:02 PM revealed, .1. Son c/o (complaint of) staff abusing his father . Interview with the SSD on 5/11/16 at 8:39 AM, in the SSD office, confirmed the SSD informed the Director of Nursing (DON) and Administrator of the allegation of abuse immediately following the conference call with Resident #1's son on 4/28/16. Interview with the Administrative Assistant on 5/11/16 at 9:06 AM, in the SSD office, confirmed she notified the Administrator and the DON of the allegation of abuse made during a phone call with Resident #1's son on 4/28/16. Interview with the QA Nurse/3rd Floor Unit Manager on 5/11/16 at 9:10 AM, in the SSD office, confirmed the QA nurse/3rd floor Unit manager reported the allegation of abuse to the DON and the Administrator, and they were responsible for initiating an abuse investigation. Interview with the DON on 5/11/16 at 1:25 PM, in the DON's office, confirmed the Administrator was aware of the allegation of abuse on 4/28/16. Continued interview confirmed the facility did not think the resident had been abused but did not complete a thorough investigation for the allegation of abuse for Resident #1. Interview with the Administrator on 5/9/16 at 3:20 PM and on 5/11/16 at 1:35 PM, in the Administrator's office, confirmed the Administrator was aware of the allegation of abuse on 4/28/16 and did not feel the resident had been abused. Continued interview confirmed the facility failed to report the allegation of abuse to the State Agency and failed to thoroughly investigate an allegation of abuse for Resident #1.",2019-05-01
5947,TRINITY HEALTH AND REHABILITATION CENTER,inf,700 WILLIAMS FERRY RD,LENOIR CITY,TN,37771,2018-08-29,609,D,1,1,FP2211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to report an allegation of abuse to the state agency for 1 resident (#34) of 3 residents reviewed for abuse of 24 sampled residents. The findings include: Review of the facility Abuse Prevention/Reporting Policy and Procedure updated 5/9/18 revealed .facility management is required to accept all allegations of abuse and conduct a complete and thorough investigation including reporting to the proper authorities .the Administrator or D.O.N (Director of Nursing) will report all allegations of abuse, alleged violations and .incidents . Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual Minimum (MDS) data set [DATE] revealed a Brief Interview of Mental Status of 9 (indicating moderate cognitive impairment). Interview with Resident #34 on 8/27/18 at 9:30 AM, in the resident's private room, revealed she notified the facility .4 to 5 weeks ago . of physical and sexual abuse. Continued interview revealed Resident #34 informed the Social Service Director (SSD) of the allegation of abuse. Interview with the SSD on 8/27/18 at 11:50 AM, in her office, confirmed Resident #34 informed her of the alleged abuse. Continued interview confirmed the SSD informed the Administrator .the next day . Interview with the Administrator on 8/27/18 at 12:10 PM, in the Administrator's office, confirmed he was aware of .something . the Resident #34 reported to the facility, and confirmed the facility failed to report Resident #34's allegation of abuse to the state agency.",2018-11-01
1824,WYNDRIDGE HEALTH AND REHAB CTR,445304,456 WAYNE AVENUE,CROSSVILLE,TN,38555,2018-08-29,657,G,1,1,6O4N11,"**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 comprehensive care plan for transfers for 1 resident (#19) of 6 residents reviewed for accidents of 31 sampled residents. The facility's failure to revise the comprehensive care plan for Resident #19 resulted in actual Harm when Resident #19 sustained a femur (long bone of upper leg) fracture during an improper transfer requiring surgery. The findings include: Review of the Facility Policy, Falls Management, undated, revealed, .Policy: Residents at risk for falls are identified to prevent future falls and maintain maximum level of function through use of interventions, as appropriate. Procedures: 1. A fall assessment will be completed on admission, quarterly (following the MDS (Minimum Data Set) schedule) and as needed. 2. The Care Plan will reflect measures implemented to prevent falls as appropriate. 3.) The Committee members will maintain/monitor as indicated . New interventions to Care Plan . Medical record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #19's Significant Change of Status MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating the resident was moderately cognitively impaired for daily decision making. Continued review revealed the resident required extensive assistance with activities of daily living (ADLs) and 2 person physical assist for transfers and toileting. Medical record review of Resident #19's care plan initiated 1/26/16 and last revised 10/4/17, revealed, the resident had interventions for assistance with transfers as needed and required assist of 1-2 persons and gait belt use. (A gait belt is a device used by caregivers to transfer care receivers with mobility issues from one position to another, from one location to another or while assistively ambulating patients who have problems with balance.) Medical record review of a Fall Risk assessment dated [DATE] revealed Resident #19 was a high risk for falls. Review of a facility fall investigation dated 1/5/18 at 12:50 PM revealed .CNA (Certified Nursing Assistant) was attempting to assist resident back to w/c (wheelchair) when legs went out & (and) resident fell to floor, resident sitting bullfrog legged on floor in bathroom. No gait belt was used. Medical Director and family notified . The interventions initiated after the fall were .staff education use of gait belts for all transfers & (and) to be 2 person assist . Review of the hospital records revealed the resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED].#19 was transferred for orthopedic consult and subsequent surgical repair. Continued review revealed Resident #19 was discharged from the hospital on [DATE]. Interview with MDS Licensed Practical Nurse (LPN) #1 on 8/29/18, at 8:56 AM in the conference room revealed, LPN #19 had cared for the resident at times in the past and even though the care plan stated the resident was a 1-2 person assist for transfers, she would have asked for help transferring the resident and would consider the resident a 2 person assist. Interview with Risk Management LPN #3 on 8/29/18, at 9:40 AM, in the conference room, revealed the LPN was in charge of investigating falls and completing reports on falls. LPN #3 stated Resident #19 needed 2 persons to assist to ensure a safe transfer. Interview with the Director of Nursing (DON) on 8/29/18, at 11:45 AM, in the conference room revealed the comprehensive care plan revised 10/4/17 should have included a 2 person assist for a safe transfer of Resident #19. The DON confirmed the facility's failure to revise Resident #19's care plan to ensure a safe transfer resulted in a fall with Harm on 1/5/18 for Resident #19 when the resident suffered a femur fracture after an improper transfer. In summary, the investigative report identified the person performing the transfer for Resident #19 as a CNA, when actually the person was a Nurse Aide (NA), not certified, who had completed the facility's Nurse Aide Training program. The NA was training on the hall with another CNA on 1/5/17, and was instructed not to do anything without the CNA present. The CNA assigned to the NA was on break at the time of the fall. Refer to F689",2020-09-01
656,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2017-09-14,280,E,1,0,TNU911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to revise the care plan to include fall interventions for three residents (#6, #9, and #1), and failed to notify the responsible parties of annual care plan conferences for five residents (#6, #7, #2, #3, and #1) of six residents reviewed for care plans. The findings included: Review of the facility policy Comprehensive Care Plan dated 5/1/12, revealed .2. Social Services staff and/or designee notifies resident and responsible party prior to each care plan meeting . Review of the facility's Clinical Care System Guidelines for falls, dated (MONTH) (YEAR), revealed, Post fall, fall event and intervention is recorded on 24 hour report, patient's care plan and caregiver guide. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan with a start date of 10/14/15 revealed .at risk for impaired mobility related to [MEDICAL CONDITION] diagnosis, history of falls . Review of facility fall investigations revealed the resident had falls on 3/28/17, 4/30/17, and 8/15/17 with interventions to prevent further falls implemented after each fall. Medical record review of the current Care Plan revealed the Care Plan was not revised to reflect the newly implemented falls interventions after the falls on 3/28/17, 4/30/17, and 8/15/17. Interview with the Director of Nursing (DON) on 9/13/17 at 8:05 AM, in the conference room, confirmed the Care Plan was not revised to reflect the fall interventions. Interview and review of the Care Plan meeting book with the Social Services Director (SSD) on 9/13/17 at 9:02 AM, in the conference room, confirmed Resident #6's responsible party was not notified of the annual care plan conference held on 8/4/17, in order for the responsible party to have an opportunity to participate in care planning for Resident #6. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview and review of the Care Plan meeting book with the SSD on 9/13/17 at 9:02 AM, in the conference room, confirmed Resident #7's responsible party was not notified of the annual care plan conference held on 5/11/17, in order for the responsible party to have an opportunity to participate in care planning for Resident #7. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan with a start date of 4/23/12 revealed .is at risk for falls due to [MEDICAL CONDITION] .history of falls . Review of facility fall investigations revealed Resident #9 had falls on 6/25/17, 7/7/17, 8/5/17, and 8/26/17 with falls interventions implemented after each fall. Medical record review of the current Care Plan revealed the Care Plan was not revised to reflect the interventions implemented after the falls. Interview with the DON on 9/13/17 at 9:58 AM, in the conference room, confirmed the Care Plan was not revised to reflect the fall interventions. Medical record review revealed Resident #2 was admitted to the facility on [DATE]. Review of Resident #2's Care Conference Summary form revealed the 5/10/17 Status Review form had been signed by various facility interdisciplinary team members but not the responsible party for the resident. Review of the Care Conference Meeting Schedule for the month of (MONTH) (YEAR), revealed Resident #2 was scheduled for an annual care conference meeting on 5/3/17 and the responsible party had not been notified. Interview with the SSD on 9/12/17 at 8:30 AM, in the conference room, confirmed Resident #2's responsible party had not been notified of the annual[NAME](YEAR) care conference meeting. Medical record review revealed Resident #3 was admitted to the facility on [DATE]. Medical record review of the resident's Care Plan Conference Summary Form: dated 4/25/17 revealed the care plan had been updated with no changes. The document had been signed by the facility's Dietary Manager, activity staff and SSD as attendees of the care plan conference. There was no indication the resident's responsible party attended the meeting. Review of the Care Conference Meeting Schedule for the month of (MONTH) (YEAR) revealed Resident #3 was scheduled for an annual care conference meeting on 4/25/17 and the responsible party had not been notified. Interview with the SSD on 9/12/17 at 8:30 AM, in the conference room, confirmed the resident's responsible party had not been notified of the annual (MONTH) (YEAR) care conference meeting. Medical record review revealed Resident #1 was admitted to the facility on [DATE]. Medical record review of Resident #1's care plan dated 10/27/15 revealed the resident was at risk for falls related to a history of falls, poor safety awareness and impaired judgment. Further review revealed the last revision to the falls interventions was on 1/24/17. Medical record review of the Nursing Note dated 4/5/47 at 4:30 PM, revealed Resident #1 was sitting on floor on buttocks with knees bent .resident unable to say how she fell . Assisted resident to wheelchair with assist of two. Medical record review of a nursing note dated 4/25/17 at 9:45 AM revealed, Technician called for help after resident had fallen in her room. Medical record review of the resident's care plan revealed the care plan was not revised to reflect new interventions implemented after the fall. Interview with the Minimum Data Set (MDS) Nurse #1 and #2 on 9/11/17 at 3:00 PM, they stated a monthly calendar was generated to indicate which residents were due for annual and quarterly conference meetings for that month. The calendar was then submitted to the Social Services Department for notification to the responsible party for the upcoming meeting. Interview with the SSD on 9/11/17 at 3:10 PM, confirmed she received the monthly care conference calendars from the MDS office. The SSD stated she then sent a letter out to the responsible party to notify them of the care conference meeting. The responsible party then called the SSD to set up the date and time of the meeting depending on their schedules. Review of the monthly calendar for the months of (MONTH) through (MONTH) (YEAR) revealed resident names had been highlighted with the letter Q next to the name. Further review revealed resident names with the letter A next to the names which had not been highlighted. Interview with the SSD on 9/11/17 at 3:10 PM, revealed the Q indicated a quarterly care conference meeting and the A indicated an annual care conference meeting. The SSD stated she had been instructed to only notify responsible parties of Quarterly meetings, and not annual care conference meetings. The SSD indicated if the name on the calendar had not been highlighted, it meant the resident was scheduled for an annual care conference meeting and the responsible party would not have been notified. Review of the Care Conference Meeting Schedule for the month of (MONTH) (YEAR), revealed Resident #1 was scheduled for an annual care conference meeting on 3/2/17 and there was no documentation the responsible party had been notified of the annual meeting. Interview with the SSD on 9/12/17 at 8:30 AM, in the conference room, confirmed the care plan for Resident #1 had not been revised to include newly implemented interventions after the falls on 4/5/17 and 4/25/17, and the responsible party had not been notified of the annual care conference meeting held on 3/2/17.",2020-09-01
2511,ETOWAH HEALTH CARE CENTER,445422,"409 GRADY ROAD, PO BOX 957",ETOWAH,TN,37331,2017-05-03,280,D,1,1,5KJC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to update the care plan after a change in the method of transfer for 1 resident (#66) of 28 residents reviewed. The findings included: Medical record review of the facility policy Guidelines for Resident Transfers dated 11/16/12 revealed .Once the resident is assessed for transfers, the appropriate transfer technique will be selected for the resident. Information regarding appropriate transfer technique for the resident will be documented on the resident care plan . Medical record review revealed Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's current plan of care with an effective date of 1/17/16 revealed .Extensive assist with transfers. Assist PRN (as needed) . Further review revealed the plan of care did not indicate the transfer technique to be used to assist in transferring the resident. Review of the facility document Residents Who Require a Mechanical Lift dated 9/7/16, revealed the document was a list of residents who were to be transferred with use of a mechanical lift and the size sling to be used for each resident. The document indicated Resident #66 required a mechanical lift with a medium sling for transfers. Interview with the Director of Nursing (DON) on 5/3/17 at 9:00 AM, in the DON's office, confirmed the resident's current care plan had not been updated to include the need to utilize a mechanical lift for safe transfers for Resident #66.",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
5539,"VANCO MANOR NURSING AND REHABILITATION CENTER, INC",445460,813 S DICKERSON RD,GOODLETTSVILLE,TN,37072,2016-02-25,226,D,1,0,OKM911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, employee file review, review of facility investigation report and interview, the facility failed to identify discrepancies on a background check for Certified Nurse Aide (CNA) #1 resulting in misappropriation of property to 1 (Resident #3) of 3 residents reviewed for abuse and neglect. The findings included: Review of a facility policy titled Background Investigations dated 10/13 revealed, .personal reference checks .credit/financial background investigations and criminal conviction investigations .be conducted on all personnel making application for employment .Particularly, all nursing homes must conduct criminal background checks on all job applicants applying for a position that involves providing direct patient care . Medical record review revealed Resident #3 was admitted to the facility on [DATE] and discharged home on[DATE]. Review of a facility incident report dated 12/22/15 revealed the facility was made aware by the local police department the social security number of Resident #3 had been used by Certified Nurse Aid (CNA) #1. Review of documents in the employee file for CNA #1 revealed a discrepancy in the employee's name, the employee's date of birth and social security number used by CNA #1. Interview with the Staffing Coordinator (SC) on 2/9/16 at 3:30 PM in the SC's office revealed she had completed the background check on CNA #1. Continued interview revealed the SC had witnessed CNA #1 write her social security number, date of birth and address on her resume and verified her signature. When asked if the SC obtained any identification prior to completing a background check, the SC stated no, that's why I had her write it on her resume, because we do the background check first and as long as it comes back with no flags on it, we're good to go. Then we call them back to get copies of their ID and have them sign all the forms and begin orientation. When asked if she had noticed the discrepancies in the CNA's date of birth, social security number and spelling of the last name, the SC stated, we didn't really until the police came and told us what she had done. Interview with the Administrator on 2/10/16 at 10:48 AM in the Administrator's office confirmed the discrepancies in CNA #1's social security number, date of birth, spelling of the name on the employment information and driver's license and completed background check. Continued interview with the Administrator confirmed the facility failed to follow facility policy by not identifying personal identification information discrepancies on the background check for CNA #1.",2019-02-01
958,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2019-12-11,600,D,1,1,JMLT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility documentation review and interview the facility failed to ensure 3 (#3, #18, #56) of #35 residents reviewed was free from abuse. The findings include: Facility policy review Abuse, Neglect, Misappropriation of Funds, revised 9/28/19 revealed, .to establish a policy and procedure designed to prohibit abuse, neglect, exploitation, involuntary seclusion of residents and/or misappropriation of resident property .the facility has a zero tolerance policy for abuse, involuntary seclusion, neglect, exploitation and misappropriation of resident property .any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator or Director of Nursing .allegation of Abuse and/or Serious Bodily Injury-2 Hour Limit: if the events that cause the reasonable suspicion of abuse immediately, but not later than 2 hours after forming the suspicion . Review of the facility investigation dated 11/4/19 revealed a witnessed altercation between Resident #3 and Resident #56. Continued review revealed Resident #56 slapped Resident #3 on 11/3/19. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Dementia without Behavioral Disturbance, Anxiety Disorder and Major [MEDICAL CONDITION]. Medical record review of Resident #3's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. Medical record review revealed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #56's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 99 indicating the resident was unable to complete the interview. Continued review revealed the resident exhibited verbal behaviors. Interview with Certified Nursing Technician (CNT) #3 on 12/11/19 at 12:50 PM in the Atrium Dining room revealed Residents #3 and #56 had a physical altercation. Continued interview revealed Resident #56 smacked Resident #3. Interview with the Director Of Nursing (DON) on 12/11/19 at 3:18 PM in her office revealed she was informed on 11/3/19 of a verbal atercation between Resident #3 and #56. Continued interview revealed she was notified the next day 11/4/19 the altercation between Resident #3 and Resident #56 became physical. Continued interview when asked to look at the incident date and the reporting date confirmed It was turned in late because I wasn't aware of the possible hitting until the next day after the incident. Review of facility investigation initiated on 11/2/19 revealed an unwitnessed altercation occurred between Resident #29 and Resident #56. Medical record review revealed Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #29's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 13 indicating the resident had no cognitive impairment. Continued review revealed the resident exhibited no behaviors. Interview with CNT #1 on 12/9/19 at 2:28 PM in the 3rd floor nurse station revealed Resident #56 was in Resident #29's room; Resident #29 was telling Resident #56 she needed to leave because that wasn't her room. Continued interview she stated I didn't see anything but Resident #29 told me Resident #56 hurt her finger and smacked her arm; I removed Resident #56 and notified the nurse. Interview with Resident #29 on 12/09/19 at 11:34 AM in her room when asked concerning an altercation with her and Resident #56 she stated, I was in my room watching T.V. (television) when the lady came into my room; I asked her to leave the room and she kept coming, she tried going around the corner of my bed so I tried to put my table in front of her to keep her from coming into my room. I kept pushing the table in front of her and she kept kicking my table then she hit me on my right arm. Interview with the DON on 12/11/19 at 3:17 PM in her office revealed she was notified that Resident #56 hit Resident #29 on the arm. Continued interview confirmed Resident #56 hit Resident #29. Review of the facility's investigation dated 11/27/19 revealed an unwitnessed physical altercation between Resident #18 and Resident #26. Further review revealed Resident #26 told the Director of Nursing that she became frustrated because she was trying to watch television when Resident #18 and Resident #3 were arguing; she (named Resident #26) asked them (Resident #3 and #18) to be quiet and they wouldn't be quiet so she slapped Resident #18 on the face. Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #26's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 14, indicating the resident had no cognitive impairment. Interview with Resident #26 on 12/9/19 at 3:02 PM in the third floor dining room when asked about the incident between her and Resident #18 she stated, We were kind of fussing last Thursday in the dining room; she didn't want me to sit where I was sitting and cussed me so I slapped her (named resident #18) across the face. Interview with the DON on 12/10/19 at 6:40 PM in her office revealed a physical altercation between Resident #18 and Resident #26 was reported to her on 11/27/19. Continued interview revealed Resident #26 slapped Resident #18 across the face. Review of the facility investigation dated 12/3/19 revealed a physical altercation between Resident #65 and Resident #18 occurred in the dining room witnessed by Resident #58. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #18's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 4, indicating the resident had severe cognitive impairment. Medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #58's MDS dated [DATE] revealed the resident had a BIMS score of 15, indicating the resident had no cognitive impairment. Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #65's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 15, indicating the resident had no cognitive impairment. Interview with the Resident #65 on 12/9/19 at 2:53 PM in the third floor dining room when asked about an incident between her and Resident #18, she stated (named Resident #18) has a tendency to cuss me and I got mad and just went off and hit her. Interview with CNT #2 on 12/10/19 at 3:35 PM in the third floor nurses station when asked about the altercation between Resident #18 and #65 she stated, I heard (named Resident #18) screaming and I went in the dining room and she was sitting at the table with a cup of coffee and (named Resident #65) had a hold of (named Resident #18) arm. Continued interview revealed she removed Resident #18 and notified her supervisor. Interview with Resident #58 on 12/10/19 at 4:02 PM in the resident's room when asked if she witnessed an altercation between two residents she stated (named Resident #65) can't get along with (named Resident #18); They started arguing and (named Resident #65) went to (named Resident #18) table and started fighting with her (named Resident #18), hitting her. Interview with the DON on 12/10/19 at 6:52 PM in her office revealed the nursing supervisor notified her of a physical altercation between Resident #18 and Resident #65. Continued interview confirmed Resident #65 grabbed Resident #18's arm and Resident #18 hit Resident #65.",2020-09-01
2436,COMMUNITY CARE OF RUTHERFORD,445406,901 COUNTY FARM RD,MURFREESBORO,TN,37127,2019-06-26,656,G,1,0,6YF811,"**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 follow the care plan for Resident #1 related to transfers which caused harm that resulted in a Right Humerus Fracture for 1 resident (Resident # 1) of 6. The findings include: Facility policy review, Comprehensive Care Plan, dated (YEAR) revealed .the facility will develop and implement a care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care .the care plan will include healthcare information necessary to properly care for a resident . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with readmission on 5/28/19 with [DIAGNOSES REDACTED]. Medical record review of Resident #1's Quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 00 indicating the resident was severely cognitively impaired. Continued review revealed the resident required total assist of staff with transfers. Medical record review of Resident #1's Care Plan dated 4/13/18 revealed .Transfer assistance of full body lift x 2 (two people assist) assist . Medical record review of Resident #1's Nurse Aid Information Sheet dated 4/29/19 revealed .full body lift x 2 assist for transfers . Medical record review of Resident #1's Resident Incident Report dated 5/18/19 revealed .CNA (Certified Nurse Assistant) (#3) called this nurse (Licensed Practical Nurse #2) (LPN) to the shower room .Resident laying on back on floor, CNA #3 has to assist resident to the floor because the resident was sliding out of the lift . Facility documentation review of the Injury Investigation form for Resident #1 dated 5/23/19 revealed .Fall was noted on 5/18/19 . resulting in a right humerus fracture. CNA was getting the resident in the shower chair via (by) stand up lift (mechanical equipement used to raise residents from sitting position to standing) .Resident is care planned for the full body lift with 2 people assist . Facility documentation review of the Inservice and Sign-in sheet Transfer and Lifts policy, dated 4/30/19 revealed CNA #3 had prior in-service training on proper use of lifts and transfer procedures. Facility documentation review of the Mechanical Full Body Lifts and Mechanical Stand Up Lifts General Procedure Guides inservice dated 5/2/19 revealed CNA #3 demonstrated competency in the use of both mechanical lifts. Review of Employee Disciplinary Action form dated 5/28/19 for CNA #3 revealed CNA #3 received a written warning for .failure to follow care plan resulting in accident/incident to patient, using incorrect lift . Interview with LPN #2 on 6/25/19 at 2:20 PM in the conference room when asked about the incident with Resident #1 she stated she (CNA #3) used the wrong lift; she was using a sit to stand lift by herself for which the resident was not care planned for, she was care planned for the Hoyer lift. Continued interview revealed LPN #2 re-educated CNA #3 on reviewing the resident's care guide on 5/18/19. Telephone Interview with CNA #3 on 6/25/19 at 2:52 PM confirmed she did not look at Resident #1's care guide prior to lifting the resident with the sit to stand lift resulting in the resident's fall, she stated I did not look at the care guide, I didn't even know where it was. Continued interview confirmed CNA #3 used a sit to stand lift by herself to transfer Resident #1 for the resident's bath on 5/18/19. Continued interview CNA #3 stated As I was putting (the resident) on the stand up lift, (the resident) was sliding out, I got behind (the resident) and kneeled (the resident) to the floor. Continued interview confirmed Resident #1 was care planned to use a hoyer lift for transfers. Continued interview confirmed CNA #3 was educated to the use of mechanical lifts when transferring residents and to review resident care guides prior to performing resident care. Interview with the Director of Nursing on 6/25/19 at 4:30 PM in the conference room confirmed CNA #3 did not use the correct lift when transferring Resident #1 on 5/18/19 resulting in the residents fall and fracture to the right humerus. Continued interview confirmed 2 people are required to transfer Resident #1 with the Hoyer lift. Continued interview confirmed CNAs were to look at the CNA care guide prior to providing care to the resident. Interview with the Staff Development Coordinator on 6/26/19 at 9:17 AM in the conference room confirmed CNA #3 was educated to refer to the CNA care guide prior to performing any resident care. Interview with the Administrator on 6/26/19 at 3:03 PM in the conference room when asked about the incident with Resident #1 which resulted in a [MEDICAL CONDITION] humerus she stated stated the appropriate interventions were in place and each staff member is to look at the resident's information sheet and double check the care guide to review what kind of lift to use on the resident for transfers.",2020-09-01
2437,COMMUNITY CARE OF RUTHERFORD,445406,901 COUNTY FARM RD,MURFREESBORO,TN,37127,2019-06-26,689,G,1,0,6YF811,"**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 prevent an injury during a transfer resulting in a Right Humerus Fracture causing Harm to 1 resident (Resident # 1) of 4. The findings include: Facility policy review, Patient/Resident Transfer and Handling Policy and Procedure Manual, undated, revealed .Purpose: Provide guidance and direction to promote injury free mobility/transfers for residents .This policy is intended to promote the safety/comfort of each resident .at this facility, two (2) persons should be in attendance when operating the lifts so that one person can operate the lift while the other persons attends and reassures the resident . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with readmission on 5/28/19 with [DIAGNOSES REDACTED]. Medical record review of Resident #1's Quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 00 indicating the resident was severely cognitively impaired. Continued review revealed the resident required total assist of staff with transfers. Medical record review of Resident #1's Care Plan dated 4/13/18 revealed .Transfer assistance of full body lift x 2 person assist . Medical record review of Resident #1's Nurse Aid Information Sheet dated 4/29/19 revealed .full body lift x 2 person assist for transfers . Medical record review of Resident #1's Resident Incident Report dated 5/18/19 revealed .CNA (certified nurse assistant) # 3 called (Licensed Practical Nurse #2) to the shower room. CNA #3 had to assist resident to the floor because the resident was sliding out of the lift. Medical record review of Resident #1's Progress Note dated 5/22/19 revealed .Patient has been having some increased discomfort in (Resident #1) right arm and it appears to be somewhat out of place and bent .It is tender to touch along the humerus .ordered x-ray of the shoulder and humerus . Medical record review of Resident #1's Radiology Report dated 5/22/19 revealed .there is a [MEDICATION NAME] fracture involving the right proximal humerus at the head/neck with mild displacement medially of the humeral shaft . Facility documentation review of the Injury Investigation form for Resident #1 dated 5/23/19 revealed .Fall was noted on 5/18/19 .CNA was getting the resident in the shower chair via (by) stand up lift .Resident is care planned for the full body lift with 2 person assist . Facility documentation review of the Inservice and Sign-in sheet Transfer and Lift policy dated 4/30/19 revealed CNA #3 had prior in-service training on proper use of lifts and transfer procedures. Facility documentation review of the Mechanical Full Body Lifts and Mechanical Stand Up Lifts General Procedure Guides inservice dated 5/2/19 revealed CNA #3 demonstrated competency in the use of both mechanical lifts. Review of Employee Disciplinary Action form dated 5/28/19 for CNA #3 revealed a written warning for .failure to follow care plan resulting in accident/incident to patient, using incorrect lift . Interview with LPN #2 on 6/25/19 at 2:20 PM in the conference room when asked about the incident with Resident #1 she stated she (CNA #3) used the wrong lift; she was using a sit to stand lift by herself for which the resident was not care planned forFurther interviewed revealed that the CNA #3 stated As I was putting (Resident #1) on the stand up lift, (the resident) was sliding out, I got behind (the resident) and kneeled (the resident) to the floor Telephone Interview with CNA #3 on 6/25/19 at 2:52 PM confirmed she did not look at Resident #1's care guide prior to lifting the resident with the sit to stand lift resulting in the residents fall and fracture to the right humerus. Interview with the Director of Nursing on 6/25/19 at 4:30 PM in the conference room confirmed CNA #3 did not use the correct lift when transferring Resident #1 on 5/18/19 resulting in the residents fall and fracture to the right humerus. Interview with the Staff Development Coordinator on 6/26/19 at 9:17 AM in the conference room confirmed CNA #3 was educated to refer to the CNA care guide prior to performing any resident care. Interview with the Administrator on 6/26/19 at 3:03 PM in the conference room when asked revealed concerning the incident with Resident #1 fall and fracture stated the appropriate interventions were in place and it is the responsibility of each staff member to look at the resident's information sheet and double check the care guide to review what kind of lift is used for resident transfers. CNA #3 did not use the right tranfer equipment and failed to get assitance resulting in fall and [MEDICAL CONDITION] humerus.",2020-09-01
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
815,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2018-02-23,657,D,1,0,42HQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility documentation review, and interview, the facility failed to timely revise a plan of care to address manipulative behaviors for 1 of 7 samples residents (Resident #6). Findings include: Review of the undated facility policy MDS/Care Plans revealed .The facility must develop a comprehensive care plan to meet a resident's .needs .are reviewed and/or revised . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed adequate hearing and vision, clear speech, usually made self understood, and understood others; Brief Interview for Mental Status (BIMS) was 13/15, indicating he was cognitively intact; exhibited no [MEDICAL CONDITIONS], or behaviors; exhibited little interest, feeling down/depressed, tired, change appetite for 2-6 days of the review period. Medical review of the Quarterly MDS dated [DATE] revealed adequate hearing and vision, clear speech, usually made self understood, and understood others; BIMS score of 14/15; exhibited feeling down/depressed for 2-6 days of the review period; and exhibited no [MEDICAL CONDITIONS], or behaviors. Medical record review of facility documentation dated 1/31/18 revealed Resident #6 informed Certified Nurse Aide (CNA) #3 of CNA #1 got in bed with Resident #6 on 1/30/18. Further facility documentation review revealed the resident had made a false accusation. Medical record review of the care plan dated 2/12/18 revealed on a problem was initiated addressing the resident .exhibiting behavior symptoms as making false accusations toward staff while providing care and being manipulative toward staff when providing care . The approaches dated 2/12/18 included .Acknowledge resident feelings & (and) try to negotiate an agreement to stay until all concerned parties can be brought together to satisfactorily strategize the resident's needs; Document behaviors. Attempt to identify pattern to target interventions; Staff will enter (resident's) room with two people to provide care due to making false allegations . The approach dated 2/16/18 revealed .Will be refer to psych (psychiatric) for evaluation . Interview with the Registered Nurse (RN) #1/MDS Coordinator on 2/21/18 at 8:45 AM in the conference room revealed the comprehensive care plan and the Certified Nurse Aide (CNA) Bedside Care Plans, addressing resident care and needs, were updated with any new concerns or interventions. Further interview confirmed the facility failed to timely revise the care plan after the false allegation and manipulation of staff was reported on 1/31/18. Interview with the Social Worker (SW) on 2/21/18 at 9:32 AM in the conference room confirmed the SW was responsible to address behaviors on the MDS and the care plan. Further interview confirmed the facility failed to timely revise the care plan after the resident's false allegation and manipulation of staff was reported on 1/31/18. Interview with the Administrator on 2/21/18 at 10:52 AM in the conference room confirmed the facility failed to revise the care plan timely after the event was reported on 1/31/18.",2020-09-01
3172,LIFE CARE CENTER OF RHEA COUNTY,445494,10055 RHEA COUNTY HIGHWAY,DAYTON,TN,37321,2019-11-26,600,D,1,0,10SX11,"**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 prevent abuse for 1 resident (#2) of 5 residents reviewed for abuse. The findings include: Review of the facility policy, Protection of Residents: Reducing the Threat of Abuse & Neglect, undated revealed .resident has the right to be free from abuse .Resident's must not be subjected to abuse by anyone .includes but is not limited to .other residents .residents will be protected from all types of abuse .Identify, correct and intervene in situations in which abuse .is more likely to occur .Identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors which might lead to conflict .such as: Verbally aggressive behavior; Physically aggressive behavior .Following identification of alleged abuse, the resident(s) .are protected .to prevent recurrence .Interventions must be implemented to assure the safety of all residents . 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 scored a 13 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Further review revealed Resident #1 had verbal behaviors directed towards, and of rejection of care. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's significant change in status MDS dated [DATE] revealed the resident scored a 6 on the BIMS indicating the resident had severe impairment. Further review revealed the resident had no verbal or physical behaviors exhibited, no rejection of care and no wandering exhibited. Medical record review of the Comprehensive Care Plan for Resident #1 revealed .has potential to throw items .r/t (related to) Anger, Poor impulse control, [MEDICAL CONDITION] disorder .has potential to be verbally aggressive . AT RISK FOR INEFFECTUAL COPING DUE TO DX (diagnosis): ANXIETY AND DEPRESSION .has a psychosocial well-being problem R/T (related to) DECREASED SENSE OF INITIVATIVE, UNSETTLED RELATIONSHIPS, DEPRESSION . Medical record review of Resident #1's behavior note dated 11/9/19 revealed .cussing, screaming, swinging .not easily redirected . Medical record review of Resident #1's behavioral note dated 11/10/19 revealed .cussing, verbally aggressive . hollering .not easily redirected . Review of the facility documentation review dated 11/14/19 revealed .On 11/9/19, while leaving the dining room, Resident #1 .initiated an attempted physical altercation with Resident #2 resulting in Resident #2 obtaining a skin tear to their left hand . Interview with Resident #1 was attempted on 11/25/19 at 2:15 PM, in the resident's room, revealed the resident stated to the surveyor .Get the (explicit) out of here. I'm not talking to you or any (explicit) body from the state . Interview with CNA#1 on 11/25/19 at 3:32 PM, at the 200 hallway nurses station, revealed (Resident #1) .knows what she is doing .knows right from wrong .she is easily set off and at times combative with staff . Continued interview confirmed Resident #1 was verbally abusive towards other residents and was not easily redirected by staff. Observation and Interview with Resident #2 on 11/25/19 at 3:50 PM, in the breezeway of the main entrance, revealed she had an altercation with another resident about a week ago. The resident states .that one lady (Resident #1) fusses with everyone all the time and wants to fight them . Continued interview revealed that during the altercation with the other resident she got a sore on her hand. (resident showed surveyor her left hand with an area on the top of the hand with scab on top of it). Observation of the Resident #2's left hand revealed a scabbed area to the top of the hand. Interview with LPN #1 on 11/26/19 at 8:27 AM, in the conference room, revealed Resident #1 does exhibit behaviors. She gets mad .cusses .swings .this is typical behavior for her . Interview with CNA #3 on 11/26/19 at 10:21 AM, in the conference room, confirmed on 11/9/19 Resident #2 entered the dining room and Resident #1 yelled .Shut up . and then witnessed Resident #1 hit Resident #2. Continued interview revealed Resident #1 .yells and cusses all the time on a daily basis and was verbally agressive toward others. Interview with the Administrator on 11/26/19 at 1:24 PM, in the conference room, confirmed she was aware of the altercation between the two residents that resulted in a skin tear to Resident #2.",2020-09-01
3207,THE MEADOWS,445496,8044 COLEY DAVIS ROAD,NASHVILLE,TN,37221,2018-08-21,609,D,1,0,O0KR11,"**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 staff failed to timely report an allegation of verbal abuse to facility administrative staff for 1 of 3 residents (#1) reviewed for abuse. The findings include: Review of the facility policy, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 12/11/17, revealed .Abuse, Neglect, Misappropriation of Property and exploitation .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 .Reporting Policy .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, but not later than 2 hours after forming the suspicion if the events that cause the suspicion involve abuse or result in serious bodily injury . Medical record review revealed Resident #1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to a psychiatric hospital 6/28/18 and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had minimal difficultly hearing, clear speech, usually made himself understood, he sometimes understood others and had impaired vision. He was severely cognitively impaired as indicated by the 0 out of 15 Brief Interview for Mental Status (BIMS) score. He had no change in acute mental status, was inattentive and had disorganized thinking which changed in severity. He experienced delusions, was verbally abusive for 1-3 days, and refused care and wandered for 1-3 days of the review period. The resident required extensive 2+ staff assistance with bed mobility transfers, dressing, toileting, and hygiene. He was always incontinent of bladder and frequently incontinent of bowel. Medical record review of the Significant Change MDS dated [DATE] revealed Resident #1 had moderate difficulty hearing, had unclear speech, sometimes made himself understood, rarely understood others, and had moderately impaired vision. He had a 4 out of 15 BIMS score indicating severe cognitive impairment. He had had an acute change in mental status, no [MEDICAL CONDITION], had an appetite change in the past 2-6 days, was verbally and physically abusive in the past 1-3 days and refused care for the past 2-6 days of the review period. He required total 2+ staff assistance for bed mobility, transfer, toileting; required extensive assistance of 2+ staff for dressing, hygiene; and was always incontinent of bowel and bladder. Review of facility documentation of the event revealed on 8/8/18 at 1:40 PM Certified Nurse Aide (CNA) #2 informed Licensed Practical Nurse (LPN) #2/Assistant Director of Nursing (ADON) of an allegation of verbal abuse involving CNA #1 and Resident #1 on 8/7/18 at about 10:00 AM-10:30 AM. Further documentation revealed CNA #1 reportedly told Resident #1 if the resident hit her she would hit him back and she would drop him to the floor. Review of the facility documentation of the event included a written statement by CNA #2, the witness, dated 8/8/18 revealed .I was helping (CNA #1) clean up (Resident #1) .(Resident #1) was being combative, calling names and hitting. (CNA #1) was telling (Resident #1) she would hit (Resident #1) back and it would be the last time he ever hit anyone. (CNA #1) told him she would drop him in the floor . Observation on 8/20/18 at 9:05 AM revealed Resident #1 in his room in bed facing the hallway door with his eyes shut and softly snoring. The bed was in the lowest position, and the head of the bed was elevated, with two 1/4 side rails up bilaterally at the head of head. Observation on 8/20/18 at 11:45 AM revealed CNA #3 in the process of positioning Resident #1 in the bed onto his back. The resident jerked his arms and head when the CNA lowered the head of the bed and again when she raised the bed height. The resident never made any attempt to touch, reach for, bite, hit or kick at the CNA during the repositioning and continence check. Observation on 8/21/18 at 8:00 AM revealed Resident #1 in bed with his eyes shut and softly snoring was positioned on his back using round pillows bilaterally at his sides. The bed was in a low position, and two 1/4 side rails were up bilaterally at the head of the bed. Telephone interview with CNA #2, on 8/20/18 at 12:50 PM revealed CNA #1 asked her for help on 8/7/18 about 10:00 AM to 10:30 AM in Resident #1's room to provide care to the resident. Further interview revealed CNA #2 had not worked with CNA #1 with providing resident care prior to that day.We both went in room to give him bath and he was hitting, biting, cursing, and she told him 'if you hit me I'll hit you back and I'll drop you on the floor' . When asked why the CNA had not reported the incident immediately after the event occurred the CNA stated .I was scared. I know that's not an excuse but I was nervous about it. I thought it was wrong what she said but I had to think about it. I knew it was directed at the resident and was wrong. I know I was to report it immediately. I knew if I reported it she could be removed, fired, lose her job and that's serious and I was just scared . Interview with LPN #2/ADON on 8/20/18 at 2:25 PM in her office revealed CNA #2 came to the LPN/ADON's office the afternoon of 8/8/18 and told the LPN/ADON she had concerns involving CNA #1. Further interview revealed CNA #2 told LPN #2/ADON during rounds on 8/7/18 around 10:00 AM with CNA #1 they went into Resident #1 room. CNA #2 stated the resident was .out of it and combative during care . and CNA #1 made a remark .if you hit me I'll hit you back, last thing you'll do, and stop hitting me or I'll drop you to the floor . Interview with the Administrator/Abuse Coordinator and the DON on 8/21/18 at 1:30 PM in the conference room agreed CNA #2 failed to report the allegation of verbal abuse immediately after the event to the facility administrative staff per facility policy.",2020-09-01
685,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2017-11-15,322,G,1,0,JVWH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility incident report review, hospital record review, observation and interview, it was determined the facility failed to ensure staff provided appropriate care and services for the Percutaneous Endoscopic Gastrostomy (PEG) Tubes for 2 of 3 (Residents #1 and #2) sampled residents reviewed with PEG tubes. The failure to ensure that PEG tube feedings were administered through the PEG tube resulted in actual harm to Resident #1 who had Nepro Carb Steady (carbohydrate nutritional product for residents with kidney disease) administered through his peritoneal [MEDICAL TREATMENT] catheter. The findings included: 1. The facility's Enteral Tube Feeding Continuous Pump policy, documented .The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally .Preparation .3. Ensure that the equipment and devices are working properly .General Guidelines .3 .Check the following information: .e. Access site (PEG insertion site) .Steps in the Procedure .Verify placement of tube: .7. Auscultate: (listening for internal sounds with a stethescope) a. Do not rely on this as the singular method to differentiate between respiratory, gastric, [MEDICAL CONDITION] and bowel placement. b. Attach 60 mL (milliliters) syringe containing approximately 10 mL air. c. Auscultate the abdomen (approximately 3 inches below the sternum) while injecting the air from the syringe into the tubing .8. When correct tube placement has been verified, flush tubing with at least 30 mL warm water (or prescribed amount) .Check gastric residual (stomach contents amount) volume (GRV): 1. Aspirate stomach contents .Reporting .1. Report complications .2. Report negative consequences of tube use .4. Report other information in accordance with facility policy and professional standards of practice . 2. Medical record review for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Physicians Orders received by Registered Nurse (RN) #1 on 10/31/17 and signed by the physician on 11/3/17, documented .TUBE FEEDING FORMULA Nepro Carb Steady RATE 45 mL/hr (milliliters per hour) .H2O (water) FLUSH 60 cc (cubic centimeters) 1 (one) HOURS .ENSURE PEG DISK ROTATES EVERY SHIFT .CHECK PEG TUBE PLACEMENT FOR AUSCULTATION .CHECK RESIDUAL . Review of the Initial Care Plan dated 10/27/17 revealed .FEEDING TUBES .Observe peg tube/[DEVICE] (gastrostomy tube) site for S/S (signs and symptoms) of infection/irritation .Peg care every shift & prn (as needed) .*check Peg tube placement By auscultation .* Check residual .Renal/[MEDICAL TREATMENT] .[MEDICAL TREATMENT] as ordered .Shunt care .*Peritoneal catheter (Not in use) (Lower Lt (left) Q (quadrant)) .*[MEDICAL TREATMENT] 3 x (times) wk (week) . Review of the Admission Evaluation and Interim Care Plan Skin Condition Body Diagram dated 10/27/17 revealed .PEG site .Peritoneal Catheter (plastic flexible tube inserted into the abdomen to allow [MEDICAL TREATMENT] fluid to enter abdominal cavity, dwell inside for a while and then drain back out again) .LA (left arm) AV fistula. Review of the initial Admission/Readmission Nurses Notes dated 10/27/17 at 8:20 PM revealed .Resident is currently non verbal @ (at) this time but is alert & awake .Abd. (abdomen) soft nontender/nondistended c (with) bowel sounds in all 4 quads (quadrants) Noted peritoneal [MEDICAL TREATMENT] cath. (catheter) to LL (left lower) quad of Abd. Has a PEG which is patent & intact. Receives [MEDICAL TREATMENT] x (times) 3 days wkly (weekly). AV fistula to Lt. (left) upper arm c no problems. Has palpable thrill and audible bruit (an indication of a well functioning [MEDICAL TREATMENT] fistula) .Requires total care with all ADLs (activities of daily living) . Review of a facility incident report revealed .(Resident #1) is alert but he is nonverbal. Resident was admitted to facility on 10/27/17 at 8:20 pm for skilled services under the care of (named Medical Director) .Resident admitted with a peg tube located in his left upper abd. quadrant and a peritoneal catheter in lower left abdominal catheter (quadrant). On the evening of 10/31/2017 (named RN #1) entered resident's room. (RN #1) was unaware that resident had a peritoneal catheter. (RN #1) connected the peg tube feeding to the peritoneal catheter. (RN #1) started the tube feeding at 8:45 pm. The error was discovered by the 11-7 (11:00 pm-7:00 am) nurse (LPN #1) at 5:45 am. (LPN #1) stopped the feeding immediately .called (RN #1) and she immediately came to the facility and notified The DON (Director of Nursing). I the DON notified (Medical Director) and orders were given to transfer resident to the hospital .(RN #1) called the family and spoke with the responsible party .resident was transported via 911 ambulance . Interview with the Administrator on 11/12/17 at 6:50 PM in the conference room, the Administrator was asked about Resident #1. She stated, .he was on a continuous feed (PEG tube infusion) until he went out to [MEDICAL TREATMENT] .then it was stopped .his peritoneal tube was not in use .he had a shunt for [MEDICAL TREATMENT] (indicated her left arm) .went to (named hospital) on the 1st (11/1/17) .was in ICU (Intensive Care Unit) for 3 days, then on the 4th day he went back on the vent (ventilator) . Interview with the DON on 11/12/17 at 6:50 PM in the conference room, the DON stated RN #1 .was not aware he had 2 tubes .she checked placement .checked residual .tubing had a flap on it, said she (RN #1) wondered why they did that .took the flap off and put an adapter on it . When the DON was asked if nurses undergo a skills check-off (nursing competency skills validation) prior to working at the facility, the DON stated that they do a skills check-off upon hire and annually. A written statement signed by RN #1 documented, .On the night of Oct (October) 31st at 845/pm I prepared to hang Nepro on (Resident #1). I checked his residual. The residual was zero. I did not know he had a peritoneal cath (catheter) & a peg tube. Resident was comfortable c no s/s (signs & symptoms) of distress. I did not provide any other services. Around 630/am I received a call from (named LPN #1) 11-7 (11:00 pm-7:00am) charge nurse. She informed me Resident (#1) had another tube higher up. I Jumped in my truck immediately & (and) came to the facility. B/P (blood pressure)153/94 (pulse)- 117 (pulse documented in medical record 119) (respirations), - 20 temp (temperature) 100.2 (degrees Fahrenheit). I called the Director (DON). Director informed me she was calling (named Medical Director). DON returned call back to facility & instructed to send out 911. 911 came to the facility immediately. Family notified. Report called to (named hospital) & spoke to a female nurse in the ER (emergency room ). Gave vital signs to nurse and informed her we were sending out due to Resident receiving tube feedings through his peritoneal cath - Informed nurse this is exactly why we are sending the Resident out. Family notified. Resident was being sent to hospital & reason for sending out. On exit Resident was easily aroused c (with) no s/s (signs and symptoms) of distress . Telephone interview with RN #1 on 11/15/17 at 11:34 AM, RN #1 was asked about the incident with Resident #1 on 10/31/17. She confirmed her written statement, and stated .I went in to prepare to give him (Resident #1) his feeding .I aspirated and hooked up his feeding and that's all . When she was asked if there were any problems with his feeding, she stated, .no .a cap was on it and I had to go get a connection for it .I took the cap off and put a connection on it . She was asked if she was aware that Resident #1 had a peritoneal catheter, and she stated No. She further stated that she had taken care of him one other time in the past. A written statement signed by Licensed Practical Nurse (LPN) #1, dated 11/1/17, documented .During shift change off going nurse (RN #1) stated she couldn't find the end of the peg tube and she had replaced it. On going nurse (LPN #1) went to the resident (Resident #1) room to observe the new pegtube. Nepro was running through the line. At 5:45 am nurse (LPN #1) return to resident (Resident #1) room to give 6AM meds. CNA (Certified Nursing Assistant #1) was already inside resident room and ask for assistance in repositioning and turning; during this time CNA (CNA #1) changed resident gown and this is when nurse (LPN #1) notice that the resident was not receiving tube feeding in the right tubing. Resident (Resident #1) was receiving feeding through his peritoneal catheter. Nurse (LPN #1) immediately disconnect the feeding and informed RN supervisor (RN #2). The charge nurse (LPN #1) and RN supervisor (RN #2) assessed the resident. The unit manager (RN #1) which was the nurse who intact (attached) the feeding was notified and she return to the facility @ 6:15am. Unit Manager (RN #1) called the DON who contact the doctor. Charge nurse (LPN #1) was getting vitals signs which was as following B/P (blood pressure) 159/94, Pulse 119 Respiration 20, Blood Glucose 159. Unit Manager (RN #1) receive orders @ (at) 6:30 am to send resident (Resident #1) to the ER (emergency room ) for further evaluation. Nurse (LPN #1) and CNA (CNA #1) stayed with resident until paramedic arrived to transport . Telephone interview with LPN #1 on 11/15/17 at 9:50 AM, LPN #1 confirmed her written statement. She stated, .I can't remember his (Resident #1) name .only had him one time .I remember the Unit Manager (RN #1) was on duty that night .she was on a cart .in report she (RN #1) said, '(named LPN #1) .I had to alter his (Resident #1) feeding tube because someone took the end off .I (RN #1) spent two hours trying to get that end on' .I (LPN #1) went down there (Resident #1's room) and checked to see what she (RN #1) was talking about and everything was running okay .end looked like a PEG tube .I thought she (RN #1) said the end was off .didn't check the site .he (Resident #1) don't get no midnight meds (medications), he (Resident #1) got 6:00 meds .I went down there with the aide and I told her to change his sheets and get him ready while I was giving him his meds (medications) .as soon as she turned him over and uncovered him, I saw he was hooked up to the wrong tube .peritoneal catheter .I unhooked it immediately .went and got the night supervisor (RN #2) .she (RN #2) came down there and checked him (Resident #1) .we knew it was a peritoneal catheter, but we checked the chart just to make sure .called the Unit Manager (RN #1) .she (RN #1) said call the doctor and get a KUB (kidney, ureter, and bladder study is an X-ray study) .we called (named Medical Director and Resident #1's provider), but he said don't get a KUB send him to the ER (emergency room ) .called the family and let them know what happened .I (LPN #1) stayed with him until he left . She was then asked if she had checked on him during the night, and she stated .yes .even at the time his stomach wasn't distended .didn't grimace or anything when I pressed on it .was fine through the night . When she was asked if she was aware, prior to that night, that he had two abdominal tubes, she stated, .I knew the first night he was admitted .I had him that night .another nurse admitted him .was told in report .was also written in his chart in the nurse's notes . Review of the hospital records revealed the following: a) Computerized [NAME]ography (CT) Scan dated 11/1/17 at 2:50 PM - .Numerous nondistended fluid-filled loops of small bowel are noted with associated bowel wall thickening and adjacent fluids .A PEG tube is noted with balloon in the stomach. Fluid is present diffusely throughout the colon with associated air-filled levels .There is a 5.8 x 4.3 cm (centimeter) irregular gas fluid collection superior to the bladder. This is concerning for abscess .A small amount of free fluid is seen within the pelvis .IMPRESSION: .2. Small amount of free intraperitoneal air. Etiology uncertain, however this is concerning for bowel perforation .4. [MEDICATION NAME] (within a tube or tubular organ) fluid throughout nondistended small bowel with associated bowel wall thickening and adjacent free fluid. [MEDICATION NAME] fluid with air- fluid levels throughout a nondistended colon. These findings are concerning for [MEDICATION NAME]. Consider infectious, [MEDICAL CONDITION] ischemic (insufficient blood flow) etiologies. 5. Small amount of free fluid in the abdomen and pelvis . b) Operative Report dated 11/1/17 at 8:35 PM- .FINDINGS: The patient had copious white fluid within the abdominal cavity .There was copious white fluid that was suctioned out. We then retrieved the peritoneal [MEDICAL TREATMENT] catheter from the abdominal cavity .After suctioning all the fluid possible, we then irrigated the abdominal cavity in all 4 quadrants in the [MEDICAL CONDITION] (area under the diaphragm) space and subhepatic (area under the liver) spaces as well as the pelvis with 7 liters of warm saline. At the end of the irrigation, the effluent (outflowing fluid) was clear .He did have some changes of [MEDICAL CONDITION] (low blood pressure) during the operation. He was taken to the intensive care unit in guarded condition . c) Progress Note dated 11/6/17 - .Back on vent (ventilator) for stridor (high pitched breath sound) . The failure of the facility to ensure that PEG tube feedings were administered appropriately through the PEG tube to Resident #1 who had Nepro Carb Steady administered through his peritoneal [MEDICAL TREATMENT] catheter for approximately 9 hours resulted in actual harm. He was sent to the hospital, had emergent surgery and remained in the hospital at the conclusion of this survey. 3. Medical record review for Resident #2, documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. A Physician order [REDACTED].Give Glucerna 1.2 1 (one) can ppt (per PEG Tube) tid (three times a day) . Physician's recertification orders signed 11/3/17, documented .H2O MED FLUSH 60 cc BEFORE & AFTER EACH MED PASS . Observations in Resident #2's room on 11/13/17 at 10:50 AM, revealed LPN #5 checked the tubing for the proper label as his PEG tube, checked placement per auscultation and aspiration, and then administered the bolus of Glucerna 1.2. LPN #5 did not flush the PEG tube prior to administering the bolus. He stated, .I skipped a step .I'm just going to be honest .supposed to flush with 30 ccs before and after . LPN #5 flushed with 60 cc after administering the bolus of Glucerna 1.2. LPN #5 confirmed he failed to follow Physician order [REDACTED].",2020-09-01
1971,THE PALACE HEALTH CARE AND REHABILITATION CENTER,445329,309 MAIN ST,RED BOILING SPRINGS,TN,37150,2018-07-18,609,D,1,0,GKUR11,"**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 within the 2-hour time frame as required to the state agency for 2 residents of 5 sampled residents (Resident #1 and Resident #2) reviewed for abuse. Findings include: Review of the facility policy Abuse, Neglect, Exploitation & Misappropriation effective 11/30/14 and revised 11/28/17 revealed, .any employee .who witnesses or has knowledge of an act of abuse or an allegation of abuse .is obligated to report such information immediately, but not later than 2 hours after the allegation is made . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. Review of the medical record revealed Resident #2 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of an Admission MDS dated [DATE] for Resident #2 revealed a BIMS score or 15 indicating no cognitive impairment. Review of a facility investigation revealed the allegation of resident to resident abuse occurred 1/29/18 at 11:00 PM. Continued review revealed the abuse protocol was initiated by Certified Nurse Aide #2 and Licensed Practical Nurse (LPN) #2. Further review revealed LPN #2 did not report the allegation of resident to resident abuse to the Director of Nursing (DON) until 1/30/18 when she arrived at work. Continued review revealed the DON reported the allegation of abuse to the state agency on 1/30/18 at 8:17 AM. Interview with the DON on 7/16/18 at 2:30 PM in the conference room confirmed LPN #2 failed to report the allegation of resident to resident abuse immediately according to facility policy.",2020-09-01
1565,TENNESSEE VETERANS HOME,445270,PO BOX 10299,MURFREESBORO,TN,37129,2018-11-07,609,D,1,0,LV7111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review and interview the facility failed to report a suspected allegation of abuse within the 2-hour time frame as required to the State Agency. Continued review revealed nursing staff failed to report a suspected allegation of abuse immediately to the Administrator according to facility policy for 1 resident of 3 sampled residents (Resident #1) reviewed for abuse. The findings include: Review of the facility policy, Abuse & Neglect of Residents and Misappropriation of Resident's Property revised 11/9/16 revealed .the incident .reported to the Department of Health within prescribed time frame (2 hours) .any alleged violation involving .neglect, abuse .must be reported immediately to the Administrator . Medical record review revealed Resident #2 was admitted [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 13 indicting no cognitive impairment. Total assistance of 2 staff was required for transfers, toileting, personal hygiene, and bathing. Continued review revealed Resident #2 was always incontinent of bowels and had an indwelling urinary catheter in place. Further review revealed the resident's pain level was frequently assessed, he was appropriately medicated for pain, and relief was received from the pain medication. Resident #2 received nutrition and hydration by way of a gastrostomy tube (GT) (a tube to provide liquid nutritional supplementation into the stomach). Review of the facility investigation revealed .on 10/23/18 at approximately 9:00 AM (Administrator) was notified .was an allegation .the State Incident reporting system was notified of the initial allegation on 10/23/18 . The time indicated in the Incident Reporting System (IRS) Identification was 1729; 5:29 PM in standard time. Telephone interview with Licensed Practical Nurse (LPN) #1 on 11/6/18 at 1:45 PM revealed on 10/22/18 Certified Nurse Aide (CNA) #1 came up to the nurse's station on the North Unit during morning shift change and told LPN #1 and LPN #2 she had placed Resident #2 in an uncomfortable position because CNA #1 stated she wanted to show Resident #2 she could be a [***] too. Continued interview revealed CNA #1 turned and walked away from the nurse's station. Further interview revealed on 10/23/18 the Director of Nursing (DON) was making morning rounds on the North Unit and LPN #1 reported the allegation made by CNA #1 to Resident #2 to the DON. LPN #1 confirmed she was trained in immediate abuse reporting to the Administrator and did not report the allegation of abuse made 10/22/18 immediately to the Administrator until 10/23/18. Telephone interview with LPN #2 on 11/6/18 at 3:34 PM revealed on 10/22/18 at the change of shift, LPN #2 was giving report to LPN #1 when CNA #1 came up to the North Unit nurse's desk and stated to both of them she had put Resident #2 in an uncomfortable position. CNA #1 immediately turned and walked away from the nurse's station. Further interview confirmed LPN #2 did not report the allegation of abuse immediately, as trained, to the Administrator.",2020-09-01
3275,"THE WATERS OF SMYRNA, LLC",445502,202 ENON SPRINGS ROAD EAST,SMYRNA,TN,37167,2018-01-16,610,E,1,0,POU411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview the facility failed to ensure appropriate interventions were put into place to ensure residents were protected from abuse by 3 residents (#15, #31, #13) who were perpetrators; 3 residents (#14, #16, #21) who were victims; and unknown numbers of other potential victims whom the facility could not identify of 16 residents reviewed for abuse. The findings included: Review of facility policy, Abuse Prevention Program, updated 1/19/17, revealed .It is the policy of this facility to prevent resident abuse, neglect, mistreatment, and misappropriation of resident property .All alleged violations MUST be reported to the Administrator and Director of Nursing (DON) .After notification of alleged abuse or neglect the Administrator or person in charge of the facility shall immediately commence an investigation of the incident reported . Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE], revealed Resident #15 scored 1 on the Brief Interview for Mental Status (BIMS) indicating he was severely cognitively impaired. Continued review of the MDS revealed Resident #15 required extensive assistance with transfers, dressing, grooming, and bathing. Further review of the MDS revealed Resident #15 displayed no behaviors, either physical or verbal, toward others; had no wandering; and had no resistance to care. Medical record review of Resident #15's Progress Notes included the following information: Medical record review of Progress Notes dated 8/5/17 revealed there were multiple aggressive behaviors noted today. Witnessed going into another patient's room and hit her . Medical record review of Progress Notes revealed a late entry on 9/3/17 for 9/2/17 which stated, .Reported to this nurse resident hit at a family member and a resident . Medical record review of Progress Notes dated 9/3/17, revealed the .Resident hit resident in (room number) twice this AM . Medical record review of Progress Notes dated 9/24/17 revealed multiple entries including: 9/24/17 (entry was struck through indicating it was to be ignored) Resident has hit another resident, chased a family member, attempting to hit her, and hit two staff members, and groped breasts of another incapacitated resident. 9/24 (entry was struck through indicating it was to be ignored) .He was witnessed by another resident groping the breasts of an incapacitated resident who is unable to speak or remove herself from the situation .C Wing Nurse reported to this nurse that he kicked another resident. 9/24/17 11:30 AM .Resident was exhibiting repeated intrusive behaviors, wandering in and other of other resident's rooms .attempting to touch other residents . The 11:30 AM note did not address the previous information which was struck through, including Resident #15 hitting a resident, kicking, or touching the breast of an incapacitated resident. Interview with the Director of Nursing (DON) on 1/8/18 at 10:30 AM in the conference room during the Entrance Conference, revealed the DON was asked to provide all the facility's abuse investigations. Review of the investigation files provided by the DON revealed that none of these 4 allegations of resident-to-resident abuse had been investigated. The only abuse investigation related to Resident #15 provided was a different allegation of physical resident-to-resident abuse, when Resident #15 hit Resident #16 in the face on 12/18/17. Interview with the DON on 1/9/18 at 2:54 PM in her office revealed that although she was not the Abuse Coordinator, she was the person who would be able to answer specific questions about abuse investigations, as the current Abuse Coordinator was an interim administrator who had only been working at the facility for a few weeks. Continued interview with the DON revealed she was informed there were no abuse investigations related to the incidents of 8/5/17, 9/2/17, 9/3/17, and 9/24/17 in the investigative files she had provided. Further interview revealed the DON stated she had only 1 full investigation, which was the allegation of physical abuse (when Resident #15 hit Resident #16 in the face on 12/18/17.) Continued interview revealed she stated because she had never reported the allegations to the State Survey Agency (SSA), the facility did not have a complete investigation file for those incidents. Further interview revealed although it was not a full investigation, she did keep a soft file with an incident report for each incident that occurred and stated she would provide these files for review. Interview with Corporate Consultant #1 on 1/10/18 at 9:20 AM at the C-Wing Nurses Station revealed .There is no investigation record of the 4 abuse allegations that can be found . Continued interview revealed he had obtained this information from the DON, who had been looking for any evidence of investigation of these allegation since 1/8/18. Further interview with Corporate Consultant #1 confirmed for each allegation of resident-to-resident abuse, a full investigation should have been conducted to determine if the allegation was substantiated to take necessary actions to protect residents and prevent further abuse. Additional interview with the DON on 1/10/18 at 9:45 AM at the C-hall nurses' station revealed she stated an investigation was supposed to be initiated upon receipt of an incident report. Continued interview revealed it appeared staff never generated an incident report for the August, September, or (MONTH) (YEAR) incidents. Further interview revealed there was no soft file or other documentation to show the allegations of abuse by Resident #15 had ever been investigated. Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS revealed Resident #31 had periodic confusion related to Dementia. Continued review revealed the resident displayed no behaviors during the assessment period. Medical record review of Resident #31's Progress Notes revealed multiple allegations of resident-to-resident abuse, including: 6/3/17 - Resident sent out for inpatient psychiatric hospitalization when the resident displayed, .physical aggression towards another resident . 9/16/17 - Resident #31 alleged to have hit another resident in the dining room. When asked if she hit the other resident, Resident #31 replied, .in the nose, in the nose. Just once. Just once . 9/21/17. - Resident #31 was .reported to have slapped male patient who has been invading the space of other individuals all afternoon . Interview with the DON on 1/15/18 at 3:10 PM in the conference room confirmed she had been unable to find any evidence the 6/3/17, 9/16/17, or 9/21/17 incidents were investigated. Continued interview revealed she stated, She was just sent out to the hospital each time. Further interview with the DON revealed, It's a breakdown in the system. Continued interview revealed she stated when staff sent the resident out to the hospital because of the resident-to-resident altercation, they should have also completed an incident report so the facility could start its investigation. Further interview revealed no incident report was ever completed, so it never got reported and an investigation was never initiated. Continued interview revealed the DON was asked if she knew the name(s) of the resident(s) involved in the 3 altercations which were not investigated or reported. The DON stated she did not know the residents' names and without digging into files, would not be able to determine the names of the residents whom Resident #31 had hit. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #13 scored 2 on the BIMS indicating he was severely cognitively impaired. Continued review of the MDS revealed the resident required extensive assistance with transfers, dressing, grooming, and bathing. Medical record review of Resident #13's Progress Notes revealed allegations of resident-to-resident abuse, including: 6/6/17 - Staff notified a nurse that Resident #13 .hit another resident in the head . On 1/9/18 at 10:25 AM, the DON provided material which she stated was the facility's full investigation into this event. Review of the documentation provided by the DON revealed an incident report had been completed regarding this altercation. However, review of the investigation file revealed it was not a thorough investigation. Sections of the Incident Report form which related to the resident's condition such as Predisposing Physiological Factors Predisposing Situation Factors was blank and had not been completed. Review of the investigation packet provided by the DON revealed there was no evidence the facility completed a root cause analysis to determine the possible cause of the resident-to-resident altercation. Review of a Witness Explanation of Incident dated 8/15/17 revealed a male resident alleged possible sexual abuse by telling a nurse Resident #13 was playing with a female resident's vaginal area. On 11/5/17, a hand-written witness statement revealed Resident #13 was observed fondling the breast of a different female resident, while she was sleeping in her wheelchair. Review of facility investigation records revealed there was no evidence of root cause analysis to determine the cause of these incidents. Neither of the investigations showed evidence staffing was reviewed to determine if there was lack of supervision. Interview was conducted with Corporate Consultant #1 on 1/10/18 at 9:20 AM at the C-Wing Nurses Station revealed he stated for each allegation of resident-to-resident abuse, a full investigation should have been conducted to determine if the allegation was substantiated in order to take necessary actions to protect residents and prevent further abuse.",2020-09-01
3273,"THE WATERS OF SMYRNA, LLC",445502,202 ENON SPRINGS ROAD EAST,SMYRNA,TN,37167,2018-01-16,602,D,1,0,POU411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview the facility failed to ensure residents were free from misappropriation of medications for 3 residents (#1, #2, #3) of 16 residents reviewed for misappropriation. The findings included: Review of facility policy, Abuse Prevention Program, updated 1/19/17, revealed .It is the policy of this facility to prevent resident abuse, neglect, mistreatment, and misappropriation of resident property .All personnel must promptly report any incident or suspected incident of resident abuse, mistreatment, or neglect, including misappropriation of property .Misappropriation is defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent .All alleged violations MUST be reported to the Administrator or Director of Nursing .After notification the Administrator or person in charge of the facility shall immediately commence an investigation of the incident reported .An administrator or designee shall review the findings of the investigation and determine if further training or other corrective action is needed to prevent further occurrence . Review of facility policy, Drug Diversion - Reporting and Response, revealed .Drug Diversion is the intentional and without proper authorization, using or taking possession of a prescription or a non-prescription medication or biological from the supply intended for use by the facility staff for the residents .Interviews of all appropriate staff will be completed as to their knowledge of anything that might be pertinent to the investigation .All medication storage areas will be evaluated to see that all inventory is present .Following a drug diversion the facility Administrator will hold an Ad Hoc Quality Assurance meeting to discuss the event and to determine the root cause as part of the process. The committee will define measures and interventions as appropriate to be implemented . Review of facility policy, Medication Administration, revealed .Narcotics are to be counted at the beginning and end of each shift by 2 nurses on the Narcotic Count Log, and signed by both nurses .Both nurses must see both the card and the sheet to verify both are correct .Both nurses MUST look and the front AND back of each card to verify there are NO taped backs on the card or holes or slits in the back .New narcotics received from Pharmacy require 2 nurse signatures, the date, and the amount in the card at the top of the sheet to verify prior to locking in cart .Any discrepancy in narcotic count required notification of the DON immediately. Nurses cannot leave without speaking with the DON . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED].#1 was ordered [MEDICATION NAME] (anti-anxiety) 0.5 milligrams (mg) every 24 hours as needed for anxiety. Review of a facility investigation revealed Resident #1 was discharged on [DATE] and his family stated he did not receive the bottle of [MEDICATION NAME] which he brought on admission. Continued review revealed when the bottle was located and counted there were 45 pills instead of the 60 which were in the bottle when the resident was admitted . Further review revealed the Medication Administration Records and Narcotic Count Sheets revealed Resident #1 had not received any [MEDICATION NAME] while a resident of the facility. Continued review revealed all nurses with access to the medication cart submitted urine samples for drug testing and all came back negative. Further review revealed all medication carts were audited with no discrepancies found. Continued review revealed the family was reimbursed for the missing pills. Further review revealed all licensed staff were inserviced on not accepting keys without counting every narcotic; open all bottles and count the contents; hold book and card where both nurses can see them to ensure narcotic sheets and counts are correct; and introduction of new narcotic sheets. Continued review revealed the Quality Assurance plan included a review of the major steps of the diversion policy; audits of counts and medication carts; checking the manifest logs when medications are delivered; introduction of a new narcotic count sheet; and checking daily as needed sheets against the Medication Administration Record. Review of a written statement from Licensed Practical Nurse (LPN) #9 dated 9/18/17 revealed on 8/31/17 while counting narcotics there was a bottle of [MEDICATION NAME] 0.5 mg which contained 60 pills. The bottle came in with the resident and she was told the resident didn't take them unless he was very agitated and he had not been. The following morning she counted 60 pills with LPN #13 who confirmed there were 60 pills in the bottle. Review of a written statement from LPN #6 dated 9/6/17 revealed when Resident #1 was admitted to the facility his daughter brought in his prescription bottle of [MEDICATION NAME]; it was counted by 2 nurses; and the count was 60 pills. Review of a statement from LPN #10 dated 9/6/17 revealed on 9/1/17 she packaged the pills into 6 packets of 10 pills each; taped them closed; and put them back in the bottle. When she counted Sunday night, 9/3/17, the count was the same. Review of an addendum revealed she counted narcotics with LPN #13 on Monday morning, 9/4/17, and all narcotics were accounted for except the [MEDICATION NAME] and LPN #13 did not open the bottle and count the packets with LPN #10 present. Interview with the Director of Nursing (DON) on 1/15/18 at 3:15 PM in the conference room revealed Resident #1 was admitted for respite care and his family brought in 60 pills of [MEDICATION NAME] 0.5 mg in a bottle. Continued interview revealed one of the nurses put the pills in 6 packets of 10 pills each for ease of counting. Further interview revealed after discharge the daughter called to state they had not received the resident's bottle of [MEDICATION NAME] on discharge. Continued interview revealed the DON checked the packets to find 3 packs had 7 pills in them and 3 packs had 8 pills in them. Further interview revealed all nurses with access to the medication cart submitted to urine drug testing and all came back negative. Continued interview revealed the staff did not take the packets out of the bottle and count the pills in each packet, only counted the number of packets. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED].#2 was ordered [MEDICATION NAME] (pain) 5 mg every 8 hours as needed for pain. Review of the facility investigation dated 10/15/17 revealed while counting at change of shift, 2 [MEDICATION NAME] 5 mg tablets were missing. Continued review revealed 2 tablets with the imprints AN511 were replaced and determined to be [MEDICATION NAME] (blood pressure). Further review revealed Resident #2 had not required the medication in the last 2 months. Continued review revealed tape had been placed over the holes where the medication was removed and replaced. Further review revealed all nurses with access to the medication cart were urine drug tested except one nurse who refused the test and resigned. The other drug screens came back negative. Review of a written statement by the nurse coming on duty (LPN #12) on 10/15/17 at 6:00 PM revealed she was counting the narcotic drawer with the off-going nurse (LPN #13). She noticed the back of the narcotic card was taped over 2 pills. On closer inspection these 2 pills were different from the original narcotics. The DON was notified. Interview with the DON on 1/15/18 at 3:15 PM in the conference room revealed 2 pills were punched out; replaced with blood pressure medications; and holes were taped over. Continued interview revealed one nurse refused to submit to urine drug testing and resigned. Further interview revealed the rest of the the nurses with access to the medication cart submitted to urine drug testing and came back negative. Continued interview revealed the DON conducted inservices for all licensed staff on looking at the back of each narcotic card when counting at change of shift. Further interview revealed staff were told if there was a hole in the blister then they were to pop out the pill and discard it. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED]. Review of the facility investigation revealed on 12/18/17 when LPN #5 was counting the narcotic drawer prior to the end of her shift, she found a narcotic card of [MEDICATION NAME] 5/325 milligrams (mg) with the back taped. On closer inspection she noted 13 tablets had a different marking from the rest of the tablets. LPN #5 determined the 13 tablets were Tylenol. The DON was notified and an investigation was begun. Review of a statement from Licensed Practical Nurse (LPN) #7 dated 12/18/17 revealed .(LPN #5) called me over to inspect a card and we found 13 [MEDICATION NAME] had been removed and Tylenol placed in the blisters for the [MEDICATION NAME] with tape applied. On the 15th (December) I counted the card of [MEDICATION NAME] in and brought to the nurse on duty. I didn't stay to witness the nurse sign the second signature. The card was perfect and untampered on arrival . Telephone interview with LPN #5 on 1/10/18 at 10:40 AM revealed she counted the medication cart at 6:00 AM on 12/18/17 and nothing unusual was noted. Continued interview revealed she went back to check the medication cart at 5:30 PM to check the count before shift change. Further interview revealed she noticed 13 [MEDICATION NAME] pills to be at an awkward angle, unlike the rest of the pills. Continued interview revealed she recognized the 13 pills as Tylenol since she gave it so often. Further interview revealed the back of the card had tape on it, perfectly placed with no tape hanging over. Continued interview revealed she called the on-coming nurse to verify the findings. Further interview revealed the DON and Clinical Coordinator were called, and both nurses were required to submit to urine drug screen. Continued interview revealed LPN #5 was unsure if she looked at the back of the card when she initially counted at 6:00 AM. Interview with LPN #7 on 1/14/18 at 6:30 PM in the conference room revealed he signed in the card of [MEDICATION NAME] on 12/15/17 and gave them to the nurse on C wing but did not observe her sign the acceptance sheet. Continued interview revealed 3 days later LPN #5 called and said there was a big problem. Further interview revealed he looked at the card and noted someone had cut out the metal backing; popped the pills out; replaced the pills with Tylenol; and put tape over each blister, perfectly trimmed for each one. Continued interview revealed the video did not show anyone in the medication room for the period of time needed to remove the pills; replace them; and tape the back of each blister. Interview with the DON on 1/15/18 at 3:15 PM in the conference room revealed 13 [MEDICATION NAME] pills were punched out and paper tape was placed over each blister hole. Tylenol had been inserted in place of the missing [MEDICATION NAME]. Continued interview revealed the medication was signed in on 12/15/17 but the resident was sent to the hospital on [DATE]. There was no double signature on the acceptance sheet for the medication. Further interview revealed all nurses with access to the medication cart were drug tested and found to be negative. Continued interview the DON confirmed the facility failed to prevent misappropriation of narcotics and failed to ensure the change-of-shift narcotic counts was conducted according to facility policy.",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
1549,"LEBANON CENTER FOR REHABILITATION AND HEALING, LLC",445268,731 CASTLE HEIGHTS COURT,LEBANON,TN,37087,2019-06-10,600,D,1,0,BKNE11,"**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 assume responsibility for ensuring the safety and well-being of a resident by failing to protect a resident from verbal and physical abuse by a staff member for 1(Resident #2) of 3 residents reviewed. The findings included: Review of facility policy, Abuse and Neglect Prohibition, revised 7/2018, revealed .Each resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms .Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or to others regarding the resident or within the resident's hearing distance regardless of their age, ability to comprehend, or disability .Physical abuse includes, but is not limited to, hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment .Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .The facility will screen for employees with a history of abusive behavior .The facility will train each employee on this policy during orientation, annually, and more often as determined by the facility .The facility Quality Assurance & Performance Improvement Committee will review available data to identify patterns and trends that may indicate the presence of abuse .The facility will protect residents from harm during the investigation .The facility will timely conduct an investigation of any alleged abuse/neglect .Any employee alleged to be involved in an instance of abuse and/or neglect will be interviewed and suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated .The QAPI Committee may make recommendations to the Policy and Procedure Steering Committee for modifications based on identified opportunities for improvement resulting from the review of the investigation . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 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 #2 required extensive assistance of 1 person with transfers, dressing, toileting, grooming, and bathing; was occasionally incontinent of bladder; and was always continent of bowel. Review of facility investigation of a written statement from Registered Nurse (RN) #1 dated 4/27/19 revealed .I was asked by a nursing technician to visit a resident (named Resident #2) who had made a statement that night nurse (named RN #2) had touched a resident. I visited this resident who said at approximately 2400 the nurse told (named Resident #2) that she would be receiving her medications. (named Resident #2) stated she had been asking since 1930 (7:30 PM) for her pain medication. (named Resident #2) again asked at 0030 (12:30 AM) for her medications and (named RN #2) scolded her verbally and was pointing her finger near her face. She continued to scold her at which point the finger hit the upper lip of (named Resident #2). (named RN #2) apologized to the resident for hitting her in the face. Soon after the incident she received her medications. (named Resident #2) verbalized the above events to myself and in the presence of (named LPN #1) and (named CNA #1) . Review of facility investigation of a written statement from Certified Nurse Aide (CNA) #1 dated 4/27/19 revealed .I arrived on 110B to toilet her. During conversation about her having a rough night she had told me her night shift nurse had been very rude and physical with her by scolding her and pointing a finger to her face and physically touching her above the lip during this time. All (named Resident #2) was asking about was her medicine around 7pm - 7:30. Afterwards she finally received her medicine around 12 - 12:30 AM. I immediately reported this to the nurse and supervisor. I ensure (named Resident #2) she was doing right by telling me. She would be safe . Review of facility investigation of a written statement from Licensed Practical Nurse (LPN) #1 dated 4/27/19 revealed .I was approached by (named CNA #1) to come to room [ROOM NUMBER]B. Upon entering the room the patient stated last night the nurse was off the chain. Pt stated that she began asking for her night meds at 730pm so she could rest. The nurse did not come stated the pt until after midnight. The pt stated that the nurse began to scold her by pointing her finger in her face and telling her she had no meds at this time because they haven't come from the pharmacy. The pt then stated that when she told the nurse that she had been receiving medications all day and she knows they are there the nurse began pointing her finger in her face and scolding her. Pt stated the nurse pushed her upper lip with her pointed finger of her right hand. Pt then stated she told the nurse to never touch her again and the nurse immediately apologized and became nice and went to get her medication. I immediately informed nursing supervisor who then reported to the administrator and director of nursing (DON) . Review of facility investigation of an interview between the DON and Resident #2 dated 4/27/19 revealed .(named Resident #2) stated that nurse (named RN #2) had yelled at her pointing her finger in her face and her finger hit her lip. When asked why the nurse was yelling Resident stated she had asked for pain medication and the nurse was yelling at her saying that her med had not come in yet and there was nothing she could do about it. When asked if she felt the nurse meant to hit her lip (named Resident #2) said I don't think she did. I think it was an accident. When asked how she felt she stated she made me mad. I'm [AGE] years old and don't need to be talked to like that. I was so mad that I wanted to take this (held up TV remote) and hit her in the head with it. I am not afraid, she just made me mad. Assured (named Resident #2) that it would be taken care of and nurse would not be back . Review of facility investigation of an interview between the DON and RN #2 dated 4/29/19 revealed .Asked (named RN #2) if she remembered anything that transpired with (named Resident #2) on Friday 4/26/19. (named RN #2) said I don't remember her or much from that night I was tired. Explained who the resident is and what she said (named RN #2) had done. (named RN #2) said I was pointing at the meds because (named Resident #2) refused to take one and I was indicating which pill. Resident turned her face and my finger touched her lip. I apologized for that. (named RN #2) said she didn't remember yelling at her or talking about her pain meds. Maybe patient sensed I was stressed and took it that I was yelling. (named RN #2) once again stated she couldn't remember . Interview with the Administrator and DON on 5/9/19 at 3:10 PM in the conference room revealed Resident #2 can get testy at times but cooperated with therapy this admission. Prior admissions she had refused therapy at times. The alleged perpetrator pointed her finger in the resident's face and touched her lip when the resident turned her head. The resident told them she didn't need to be chastised in that manner. The nurse said she was trying to find which pill the resident refused and was pointing to it. The nurse was suspended during the investigation and then terminated. Interview with the Administrator on 6/10/19 at 9:30 AM in the conference room revealed as the incident was being investigated it became a he said, she said situation. The Administrator reported it and terminated the nurse as a precaution and also because the nurse was just not making it. When she visited the resident to apologize for the incident the resident was not upset and said she was well cared for in the facility and that is why she keeps coming back for rehabilitation. The Administrator stated the nurse may have raised her voice thinking the resident did not understand what she was telling her about not taking 2 of her pills. Telephone interview with Resident #2 on 6/10/19 at 10:50 AM revealed she was a nurse for many years and the incident didn't bother her. She said she realized they had to report it but it was not a major issue. At the time of the incident she was mad at what occurred but had no fear. It was an accident the nurse's finger touched her lip and only because she turned her head. In summary, Resident #2 asked for pain medication at 7:30 PM according to the resident. She received the medications at midnight along with a scolding from the nurse who also pointed her finger in the resident's face. As the resident turned her head the nurse's finger contacted the resident's skin on the face. The resident was upset at the time of the incident. This behavior constituted verbal and physical abuse.",2020-09-01
2336,MANCHESTER HEALTH CARE CENTER,445391,395 INTERSTATE DRIVE,MANCHESTER,TN,37355,2017-05-03,225,E,1,1,1K2B11,"**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 conduct an investigation of an injury of unknown origin for 1 resident (#175) of 3 residents reviewed for injuries of unknown origin and failed to throughly investigate two behavior related incidents involving three residents (#176, #45, #112) of 19 residents reviewed for behaviors. The findings included: Review of facility policy, Abuse Prevention Standard, revised 9/2015 revealed .the facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical, and/or mental abuse, corporal punishment, involuntary seclusion, or misappropriation of resident property by any facility staff member, other residents, consultants, volunteers, staff of other agencies, family members, legal guardians, friends, or other individuals .The facility will thoroughly investigate, under the direction of the Administrator, all injuries of unknown origin to determine if abuse or neglect was involved .The results of the investigating will be reviewed by the facility's Quality Assurance/Performance Improvement Committee (QAPI) and entered into the minutes . Medical record review revealed Resident #175 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #175 scored 15 on the Brief Interview for Mental Status indicating she was alert, oriented, and able to make her needs known. Continued review revealed Resident #175 required extensive assist of 1 person for transfers, dressing, grooming, and bathing; setup for eating; was always continent of bladder and occasionally incontinent of bowel. Review of facility policy, Abuse and Event Management Standard, revised 9/2015 revealed, .Resident-to-Resident Abuse Policy .All incidents are to be documented in the resident's medical record with intense monitoring to continue for at least 72 hours .Reporting/Investingation/Response Policy .Facility Social Worker Duties .to provide counseling and support to the resident .to be documented in the resident's clinical record . Review of the Fast Pace-v3-14 form dated 10/28/16 at 2:30 PM revealed a Resident-to-Resident altercation dated 10/27/16 at 5:00 PM in the fine dining room, between Resident #45 and Resident #176. The altercation consisted of Resident #176 initiating a verbal exchange with Resident #45, concluding in Resident #176 hitting Resident #45 on the legs above the knees. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #176 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Progress Notes, dated 10/27/16 revealed, .resident (#45) involved in an incident with another resident (#176) .resulted .getting struck by other resident (#176) .will continue to monitor . Continued review revealed no further documentation or monitoring noted. Resident #45 was asked to allow nursing to assess him and he refused. Resident #176 was transferred to a facility providing behavior monitoring and management on 10/27/16. Medical record review revealed no documentation of follow-up by Social Services for Resident #45 following the Resident-to-Resident altercation dated 10/27/16. Interview with the Administrator on 5/3/17 at 11:30 AM in the Adminstrator's office confirmed the investigation provided was the only information available for 10/27/16 Resident-to Resident altercation. Interview with the DON on 5/3/17 at 2:00 PM in the Conference Room confirmed there was no documentation for, .intense monitoring to continue for at least 72 hours . per facility policy. Further interview confirmed Social Services failed to follow-up or investigate the Resident-to-Resident altercation 10/27/16 involving Resident #45 and Resident #176. Review of an Orthopedics follow-up appointment dated 9/7/16 revealed Resident #175 was complaining of right knee and hip pain. The physician felt the hip pain was knee pain referred to the hip. An x-ray of the knee was ordered but no x-ray of the hip was ordered. Medical record review of a Nurse Practitioner note dated 10/6/16 revealed Resident #175 complained of pain in her right lower extremity but less than previously so the scheduled [MEDICATION NAME] (pain medication) was changed to as needed. It was also documented Resident #175 had a medical history of [REDACTED]. Medical record review of a Nurse Practitioner note dated 10/10/16, revealed Resident #175 complained of severe right hip pain. The pain was described as a constant ache increasing to sharp with movement. The pain was unrelieved by the current care plan and the resident needed a hip x-ray which was done on 10/10/16 and was read as .no fracture or dislocation but if symptoms persist, repeat imaging in a few days or additional imaging with CT (computerized tomography) or MRI (magnetic resonance imaging) may be necessary for further evaluation . Medical record review of a Nurse Practitioner note dated 10/12/16 revealed Resident #175 complained of muscle pain/spasm in the right hip and groin area. The pain was described as an intermittent ache and throb. Medical record review of a Nurse Practitioner note dated 10/18/16 revealed Resident #175 was to be non weight bearing on the right lower extremity until cleared by Orthopedics. The tibial plateau fracture was stable but not healed. The resident was able to do passive range of motion exercises with the right knee. The x-ray from 10/10/16 was suspicious for a femoral neck fracture or other type of [MEDICAL CONDITION] so an MRI was ordered. Medical record review of nursing notes dated 11/2/16 revealed Resident #175 had an MRI of the right hip. Medical record review of a nursing note dated 11/4/16 revealed the nurse spoke to Resident #175 about impending transport and admission to the hospital due to recent [MEDICAL CONDITION]. The resident stated she had no falls since admission but her thigh and right hip just started hurting. Medical record review of nursing notes dated 11/8/16 revealed Resident #175 was to have surgery on the right hip that same evening and be transferred to a nursing facility closer to her family after recovery. Medical record review of a radiology report of the right hip dated 11/12/16 revealed Resident #175 had .diffuse [MEDICAL CONDITION] in soft tissues and the proximal femur as well as a subcapital fracture (below the neck of the femur) mildly impacted of the femoral neck. [MEDICAL CONDITION] extends into the gluteus maximus and medium muscles (buttocks muscles) and into the thigh muscles . Medical record review of a physician's note dated 11/29/16 revealed .It is my professional opinion after reviewing documentation and diagnostics the resident's right femoral neck fracture identified on 11/2/16 is pathological in nature. The resident's age and medical history of [REDACTED]. Review of the facility's investigation packet revealed no evidence of an investigation. There were no statements from staff regarding any falls sustained by Resident #175 as well as assistance required by the resident. There was no documentation from staff, therapy, or roommate regarding possible causes of the injury of unknown origin. Interview with Certified Nursing Aide #6 (CNA) on 5/3/17 at 1:30 PM on the 300 hall where Resident #175 had resided, revealed she was unaware of any falls the resident sustained [REDACTED]. CNA #6 also stated Resident #175 required a lot of assistance with all Activities of Daily Living (ADL) because of the tibial fracture of her right leg. Interview with CNA #7 on 5/3/17 at 1:45 PM on the 300 hall, revealed she was unaware of any falls the resident had while in the facility. She did not witness any falls nor did the resident complain of falling to CNA #7. The CNA also stated Resident #175 required assistance with transfers as well as ADLs so the staff would have been aware if the resident had fallen. Interview with the Director of Rehab, on 5/3/17 at 3:00 PM in the conference room, revealed Resident #175 was alert and oriented and had sustained a tibia/fibula fracture during a fall at home. The Director stated the resident was non weight-bearing on the right leg. Continued interview with the Director revealed Resident #175 had no falls while in the facility. Resident #175 complained of increasing hip pain so was sent to the hospital where a [MEDICAL CONDITION] was found. The resident had gone to an Orthopedic appointment earlier but no fracture was found. Interview with the Director of Nursing (DON) on 5/3/17 at 4:20 PM in the conference room, revealed she was unable to recall the resident or any issues with her. Continued interview the DON confirmed there was no completed investigation into the injury of unknown origin. Review of facility policy, Abuse and Event Management Standard, revised 9/15 revealed .It is the policy of this facility to take all steps reasonable and necessary to protect the residents from harm at all times, including protection from physical and verbal abuse from other residents .The Administrator, Director of Nursing or their designee assumes responsibility for notification of the incident and investigation findings as well as follow-up .An investigation report is to be completed, to include the written summary of the investigation and facility actions taken . Medical record review revealed Resident #112 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5-day MDS assessment dated [DATE] revealed Resident #112 had a BIMS of 14 indicating the resident was cognitively intact. Medical record review of a nurse's note dated 12/18/16 revealed .Resident got a hold of fire extinguisher and pulled pin and ran down 200 hallway spraying every where .Told resident to stop but he would not .Police approached him and attempted to just talk to him but he made a fist and attempted to hit one of the officers . Medical record review of a Social Service note dated 12/20/16 revealed resident was discharged on ,[DATE] with behaviors. Review of the facility investigation received from the DON on 5/2/17 in the conference room revealed one undated typed note from the Social Director which documented Spoke with residents that were interviewable about the incident that occurred on 12/18. No resident seemed to have any psychosocial factors other than wanting to know when they were going to get some of their personal belonging back from housekeeping. This social worker informed the residents that they were being washed and would be returned after being cleaned. Continued review of the facility investigation revealed 6 employee statements recounting their rememberances of the fire extinguisher incident. Further review revealed one witness statement report from a resident in room [ROOM NUMBER]B that was hit by and sprayed with the fire extinguisher who received an evaluation at the Emergency Department with no injuries. Continued review revealed an In-Service form dated 12/18/16 .Topic .Be aware of resident behavior that would indicate an interest in fire extinguisher or pull stations . signed by 20 employees. Interview with the DON on 5/3/17 at 2:50 PM in the conference room revealed there was no other available information for the facility investigation. Continued interview confirmed the facility failed to conduct and document a complete and thorough investigation for Resident #112's behaviors and fire extinguisher incident that occurred in (MONTH) (YEAR). Review of facility policy, Abuse and Event Management Standard, revised 9/2015 revealed, .Resident-to-Resident Abuse Policy .All incidents are to be documented in the resident's medical record with intense monitoring to continue for at least 72 hours .Reporting/Investingation/Response Policy .Facility Social Worker Duties .to provide counseling and support to the resident .to be documented in the resident's clinical record . Review of the Fast Pace-v3-14 form dated 10/28/16 at 2:30 PM revealed a Resident-to-Resident altercation dated 10/27/16 at 5:00 PM in the fine dining room, between Resident #45 and Resident #176. The altercation consisted of Resident #176 initiating a verbal exchange with Resident #45, concluding in Resident #176 hitting Resident #45 on the legs above the knees. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #176 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Progress Notes, dated 10/27/16 revealed, .resident (#45) involved in an incident with another resident (#176) .resulted .getting struck by other resident (#176) .will continue to monitor . Continued review revealed no further documentation or monitoring noted. Resident #45 was asked to allow nursing to assess him and he refused. Resident #176 was transferred to a facility providing behavior monitoring and management on 10/27/16. Medical record review revealed no documentation of follow-up by Social Services for Resident #45 following the Resident-to-Resident altercation dated 10/27/16. Interview with the Administrator on 5/3/17 at 11:30 AM in the Adminstrator's office confirmed the investigation provided was the only information available for 10/27/16 Resident-to Resident altercation. Interview with the DON on 5/3/17 at 2:00 PM in the Conference Room confirmed there was no documentation for, .intense monitoring to continue for at least 72 hours . per facility policy. Further interview confirmed Social Services failed to follow-up or investigate the Resident-to-Resident altercation 10/27/16 involving Resident #45 and Resident #176.",2020-09-01
5937,WHARTON NURSING HOME,445510,878-880 WEST MAIN STREET,PLEASANT HILL,TN,38578,2015-11-18,225,D,1,0,TUIO11,"**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 conduct complete investigations of injuries of unknown origins to elicit possible causes of the injuries and determine if resident abuse was involved for 5 (Residents 1, 2, 5, 7, 11) of 11 residents reviewed. The findings included: Review of the facility policy entitled Abuse and Neglect - Clinical Protocol, revised (MONTH) 2007, revealed .Should an incident or suspected in cident of resident abuse, mistreatment, neglect, or injury of unknown origin be reported, the Administrator or his/her designee, will appoint a member of management to investigate the alleged incident. The individual conducting the investigation will: 1. Review the completed documentation forms. 2. Interview the person reporting the incident. 3. Interview any witnesses to the incident. 4. Interview staff members on all shifts who have had contact with the resident during the period of the alleged incident. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken. 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 scored 7/15 on the Brief Interview for Mental Status (BIMS) indicating the resident was moderately cognitively impaired. Continued review of the MDS revealed Resident #1 required Extensive assistance of two people with transfers and bathing; extensive assistance of one person for dressing and grooming; required supervision with eating; was frequently incontinent of bladder but continent of bowel. Medical record review of nursing notes dated 6/13/15, at 1:45 AM, revealed Resident #1 was unable to sleep due to generalized pain, especially in the back and neck. Continued review of the medical record revealed Resident #1 had facial grimacing with even minimal movement. Further review of the medical record revealed the resident was ordered [MEDICATION NAME] (narcotic [MEDICATION NAME]) 7.5/325 milligrams (mg) every 4 hours as needed for pain. Continued review of the medical record revealed a nursing note dated 7/12/15, which stated Resident #1 complained of lower back pain and stiffness; was hurting more; and was more incontinent of urine than previously. Further review of the medical record revealed at this time a urinalysis and urine culture were ordered which were positive for bacteria so the resident was started on antibiotics. Continued review of the medical record of nursing notes dated 7/16/15, at 3:30 AM, revealed Resident #1 was screaming and yelling out when the Certified Nursing Aide (CNA) was checking her to see if she was dry or wet. Further review revealed the CNA requested Resident #1 turn over so she could be repositioned and the resident was screaming I can't breathe and I can't move. Continued review revealed the CNA asked the resident to move her legs and bend her knees which she was able to do without complaints of pain. Further review of nursing notes on the same day at 10:49 AM, revealed Resident #1 was out of bed with assistance and use of the stand-up life. Continued review revealed the resident complained of pain in the lower back in the center, which felt like it was in a bone of the sacrum; and was incontinent more frequently. Further medical record review revealed Resident #1 underwent a Magnetic Resonance Imaging (MRI) of the spine which showed .acute compression fracture (one vertebra is reduced in size by 2 other vertebrae) involving L2 (second lumbar vertebra) with approximately 42% loss of height and some herniated disc material into spinal canal at L1-2 causing compression of nerve roots. Most likely [MEDICAL CONDITION] and fracture is pathological in nature . Review of the facility investigation revealed a statement from the Medical Director dated 7/27/15, stating .No falls or incidents last 6 months. Low back pain onset (MONTH) with prescribed pain management. (MONTH) pain continued. Urinalysis was obtained 7/13/15 with results from culture 7/17/15 and antibiotic therapy ordered for 8 days. MRI L-spine was ordered and performed 7/21/15 with results 7/27/15. Findings are as follows: Acute compression fracture involving the second lumbar vertebra with approximately 42% loss of height and some herniated disc material into the spinal canal at L1-2 causing compression of nerve roots. Per radiologist this is most likely osteoporotic. I agree that due to the extent of [MEDICAL CONDITION] this fracture is pathological in nature . Medical record review of physician's orders dated 8/3/15, revealed Resident #1 was ordered [MEDICATION NAME] (extended release [MEDICATION NAME]) 30 mg Twice daily. . Medical record review of nursing notes dated 8/3/15, at 3:15 AM, revealed Resident #1 stated .My daughter thinks maybe I got that compression fracture from sitting down too hard in my chair . Further review of the nursing note revealed the nurse asked the resident if she had ever fallen in any way and the resident stated she had not fallen that she could remember. Review of the facility investigation revealed no actual investigation of possible causes of the fracture; no interviews with staff to determine if the resident had fallen or if they were aware of any instances when the injury could have occurred; no summary of the investigation from the Administrator/designee; no immediate interventions put into place; and no long term approached to prevent this type of injury from occurring in the future. Medical record review revealed Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE], revealed Resident #2 scored a 3 on the Brief Interview for Mental Status which indicated the resident was severely impaired cognitively. Continued review of the MDS revealed Resident #2 required extensive assistance of two people for transfers, dressing, grooming, and bathing; limited assistance of one person for eating; and was always incontinent of bowel and bladder. Review of the facility investigation revealed an Incident Report dated 4/23/15, which stated .when staff got resident up for supper they reported resident was lying in bed with left arm behind her and was lying on it c/o (complaining of) some pain. About 8:15 Certified Nursing Aide (CNA) caller nurse to room to report resident had bruising left shoulder; [MEDICAL CONDITION]; c/o pain on movement. Bruising was noted to be 6 centimeters (cm) x (by) 10 cm. Review of the facility investigation revealed an assessment from the emergency room dated 4/24/15, which documented .left elbow, wrist, and hand normal. Comminuted (bone edges not meeting) (L) (left) humeral (bone of upper arm) neck fracture and a shoulder immobilizer was prescribed . Review of an undated written statement by Licensed Practical Nurse (LPN) #1 revealed she was told Resident #2 was c/o arm pain so she administered the resident's scheduled pain medication. Continued review of the statement revealed .CNAs reported to me that resident had been laying with arm behind her and laying on it when they got her up. I was called to resident's room after dinner to check resident's arm. I noted [MEDICAL CONDITION] and bruising left shoulder area. I called (named physician) and got order for x-ray . Review of a written statement by CNA #1 dated 4/24/15, revealed .on 4/23/15 when (named resident #2) was in recliner at 1:00 - 1:15 PM she was positioned on her left side when we got her up to go to her room but she was practically on her left side facing the bar with pillow and her arm was under her because she rolled too much her left. So when we got her up she was saying her arm was hurting and she grabbed her shoulder. When we got her in her room and put her in bed she was on her back so we could change her and she then rolled on her left side saying it was hurting. A few minutes later she was hollering that her arm was still hurting so me and (named CNA #3) repositioned her . Review of a statement by CNA #2 dated 4/24/15, revealed .On Thursday (MONTH) 23 not long after breakfast (named Resident #2) was put in recliner in living room. She doesn't like to sit on her butt when in recliner and was moving around so she was positioned on her side. She was yelling a lot that she was hurting. A little bit later she was turned on her other side (right I believe) and seem to rest better. I did not help get her in wheelchair for lunch. After lunch (named CNA #1) ask me if I would help her pull (named Resident #2) up in bed. I noticed (named CNA #1)'s neck was red I ask what happen she said (named Resident #2)'s arm hit her in the neck while transferring her to bed. I do not know if (named CNA #1) did the transfer by herself or if someone helped her. When I walked in (named Resident #2) was yelling you broke my arm. That is first time I heard (named Resident #2) say anything about her arm . Review of a statement dated 4/24/15 written by the Certified Occupational Therapy Assistant, revealed .around 1:10 PM I walked by pt. (patient) room to get someone else for therapy and pt. was yelling they broke my arm, they broke my arm. Caregiver (named CNA #2) walked into room and states Pt. hit other caregiver's neck accidentally during transfer. Review of a written statement by CNA #3 dated 4/24/15, revealed .at 2:20 PM (named CNA #1) found Resident #2 lying in bed, lying halfway on to left side lying on her arm; left arm was bent upward under her back. she was c/o pain in her arm and back. She c/o left arm pain while eating dinner at the table. At 5:30 PM we got her back to bed and she c/o left arm pain with any movement. Usually she wraps her arms around the CNA with the gait belt while transferring but on 4/23/15 she was unable to wrap the left arm around the CNA, only the right arm . Review of notes from the Orthopedic Surgeon dated 5/1/15, revealed .she had a torsional-type injury of her shoulder and sustained an upper humerus fracture. She was seen in the emergency room , put it in a sling and told to follow up with orthopedics. Left upper humerus fracture which is essentially nondisplaced. On exam she is a dementia patient and does not even know why she is here but she does have a left upper humerus fracture. She has a little bruising and ecchymosis. Our plan at this time is to go ahead and leave her in the sling . Interview with CNA #1 on 11/17/15, at 1:00 PM on the 100 Hall,revealed (named Resident 32) was afraid to be alone so the CNA picked out a recliner for the resident with a remote. Continued interview revealed (named Resident 32) .shimmied around in the chair; was on her left side; and had her right leg on the arm of the recliner . Further interview with CNA #1 revealed (named Resident #2) hollered out Oh my arm and complained of pain in the left upper arm into the shoulder. Continued interview revealed Therapy helped get the resident from the recliner into the wheelchair then to the dining room. Further interview revealed she put ( named resident #2) in bed; she pout her good arm around the neck of CNA #1 and hit her (CNA #1)'s neck on the left side; and she said her arm really hurt. Continued interview revealed CNA #2 helped her pull the resident up in bed using the pad . Interview with CNA #2 on 11/16/15 at 1:20 PM on the 100 Hall, revealed (named Resident #2 was yelling a lot and she tried to make her comfortable. Continued interview revealed (named Resident #2) wiggled a lot and got sideways in the recliner. Further interview revealed she and CNA #1 got the resident back to bed and straightened her up when the resident said she broke my arm. Continued interview revealed the CNAs could turn Resident #2 on her right side sand put a pillow behind her but she would squirm around until she was back on her left side . Review of the facility investigation revealed no summary by the Administrator or his/her designee of the incidents which occurred; results of staff interviews; immediate actions put into place; determination of possible cause of injury; and approaches to prevent further occurrences. Medical record review revealed Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of an Incident Report dated 3/24/15, revealed .CNA reported marks on resident. Resident noted to have 4 fingertip shaped and spaced marks on left forearm below elbow. Right upper arm had nickel size mark, reddish brown in color. Resident does not recall hitting self Review of an Incident Report dated 6/6/15 revealed .CNA noted upon getting resident up this AM that she had bruise to right wrist/arm area. Resident having behaviors yesterday, running into walls, furniture . Review of both Incident Reports revealed no attached investigations to determine possible cause of the bruises; no staff interviews regarding time of appearance of the bruises; no approaches to prevent this from occurring in the future. Medical record review revealed Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of an Incident Report dated 9/9/15, revealed the resident was found with .purplish bruise left upper outer thigh, 9 cm x 4 cm. Resident doesn't recall when this happened . Review of the Incident Report revealed no investigation to determine possible cause of the bruise; interviews with staff as to time of appearance of the bruise;and no approaches to prevent this from occurring in the future. Medical record review revealed Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of an Incident Report dated 6/26/15, revealed .was giving resident a shower, resident complained of pain when washing, resident has bruise on chest light reddish and abrasion on back bone between shoulder blades, resident stated when therapy transferred her this morning the gait belt slipped up and she had pain in those areas. Review of the incident Report revealed no investigation to determine if the gait belt slipping was the actual cause of the bruising; no statements from the therapist to confirm or deny the resident's statement; and no approaches to prevent this from occurring in the future. Interview with the Director of Nursing (DON) on 11/18/15, at 8:31 AM. in the Therapy Room, confirmed no in-depth investigations were conducted; no interviews were carried out; and no new approaches were instituted for all of these injuries of unknown origin, and confirmed all of them shold have had in-depth invetigations.",2018-11-01
923,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2017-06-28,323,G,1,1,QJYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to ensure safety devices were in place and functioning for 3 residents (#105, #25, #68) of 6 residents reviewed for falls. This failure resulted in Harm to 1 resident (#105) who sustained a fall with a femur fracture. The findings included: Review of facility policy, Falls Prevention Program, revised [DATE] revealed The incidence of hip fractures increase with age .Each center has a Falls Committee which monitors falls and utilizes data to systematically address falls which is a subcommittee of the Quality Assurance and Performance Improvement (QAPI) Committee. The Falls Committee takes direction from and reports to the center QAPI (Quality Assurance Performance Improvement) Committee . Medical record review revealed Resident #105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #105 scored 4 on the Brief Interview for Mental Status (BIMS), indicating she was moderately impaired cognitively. Continued MDS review revealed Resident #105 required extensive assistance of 2 people for transfers; extensive assistance of 1 person for dressing, toileting, and grooming; was dependent on 2 people for bathing; and was always incontinent of bowel and bladder. Medical record review of a Falls Investigation dated [DATE] revealed Resident #105 was found on her right side beside the bed. Continued review revealed Resident #105 had a seat belt which was found beside the chair, broken in half. Further review revealed the resident had a contusion to her head and complained of right thigh pain. Medical record review revealed Resident #105 was transported to the hospital where x-rays showed she had suffered a .comminuted intertrochanteric femoral fracture of the right side (unstable hip fracture) . The resident underwent [REDACTED]. Further medical record review revealed Resident #105 was sent out to the hospital on [DATE] and admitted with [DIAGNOSES REDACTED]. Continued medical record review revealed the resident was placed on hospice care on [DATE] and expired on [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 12:20 PM in the classroom revealed Resident #105 fell ; complained of leg pain; and hit her head in the fall. Continued interview revealed no one was sure whether she was trying to go to bed or to the bathroom. Further interview revealed the seatbelt Resident #105 was used for pelvic support. Continued interview revealed Resident #105 was [DIAGNOSES REDACTED] and could not stand or walk. Further interview with the DON revealed the zip tie must have come loose from where it was tied to the posts of the wheelchair. Continued interview revealed it is the responsibility of the Certified Nurse Aide (CNA) caring for the resident to check the seat belt and connections before using the wheelchair for a resident. Further interview with the DON confirmed this check was probably not completed if the zip tie broke. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Post Falls Nursing assessment dated [DATE] at 9:30 AM revealed Resident # 25 was found lying on floor mat bedside bed with no injury noted. Medical record review of the Post Falls Nursing assessment dated [DATE] at 6:16 PM revealed staff heard alarms sounding and found Resident #25 sitting on her buttocks by her door in her room and no injury noted. Medical record review of the Post Falls Nursing assessment dated [DATE] at 11:15 AM revealed upon entering room Resident #25 was found sitting on the floor beside the bed without injury. Medical record review of the Post Falls Nursing assessment dated [DATE] revealed .CNA was walking by room and saw patient's feet on the floor. Exiting wheelchair. Entered room and saw patient lying on the floor next to bed .Additional Comments: Alarms were not sounding and staff was educated and reprimanded for safety needs not being met . Continued review revealed the document was signed by Licensed Practical Nurse (LPN) #1. Review of Supervisory Adverse Action Notice dated [DATE] revealed .Supervisor's Statement of Incident: Employee failed to turn alarms back on patient after toileting which resulted in patient falling . Continued review revealed the document was signed by CNA #1 and LPN #1. Review of the Fall Investigation dated [DATE] revealed .Pt (Patient) was toileted by CNA and after pt (patient) was placed back in w/c (wheelchair) the alarms were not turned back on. CNA was written up and all interventions were in place . Medical record review of the care plan updated [DATE] revealed no interventions were initiated after the [DATE], [DATE], [DATE], and the [DATE] falls. Observation on [DATE] at 8:57 AM revealed Resident #25 had a seatbelt in place going across her lower abdomen through the arms of the wheelchair, around the back of and attached to the back frame of the wheelchair on the right and left sides with a zip tie wrapped around several times and secured Observation on [DATE] at 4:57 PM in Resident #25's room revealed a bathroom door alarm on the bathroom door, in the off position. Interview with CNA #1 on [DATE] at 4:54 PM at the door to Resident #25's room revealed when asked about a bathroom door alarm, she explained there was one on the door, but it was never on. We don't turn it on because we have to take her to the bathroom. When asked if she had ever seen the bathroom alarm on she stated No. That's not for these residents. Interview with LPN #1 on [DATE] at 4:58 PM in room 101 revealed the resident had multiple falls in the last couple of months. Continued interview revealed when asked about the bathroom door alarm she stated there was a bathroom door alarm on the bathroom door but it is not on. I'm not sure why it's there. Continued interview revealed she was asked about the fall on [DATE]. The LPN explained a CNA had recently toileted the resident and after transferring the resident back to the wheelchair, the Aide had forgot to put the alarm back on. Continued interview revealed the resident then fell out of her wheelchair. Continued interview with the LPN revealed it had been determined the fall was due to the alarm not being turned back on. The LPN confirmed the facility failed to prevent the resident's fall. Medical record review revealed Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Falls Investigation dated [DATE], revealed Resident #68 was found sitting on the floor near the head of the bed. His call light was on but his alarms were not in place. Resident #68 stated he was trying to go get his nurse. The resident did not sustain any injuries as a result of the fall. Review of the falls investigation revealed a Supervisory Adverse Action Notice dated [DATE] stating the patient alarms were not in place at the time of the fall and were set in place after the resident was placed in bed. Interview with the DON on [DATE] at 4:30 PM in the classroom, confirmed the report stated the resident's alarms were not in place at the time of the fall and confirmed the staff would not have been alerted to the resident's fall.",2020-09-01
5827,TENNESSEE VETERANS HOME,445270,PO BOX 10299,MURFREESBORO,TN,37129,2015-11-10,223,D,1,0,09ZM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to ensure the safety of a resident immediately after an inappropriate incident for 1 (Resident #1) of 5 residents reviewed. The findings included: Review of the facility policy entitled Abuse & Neglect of Residents and Misappropriation of Residents' Property approved 2/20/13, revealed .Any alleged violations involving mistreatment, neglect, abuse, or misappropriation including injuries of unknown source, must be reported immediately to the Administrator . Continued review of the policy revealed the investigation includes: 1. Notification of the involved resident's legal guardian or responsible family member. 2. Facility investigation will include: a. Interviewing the resident victim. b. Interviewing the alleged perpetrator. c. Interviewing all persons with firsthand knowledge of alleged incident. d. Physical examination of resident victim for evidence of abuse or neglect. f. Photographing evidence where appropriate. g. Obtaining written statements from victim, witnesses, other persons with reported knowledge as appropriate. i. Collecting, reviewing, and retaining pertinent facility documentation which may have a bearing on a full and proper investigation. 3. Any employees/volunteer/ contractor alleged to be involved in suspected abuse, neglect, or misappropriation will be removed from direct care until completion of the investigation. 4. If the alleged violation is verified, appropriate corrective action will be taken. 5. Analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. 6. Analysis of further staff training and/or monitoring needs related to residents' rights, resident care needs of the confused or behaviorally disturbed resident, etc . 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) revealed Resident #1 was moderately impaired cognitively. Continued review of the MDS revealed Resident #1 required extensive assistance of two people for transfers; extensive assistance of one person for dressing, eating, grooming, and bathing; was always incontinent of bladder and frequently incontinent of bowel. Medical record review revealed Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Annual MDS dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 indicating he was alert and oriented. Continued review of the MDS revealed Resident #2 required limited assistance of one person for transfers, dressing, and grooming; required extensive assistance of one person for bathing; was independent with eating; and was continent of bowel and bladder. Review of the facility investigation summary dated 11/4/15, revealed .On 11/3/15 at approximately 9:34 PM, Resident #1 was heard by Certified Nursing Technician (CNT) saying stop while she was walking down hallway which prompted the CNT to enter the room. Upon entering the room, CNT reported Resident #2 was standing beside the bed of Resident #1 who was in her bed. Resident #2 pants were down and he was touching and kissing her. Resident #1 BIMS score 3 (severely impaired cognitively). CNT then stepped outside the door and summoned a male tech and at that time Resident #2 reportedly pulled up his pants when male tech entered. Resident #2 was instructed to return to his room and when questioned didn't recall why he was in her room. Resident does have a [DIAGNOSES REDACTED].#2 walked to his room and got into his bed. Resident #2 placed on 1:1 and later sent out to (named hospital #1) for psychological evaluation. Resident #1 was transported to (named hospital #2) for evaluation and rape kit. The Physician and Responsible Parties were notified at the time of the incident. The Administrator, Director of Nurses, Social Worker, and local Police were all notified and reported to the facility. The female resident (#1) returned to the facility and is doing well. Social Services will be following her to ensure psychosocial needs are met. The facility staff acted in accordance with the stated policies and procedures . Review of the Police Department Incident Report dated 11/04/15, at 12:05 AM, revealed .On the above date and time I responded to (facility address) in reference to an assault. Upon my arrival I made contact with (named RN Supervisor) who is an RN Supervisor at the (named facility). She said she had been notified by an employee (named CNT #6) that she was walking down the hall when she heard patient (named Resident #1) saying stop out loud. She went in to investigate and she saw another patient (named Resident #2) standing over (named Resident #1) with his pants down kissing all over her. (named RN Supervisor) said that (named Resident #1) had her diaper spread out and (named CNT #6) attempted to get (named Resident #2) to come out of the room but he refused. She went for help and another staff member, and they were able to remove (named Resident #2) out of the room. Detectives were notified of the situation. (named Resident #1) was transported to (named hospital #2) ER (emergency room ) for analysis. (named Resident #1) suffers from serious dementia . Review of the facility investigation of a written statement by CNT #6 dated 11/3/15 at 9:40 PM, revealed .I my way down B Hall. Heard (named Resident #1) saying stop out loud. Enter in room saw (named Resident #2) standing over her. with his pants down, kissing all over her, her diaper was open on one side I ask him to come out, he still standing there, so went to get some help make him come out, CNT (named CNT #7) I ask him to come and help me get (named Resident #2) out of (named Resident #1) room . Review of the facility investigation of a written statement by CNT #7 dated 11/3/15 at 3:10 PM, revealed .The last time I saw (named Resident #2) was around 8:30 PM before I took my lunch break. My co-worker alerted me as I was charting sat the desk asking me to come quick. As we walked into (named room of Resident #1) I observed (named Resident #2) pulling up his pants. He was standing directly beside bed A looking down at her and was startled when made our presence known. I asked him to leave the room and he began to follow us out of the room. My co-worker asked (named Resident #2) while we were in the room what he was doing, he didn't immediately respond but when he did his response was Oh she ain't nothing but an old lady . Review of the facility investigation of a nursing note by the RN Supervisor dated 11/4/15 at 2:05 AM, revealed .On 11/3/15 CNT came to this supervisor at approximately 10 PM and reported that she was walking down hall and heard a woman resident saying stop. She went into her room and saw this resident (Resident #2) standing by female resident's bed and kissing all over her etc. His pants were down and he was touching her and kissing her. CNT told him to come out of the room and he did not. She then stepped outside the door and summoned a male tech and he then reportedly pulled up his pants when male tech entered and he was instructed to return to his room. He walked to his room and got into his bed. The supervisor asked him why he was in her room and he stated he didn't know. This supervisor told him he was not allowed in the womens rooms. He said I'm in bed now and I'm going to stay in bed. He is on close observation. Physician was notified and order received to send for psych (psychiatric) eval (evaluation) . Interview with CNT #7 on 11/9/15, at 3:20 PM, in the Corporate Conference Room, revealed he was assigned to Resident #2 and went for lunch at 8:35 PM. Continued interview revealed when he returned he checked on all his people then sat at the desk to chart. Further interview revealed his co-worker (CNT #6) went down the hall and peeked into (named room of Resident #1). Continued interview revealed CNT #6 tried to get Resident #2 to leave the room and then came to get help. Further interview revealed Resident #2 was standing on the side of the bed and was pulling up his pants. Continued interview revealed he said she (Resident #1) was just an old lady. Further interview revealed CNT #7 had not encountered this type of situation before and was not really sure what to do but he knew he had to separate the two residents . Interview with the RN Supervisor on 11/10/15, at 3:30 PM, in the Corporate Conference Room, revealed the CNT (#6) said she was going down the hall and heard (named Resident #1) say stop. Continued interview revealed (named Resident #2) was by the bed kissing on her body and feeling with his hands. Further interview revealed CNT #6 said stop and Resident #2 said hush and he refused to leave the room. Continued interview revealed CNT #6 got CNT #7 who helped Resident #2 leave the room and he went next door and went to bed. Continued interview revealed the RN Supervisor called the nurse on call who did not respond so she called the Director of Nursing (DON) who stated Resident #1 had to go out for an examination. Further interview revealed the resident's son was reluctant to send her to the hospital for an examination because she was [AGE] years old and the examination would be too traumatic, but the DON insisted the resident be sent out. Continued interview revealed the RN Supervisor examined Resident #1 and found no abnormalities. Continued interview with the RN Supervisor revealed Resident #1 was sent out to hospital #2 for an alleged rape examination while Resident #2 was sent to hospital #1 for a psychiatric evaluation. Interview with CNT #6 on 11/10/15, at 3:45 PM, in the Corporate Conference Room, revealed she was charting when a light went on in another resident's room. Continued interview revealed as she was walking down the hall toward that room she heard Resident #1 saying help. Stop. Leave me alone. so she entered the room to find Resident #2 standing over her (Resident #1) and was kissing her from her hip to her neck. Further interview revealed the gown of Resident #1 was pulled back and her diaper was loose on both sides, and Resident #2 was kissing her on her bare skin. Continued interview revealed Resident #2 was holding Resident #1's hands because she was hitting him. Further interview revealed Resident #2 had his pants and pull-up pulled down so she was able to see his bare rump. Continued review revealed Resident #2 scared her so she stepped to the door to call CNT #7 to help her. Further review clarified CNT #6 took a couple of steps out into the hall to get CNT #7 who was in the hall and confirmed she left the immediate bedside of Resident #1. As a result the facility failed to ensure the safety of a vulnerable resident after an alleged abuse.",2018-11-01
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
4982,FAYETTEVILLE HEALTH AND REHABILITATION CENTER,445320,4081 THORNTON TAYLOR PARKWAY,FAYETTEVILLE,TN,37334,2016-06-23,281,D,1,0,QLLM11,"**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 its policy on fall assessment and failed to follow accepted standards of practice for 1 (Resident #2) of 7 residents reviewed. This failure had the potential to cause harm to the resident. The findings included: Review of the facility policy entitled Assessing Falls and Their Causes, revised 10/10, revealed: 1. If a resident has just fallen, or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine, and extremities. 2. If there is evidence of a significant injury such as fracture or bleeding, nursing staff will provide appropriate first aid. 3. Once an assessment rules out significant injury, nursing staff will help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Discharge Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 was severely impaired cognitively. Continued review of the MDS revealed Resident #2 required extensive assist of two people with transfers, dressing, and grooming; was dependent on one person for bathing; required extensive assist of one person for eating; and was always incontinent of bowel and bladder. Further review of the MDS revealed Resident #2 exhibited behaviors of screaming at others and wandering. Medical record review of nurses' notes dated 3/20/16 at 1:05 AM, revealed .Resident noted to be on floor on rt (right) side of bed on rt (right) side. Upon assessment wide area of discoloration to anterior of hip. c/o (complaining of) severe leg and hip pain. MD (physician) notified and ordered to send to ER (emergency room ) to eval (evaluate) and tx (treat). Resident left facility at 1:25 AM via ambulance service . Review of the History and Physical from the hospital dated 3/20/16 revealed x-ray of the right hip showed a .right subcapital (under the head of the femur) femoral neck fracture which will be surgically repaired Monday morning . Continued review of hospital documents revealed Resident #2 required a blood transfusion and had the hip surgically repaired before returning to the facility on [DATE]. Interview with the Director of Nursing (DON) on 6/20/16 at 2:40 PM in the Admissions Office revealed the CNAs found Resident #2 on her knees with her torso on the bed in another resident's room (#139). Continued interview revealed the CNAs stood resident up and placed Resident #2 in a wheelchair; took her to her own room; stood her up and attempted to ambulate her when she hollered in pain and was unable to weight bear. Interview with the Administrator on 6/21/16 at 3:15 PM in the Administrator's office, stated Resident #2 fell to her knees and broke her hip. Continued interview revealed the femur head was broken off but there was no definitive root cause analysis. In further interview the Administrator stated the hip could have been cracked and the head snapped with movement to the chair and/or bed. Telephone interview with CNA #1 on 6/21/16 at 9:35 AM, revealed she and another CNA found Resident #2 in another resident's room (#139) kneeling on the floor with the rest of her body on the bed. Continued interview revealed Resident #2 often laid across the ends of beds. Further interview revealed they helped the resident to the wheelchair and put her in bed in her own room then got the nurse to come and look at her. Telephone interview with CNA #2 on 6/21/16 at 9:50 AM, revealed Resident #2 was in another room (#139) kneeling on the floor. Continued interview revealed CNA #1 and CNA #2 got her up and took her to her room then went to get the nurse. Further interview revealed they could see she was in a lot of pain so they lifted her into the chair and then into bed. Telephone interview with LPN #2 on 6/22/16 at 12:40 PM revealed she was called on her cell phone because the CNA wanted her in the room of Resident #2. Continued interview revealed when she arrived the resident was in bed and in obvious pain so she assessed the resident and determined she needed to go to the ER. Further interview revealed the CNA stated Resident #2 must have rolled out of bed. Continued interview revealed a few days later LPN #2 was called by the DON who stated they had watched the video and saw the CNAs push Resident #2 from room [ROOM NUMBER] down the hall across the dining room and into her room in a wheelchair. Further interview revealed the CNAs tried to get Resident #2 to ambulate to her room and did not realize she was hurt. Continued interview revealed when they got to the resident's room they put her to bed. Further interview revealed at the time of the incident Resident #2 was independent with ambulation. Continued interview revealed the last time she cared for Resident #2 the resident was dependent with transfers and wheel chair bound. Review of the Monthly Summary dated 3/1/16 prior to the fall, revealed Resident #2 had unclear speech and was sometimes understood so she was considered to be severely impaired cognitively. Continued review revealed Resident #2 required limited assistance with transfers; required extensive assistance with dressing, eating, toileting, and grooming; was total dependence with bathing; was always incontinent of bowel and bladder. Review of the Monthly Summary dated 5/18/16 after the fall, revealed Resident #2 revealed the resident had clear speech and was understood but had memory problems so was considered to be moderately impaired cognitively. Continued review of the summary revealed Resident #2 was total dependence for transfers, dressing, eating, toileting, bathing, and grooming; used a wheelchair; had a foley catheter in place; and was always incontinent of bowel. Review of the facility investigation dated 3/20/16 revealed Resident #2 was found by Certified Nursing Aides (CNAs) in another room with her knees on the floor and her torso on the bed. Continued review revealed the resident was unable to weight bear and had a large area of bruising on her anterior right hip. Continued review revealed the nurse documented Resident #2 rolled out of bed onto the floor and the CNAs put the resident into bed before the nurse arrived. Further review revealed no one knew how the fracture occurred. Continued review revealed the camera system was checked and showed the CNAs taking Resident #2 in a wheelchair from another room into her own room. Further review revealed the statements of the CNAs did not match the video tapes Interview with the DON on 6/22/16 at 2:30 PM in the Admissions Office confirmed Resident #2 should not have been moved by the CNAs before she was assessed by the nurse per facility policy and recognized standards of resident care. This caused potential harm to Resident #2.",2019-06-01
4096,ELK RIVER HEALTH AND REHABILITATION OF WINCHESTER,445319,32 MEMORIAL DRIVE,WINCHESTER,TN,37398,2016-11-01,224,D,1,0,O8V411,"**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 their policy for controlled substances which allowed for misappropriation of narcotics for 1 resident (#1) of 3 residents reviewed for misappropriation. The findings included: Review of facility policy, Controlled Substances, revised ,[DATE] revealed, .The facility shall comply with all laws, regulations .required to handling, storage .of Schedule II and other controlled substances .Controlled substances must be stored in the medication cart under double lock .except when it is accessed to obtain medications for residents .Nursing staff must count controlled medications at the end of each shift . Review of facility policy, Storage of Medications, revised ,[DATE] revealed, .The facility shall store all drugs .in a safe, secure, manner .Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station .Narcotics requiring refrigeration should be secured to the inside of the refrigerator in a locked box . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident was placed on hospice on [DATE] and expired on [DATE]. Medical record review of a physician's orders [REDACTED]. The bottle contained 30 ml of the medication. Medical record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The amount left to count was 29.5 ml. Review of a facility investigation with an occurrence date of [DATE] at 7:54 PM revealed during change of shift narcotic count of medication cart C, the oncoming Licensed Practical Nurse (LPN) #1 and off going LPN #2 discovered Resident #1's bottle of [MEDICATION NAME] was unable to be located. Telephone interview with LPN #1 on [DATE] at 9:35 AM revealed the LPN stated, I was counting with (LPN #2) and was told (Resident #1's) [MEDICATION NAME] had been moved from the cart to the refrigerator (in the medication room) a few days ago because it had been opened. I went to check the refrigerator and it wasn't there. Continued interview revealed the LPN stated, A few days later I went to the police station and observed a video the facility had given them. It showed me removing the [MEDICATION NAME] from the med (medication) cart on Tuesday ([DATE]) around 8:45 PM or so and going into (Resident #1's) with the bottle of [MEDICATION NAME]. I remembered he was so anxious and his head was at the foot of the bed. When I came out of the room I told my tech we needed to move him back to the head of the bed. I put the [MEDICATION NAME] back in its box when the tech called me into the room to help reposition the resident. I hadn't locked it back in the med cart, so I took the [MEDICATION NAME] in the room with me. I must have laid it down to help move the resident back to the head of the bed because I used 2 hands to do that and forgot to bring it out with me and lock it back up. When asked where she had laid the bottle of [MEDICATION NAME], LPN #1 stated, I really can't recall, but it must have been close to the resident. Either on the foot of the bed, or the bedside table. The LPN confirmed she was the last nurse to administer the [MEDICATION NAME] before it was determined to be missing. Interview with LPN #2 on [DATE] at 11:00 AM, in the conference room revealed LPN #3 had counted med cart C on [DATE] at 7:00 AM with LPN #3 and she told her the [MEDICATION NAME] had been moved to the refrigerator in the med room. LPN #2 stated, I failed to verify it was there. Continued interview revealed on [DATE] at 7:00 PM during the counting of the narcotics on the med cart with LPN #1 it was discovered the bottle of [MEDICATION NAME] was missing. Telephone interview with LPN #3 on [DATE] at 1:15 PM revealed she was told by LPN #4 on [DATE] at 7:00 PM during shift change and count of med cart C the [MEDICATION NAME] for the resident was moved to the refrigerator in the med room. The LPN stated, I did not check the refrigerator to see if it was there. LPN #3 confirmed the last time she saw the bottle of [MEDICATION NAME] was on [DATE]. Telephone interview with LPN #4 on [DATE] at 1:30 PM revealed I was told by (LPN #1) on Wednesday [DATE] at 7:00 AM shift change and count of med cart C that the [MEDICATION NAME] was moved to the refrigerator. The LPN confirmed she did not go check the refrigerator to verify the [MEDICATION NAME] was there and stated, I thought it was moved on Monday or Tuesday because (LPN #5) told us it's supposed to be stored in the refrigerator. I opened it on Sunday (,[DATE]) and gave some to the resident and put it back in the cart. I counted with (LPN #6) around 1 or 2 PM and the count was correct, and the [MEDICATION NAME] was there. Interview with the Director of Nursing (DON) on [DATE] at 3:00 PM in the conference room confirmed the facility failed to follow their policy and perform complete narcotic (controlled substance) counts and reconciliation from [DATE] at 7:00 AM through [DATE] at 7:00 AM., resulting in misappropriation of 29.5 mls of [MEDICATION NAME] for Resident #1.",2019-11-01
1385,"SUMMIT VIEW OF FARRAGUT, LLC",445258,12823 KINGSTON PIKE,KNOXVILLE,TN,37923,2018-05-03,609,D,1,1,2DL711,"**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 immediately report an allegation of abuse for 1 resident (#63) of 22 residents reviewed. The findings included: Review of the facility policy, Abuse Prevention Program, revised (MONTH) (YEAR) revealed .report any allegations of abuse within timeframes as required by federal requirements . Medical record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a score of 14 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an annual MDS assessment dated [DATE] revealed the resident had a score of 10 on the BIMS, indicating the resident had moderate cognitive impairment. Review of a Resident Abuse Investigation report dated 5/1/18 revealed .Name of Resident: (#63) .Location of Incident: Resident Room .Date Incident Occurred: Approximately 2 wks (weeks) prior to 4/26/18 .Name(s) of Individual(s) Reporting Incident: (Resident #63) .Type of Abuse .Sexual .Name of person(s) accused: (Resident #4) .Corrective action taken .Education to resident on appropriate behavior . Interview with Resident #63 on 5/1/18 at 2:37 PM, in the outside courtyard, revealed about 2 weeks ago Resident #4 had hugged her when she was sitting in her room. Further interview revealed he had touched her breast while hugging her and it made her feel uncomfortable. Continued interview revealed she reported the incident to LPN #1 one day last week. Interview with LPN #1, on 5/1/18 at 3:00 PM, at the unit 2 nurse's station, revealed Resident #63 had reported to her on 4/26/18, Resident #4 had went into her room and rubbed on her TaTa's. Further interview revealed she had informed the Director of Nursing (DON) immediately about the incident. Review of a report to the State Agency revealed .Date of Occurrence: 4/26/18 .Date of Report: 5/1/18 .Reported By: (Administrator) .Summary: Resident stated that another resident had been coming to her room over the past 2 weeks and hugging her and grabbing her breasts . Interview with the Administrator and DON on 5/1/18 at 2:34 PM, in the conference room, confirmed the facility had failed to report the allegation of abuse timely.",2020-09-01
4980,FAYETTEVILLE HEALTH AND REHABILITATION CENTER,445320,4081 THORNTON TAYLOR PARKWAY,FAYETTEVILLE,TN,37334,2016-06-23,225,D,1,0,QLLM11,"**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 investigate the cause of fractures of unknown origin for 1 (Resident #1) and failed to investigate bruises of unknown origin for 1 (Resident #3) of 7 residents reviewed for abuse/neglect. The findings included: Review of a facility policy titled Abuse Prevention/Reporting Policy and Procedure undated revealed, .Signs of Potential Abuse .Bruising not consistent with specific resident .Unexplained fracture .Staff will be provided information regarding the process for reporting .suspected abuse to their immediate Supervisor, Abuse Coordinator, local authorities and State Department of Health .Facility management is required to accept all allegations of abuse and conduct a complete and thorough investigation including reporting to the proper authorities .All reports whether from family, residents or staff will be reported immediately to the Administrator and Abuse Coordinator and or/D.O.N. (Director of Nursing) .The Administrator and the D.O.N. will conduct a comprehensive investigation of any and ALL allegations of abuse .in accordance with state law, federal regulation and The Patient Protection and Affordable Care Act (Elder Justice Act) . Review of the facility policy entitled Falls - Clinical Protocol, revealed .8. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. 12. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined the cause cannot be found or that finding a cause would not change the outcome or management of falling and fall risk. 16. The staff with the physician's guidance, will followup on any fall with associated injury until the resident is stable and delayed complications such as late fractures or subdural hematoma have been ruled out or resolved . Review of the facility policy entitled Assessing Falls and Their Causes revealed .5. Nursing staff will observe for delayed complications of a fall approximately 48 hours after an observed or suspected fall, and will document findings in the medical records . Medical record review revealed Resident #1 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 #1 was severely impaired cognitively. Continued review of the MDS revealed Resident #1 required extensive assistance with transfers, dressing, eating, and grooming; was dependent for bathing; was always incontinent of bowel and bladder; and ambulated with supervision. Review of Incident Reports for (YEAR) revealed Resident #1 sustained falls on: 3/28/16 at 1:56 AM in the dining room where he had a skin tear. 4/11/16 at 7:30 PM in the dining room 4/15/16 at 6:21 PM in his room, sustaining a skin tear 5/2/16 at 10:35 AM in his room 5/3/16 at 4:35 PM in his room 5/12/16 at 3:00 PM in the dining room and sustaining a hematoma 5/28/16 at 3:45 PM in the hallway 6/2/16 at 3:00 PM in the dining room 6/3/16 at 3:00 PM in his room 6/13/16 at 7:15 AM in his room 6/15/16 at 7:51 AM in his room. Review of the investigation of the fall which occurred on 6/2/16 revealed the resident was in the dining room; noted something on the floor; reached to pick it up; and fell from the chair. Continued review revealed the resident did not sustain any injury. Further review of the investigation revealed the cause of the accident was clutter on the floor so those items were removed from the area. Medical record review of a Fall Risk Evaluation dated 5/22/16 revealed Resident #1 scored 21 indicating he was at risk for falls. Continued review of evaluations dated 6/2/16 and 6/3/16 revealed Resident #1 again received a score of 21. Review of the investigation of the fall which occurred on 6/3/16 revealed Resident #1 was found lying face down in another room beside Bed B and had sustained a laceration to the left side of the head measuring 2.2 centimeters. Continued review revealed the cause of the incident was .Resident becomes tired after being up for extended period of time, refused to rest . Further review of the incident revealed immediate intervention included placing Resident #1 in a wheelchair with alarm to provide supervised rest periods. Medical record review of nursing notes dated 6/5/16 revealed the nurse was called to the room by the Certified Nursing Aide (CNA) to look at the resident's hand. Continued review revealed the resident's left hand was blue and swollen from the wrist to the middle of the fingers. Further review revealed Resident #1 was transferred to the hospital for x-rays of the hand. Review of the Emergency Department (ED) record dated 6/5/16 revealed the resident .sustained another fall and he was found to have metacarpal (hand) fractures of the fingers 3, 4, and 5 on the left hand. Continued review revealed the resident had a soft splint on the left forearm and hand with an ace type wrap. Further review of the ED record revealed an x-ray of the resident's left hand which showed third through fifth obliquely (fracture at an angle) oriented metacarpal fractures. Continued review of the ED record revealed the physician's statement .Consult SS (Social Services) to eval (evaluate) incident report on injury to (L) (left) hand multiple suspicious fractures . Medical record review of the care plan revealed no mention of the [MEDICAL CONDITION]; the splint on his hand; observations to be made of the fingers; and care of the splint and the resident's hand. Continued review revealed the CNA care card did not address the fractured fingers, the splint, and observations to be made of the fingers. Review of Incident Reports revealed no report for the [MEDICAL CONDITION]'s left hand. Review of the SBAR (Situation, Background, Appearance, and Review) which serves as physician notification, revealed one SBAR for each fall the resident sustained [REDACTED]. Observation of Resident #1 on 6/22/16 at 9:40 AM revealed him lying on his back, asleep, mouth breathing with oxygen cannula in place. Continued observation revealed the resident's face was very red and he had a large (5 inches by 2 inches) dark brown bruise to the back of the hand and wrist of the right hand. Further observation revealed a splint to the left hand which was wrapped with an ace bandage. Continued observation revealed the fingers of the left hand were dark blue on the back and the fingers of both hands were bent at a 90 degree angle at the knuckles. Interview with the Director of Nursing (DON) on 6/21/16 at 10:45 AM in the Admissions Office revealed Resident #1 had frequent falls. Continued interview confirmed a separate investigation into the finger fractures was not done because the facility felt they knew the cause of the finger fractures - his fall the previous night. Interview with the DON and Administrator on 6/21/16 at 3:15 PM in the Administrator's office revealed Resident #1 fell on Thursday and Friday, 6/2/16 and 6/3/16. Continued interview revealed the fingers were noted to be blue on 6/5/16 and the assumption was made the fractures occurred with the fall on 6/3/16. Continued interview revealed the facility assumed the finger fractures were related to the fall on 6/3/16 with the position of the resident when found but the exact cause of the fractures was still unknown. Continued interview revealed the Administrator confirmed the fractures of the fingers of unknown origin were not investigated. Telephone interview with (Licensed Practical Nurse) LPN #1 on 6/22/16 at 10:20 AM revealed on 6/3/16 the lady in room [ROOM NUMBER] came to the nurses' station and said a man fell in her room. Continued interview revealed she went to the room and found Resident #1 lying on his left side with his left hand stretched toward the bathroom. Further interview revealed LPN #1 assessed the resident and he had full range of movement as well as the ability to squeeze her hands equally. Further interview revealed LPN #1 did not notice any issues with the resident's left hand and said he grasped using his thumb and forefinger due to the other 3 fingers being permanently bent. Continued interview revealed LPN #1 was asked by the nurse on 6/5/16 to look at the left hand of Resident #1 which she noted to be blue from the wrist to the knuckles. Further interview revealed the resident was sent out for an x-ray of the hand where the fractures were discovered. Continued interview revealed there was nothing in change of shift report on 6/4/16 about the resident's hand being bruised and swollen. Telephone interview with CNA #3 on 6/22/16 at 11:15 AM revealed Resident #1 fell on a Friday and she was the only CNA on the hall with a nurse. Continued interview revealed another resident told her and the nurse someone fell in her room. Further interview revealed the resident was lying between the bed and air conditioner and thinks he was face down with his left side by the air conditioner and his right side by the bed. Continued interview revealed she could see his head from the door. Further interview revealed she checked his head and found the laceration above his ear. Continued interview revealed the nurse assessed the resident and no other injuries were found. Continued interview revealed Resident #1 was independent with ambulation and did not use a wheelchair at the time of the incident. Interview with the DON on 6/22/16 at 2:55 PM in the Admissions Office confirmed the facility failed to investigate the cause of the finger fractures but assumed they occurred with the fall on 6/3/16. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of a 60 day MDS dated [DATE] revealed the resident had short and long term memory loss and was severely cognitively impaired. She had behaviors of pacing, wandering, and delusions. She was independently ambulatory with supervision. Medical record review of Nurse's Notes dated 3/18/16 at 7:00 PM documented, Area above (left) eyebrow noted to be bluish-(Resident) denied any trauma-earlier in the day (Resident) was seen laying head down on tables, etc. in dining room. Medical record review of a Customer First Concern/Grievance Report for Resident #3 dated 3/21/16 revealed, .Resident has black eye . The resolution was resolved on 3/21/16 and signed by the DON and the Administrator. Interview with the Social Worker (SW) on 6/21/16 at 4:00 PM in the SW's office confirmed she received a phone call from the resident's daughter on 3/21/16 regarding a black eye observed on 3/20/16 while visiting the resident. The SW stated LPN #3 had spoken with both daughters by phone and explained the resident was laying herself on the floor, and laid her head on tables, and was most likely the cause of the bruising. Interview with the Administrator and DON on 6/21/16 at 4:15 PM in the Administrator's office confirmed they were aware of Resident #3's black eye on 3/21/16 when the daughter called and spoke with the SW. The Administrator stated they had watched video's of the resident laying her head on tables and counters and that was most likely the cause of the bruise. The DON confirmed the facility failed to conduct an investigation for a bruise of unknown origin to the resident. The Administrator confirmed the facility failed to report a black eye for Resident #3 in accordance with state law, federal regulations and the Elder Justice Act.",2019-06-01
4004,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2016-11-16,223,D,1,1,BPS311,"**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 property for one resident (#126) of 5 residents reviewed for abuse. The findings included: Review of the facility policy, Abuse, Neglect, Exploitation, revealed .According to federal regulations, the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The resident has the right to be free from mistreatment, neglect, and misappropriation of property .When suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur, an investigation is immediately warranted. Resident #126 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the facility investigation revealed on 10/24/16 the resident's daughter called to say mother's wedding band was missing and the husband saw it on 10/19/16. Continued review of the investigation revealed the Director of Nursing (DON) spoke with the Charge Nurse who saw the ring 10/19/16 and 10/22/16. Continued review revealed another nurse was not sure when she last saw the ring but it was very tight on the finger and the finger was too swollen to remove ring easily. Further review revealed the evening Charge Nurse saw the ring on 10/20/16 but only saw the resident at night and her hands were covered. Continued review of the investigation revealed the Unit Manager assessed the resident with no signs of acute injury and X-RAY confirmed no trauma. Further review revealed all departments were searched. Continued review revealed the Unit Manager stated Resident #126 fidgets about in bed and whales about so ring could have worked its way off the finger or could have been struck against the side rail and broken. Further review of the investigation of an undated statement by Charge Nurse #1 revealed the resident's husband informed her that the resident did not have her wedding ring on but no Certified Nursing Aides (CNAs) remembered seeing the ring so it was reported to the next nurse. Continued review of the investigation of a statement dated 11/1/16 from the agency CNA who cared for the resident on the day the ring was noted to be missing, stated she never noticed the ring but the resident fought her the entire time the CNA changed her. Continued statement revealed a staff person showed her the ring finger which was swollen and it looked like it would have been hard for the ring to come off. Continued review of the investigation of a summary dated 11/11/16 written by the Administrator revealed: =spoke with daughter =do not believe foul play occurred =ring appeared tight due to shape of fingers & excessive tissue =resident very jittery & moves limbs =possibly caused ring to fall off or break =resident's finger tissue is moveable Medical record review of an x-ray of the resident's ring finger dated 11/7/16 revealed mild soft tissue swelling with distal joints narrowed & sclerotic. Interview with Administrator and Unit Manager on 11/16/16 @ 10:15 AM in the conference room revealed: -family notified the Charge Nurse the ring was missing -staff started looking and Charge Nurse reported to DON -Charge Nurse asked CNAs if they saw ring -staff checked laundry, housekeeping, dietary -Charge Nurse assessed the resident's finger -fatty tissue on fingers -appeared ring was tight & could not come off -tissue moves -staff had seen ring -family said from appearance of finger they didn't want to take ring off -Administrator called jeweler to ask about stability of a ring in place over [AGE] years -resident moves about in bed and is constantly shifting -ring could have moved down finger and come off over smaller joint -ring could have been hit on rail and broken due to being worn -finger showed no injuries -daughter agreed it could have been broken or come off -daughter said if it was found that was good but if it was not found it was OK because she knew her mother moved around -police were notified in case anything was missed -police came out; said they were not going to consider it stolen; and would go ahead based on facility finding The Administrator confirmed the resident's ring was missing and had not been found.",2019-11-01
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
563,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-07-18,600,D,1,0,9S4C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to prevent physical abuse of 1 (Resident #2) of 4 residents reviewed for abuse/neglect. Findings include: Review of facility policy Abuse, Neglect, and Exploitation of Residents, revealed .The facility will not condone resident abuse by anyone including staff members, other residents, consultants, volunteers, staff of other agencies serving the resident, resident representative, family members, legal guardians, sponsors, friends or other individuals .All personnel are required to promptly report any incident or suspected incident of resident abuse .Upon receiving reports of physical or sexual abuse the nursing supervisor will immediately examine the resident .An immediate investigation will commence and a stated and signed statement from the person reporting the incident will be obtained .It is the responsibility of all staff to identify inappropriate behavior towards residents, which may include but is not limited to use of derogatory language; rough handling of residents; ignoring residents while giving care; directing residents who need toileting assistance to urinate/defecate in their clothing, etc .Physical abuse is the inappropriate physical contact with a resident which harms or is likely to harm a resident. This includes but is not limited to hitting, slapping, pinching, spitting at, kicking, etc .The facility will provide abuse prohibition training to all new employees and volunteers. All staff will receive this training on an annual basis . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 scored 0 on the Brief Interview for Mental Status indicating he was unable to answer the questions. Continued review of the MDS revealed Resident #2 required extensive assistance of 2 people for transfers, dressing, toileting, and grooming; was dependent on 2 people for bathing; and was always incontinent of bowel and bladder. Review of facility investigation of a written statement by Certified Nurse Aide (CNA) #1 revealed she was .in the middle of a round walking up to the front when she heard yelling. She heard a nurse yell at a resident as she looked down the hall and heard her say let go of my necklace you stupid [***] . She had him by the hands and had bite him was continuing yelling had his hands up to his neck and this point I had went back to my hall. I came back up to the front to her walking out the doors and was gone for about 30 minutes. Continued review revealed a clarification note by the Administrator in which CNA #1 was asked if she saw Licensed Practical Nurse (LPN) #1 actually bite down with teeth showing or did she see nurse's mouth on resident's hand. Further review revealed CNA #1 did not see the nurse actually bite but rather her lips on the resident's hand. Further review revealed the Administrator asked CNA #1 if she saw the resident had a grip on the nurse and CNA #1 said it appeared the resident had a hold of something with the nurse. Continued review revealed the Administrator asked CNA #1 if the nurse had the resident by the hands or the resident had the nurse by the hands and she said it looked like the nurse had the resident but couldn't see that clearly to say 100%. Review of facility investigation of an interview dated 6/4/18 between the Administrator, Acting Assistant Director of Nursing, and LPN #1 revealed LPN #1 stated a resident had his hands around her neck. Continued review revealed the Administrator asked if the LPN did anything inappropriate to the resident and LPN #1 stated I yelled at him to let me go. Further interview revealed the Administrator asked LPN #1 if she touched the resident in any way and she stated she had bitten the resident because I panicked and didn't know what to do because he was choking me. Continued interview revealed the Administrator clarified with LPN #1 if she bit down or put her mouth on resident hand and she said she put her mouth on his hand and her teeth did make contact with resident's hand. Further interview revealed the Administrator asked how the resident got his hands around her neck and LPN #1 stated I was behind him locking his wheelchair and he reached behind him and grabbed my throat. I didn't know how to get free. We were in the hallway and nobody was coming to help. Continued interview revealed the Administrator watched the video there were several staff members in the hallway and the description of the event did not make sense with the nurse being able to bite the resident while his hands were around her neck. Further interview revealed LPN #1 was suspended immediately. Review of facility investigation of a written statement by LPN #1 revealed I went up to the resident to help move him. I reach around the back of his wheelchair to unlock his wheels to move him when he reached backward and grabbed me by the neck. I panicked at that time and tried to release his hands from me but was unable causing me to panic further. I was at him to let go but he would not. Nobody was coming to help so I bite his hand to try and see if he would let go. He loosed his grip at that time and I was able to slip away. He had the necklace I had on in his hands so I grab the necklace and got it away from him. Interview with the Administrator and DON on 7/18/18 at 10:40 AM in the conference room revealed revealed there were no teeth marks, abrasions, or skin issues with the resident. Further interview revealed LPN #1 stated her teeth made contact with his hand because she had panicked. Continued interview revealed the Administrator terminated LPN #1 to err on the side of the resident even though she could not prove the nurse bit the resident because there were no teeth marks, but the nurse had yelled at the resident and called him a [***] which the Administrator confirmed constituted verbal abuse.",2020-09-01
760,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2018-03-07,602,D,1,0,V5FH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to protect a resident's right to be free from misappropriation of property for 1 resident (#3) of 10 residents reviewed. The findings included: Review of facility policy, Drug Diversion, POL 602.23, revised 11/28/17, revealed .Oncoming and off-going nurses complete a shift to shift count on medication cards or containers containing controlled substance medication; controlled substance medication sheets; controlled substance medications in Emergency Kits when the kit had been opened .Nurses report any discrepancies in controlled substance medication counts to the Director of Nursing Service immediately .Facility management should investigate and make every reasonable effort to reconcile reported discrepancies .Investigation includes but may not be limited to interviews, medical record review, observation of facility practices related to handling of controlled substances, evaluation if loss is associated or attributed to specific individual(s), time period, unique situation or random, and identify any potential negative impact on resident's condition or safety .If potential criminal activity is suspected notify the Administrator, pharmacy manager, and consultant pharmacist at once .Educate staff on current procedures and implement interventions if needed .Document corrective action taken .Analyze findings from any discrepancy events or substantiated thefts or diversions as part of Performance Improvement . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician's admission orders [REDACTED]. Continued review revealed Resident #3 brought a bottle of [MEDICATION NAME] from home. Facility investigation review revealed on 1/30/18 it was discovered 5 pills were missing from the bottle the resident brought in from home. Continued review revealed an investigation was conducted including staff interviews as well as police involvement. Further review revealed one nurse confessed she had taken the pills. Continued review revealed the nurse was terminated and the resident was reimbursed for the missing pills. Review of facility investigation revealed an interview with Registered Nurse (RN) #1 on 1/30/18 who stated she was speaking with the off-going Supervisor about the new admission (Resident #3). Continued review revealed RN #1 stated Resident #3 came in with 20 [MEDICATION NAME] pills but the Supervisor stated the resident had come in with 25 pills because she had counted them. Further review revealed both nurses went to the Narcotic box; counted the pills in the bottle; and arrived at a count of 20 pills. Continued review revealed RN #1 reviewed the narcotic sheet and it was labeled with 20 pills so she called the Administrator. Review of facility investigation revealed an interview with Licensed Practical Nurse (LPN) #2 on 1/30/18 revealed she was asked if she was the one who inventoried the pills of Resident #3 he brought from home and she said she was. Continued investigation revealed LPN #2 stated she counted 20 pills and stated LPN #1 had counted with her. Further investigation revealed LPN #2 was told the pills were counted previously and there were 25 pills but LPN #2 did not know how that was possible. Review of facility investigation revealed an interview with RN #2 who stated she counted 25 pills of [MEDICATION NAME] 10/325 mg which belonged to Resident #3. Review of facility investigation revealed an interview with LPN #1 on 2/1/18, who stated LPN #2 walked over to her chair at the nurses' station and said they had to count narcotics for the new admission. Continued review revealed LPN #1 was in the process of putting the new admission medications into the computer so pharmacy would deliver them. Further interview revealed LPN #1 saw LPN #2 with the bottle of pills but never actually saw her pour them out or physically see her count them but heard her count to 20 twice. Continued interview revealed LPN #1 never touched the pills nor did she physically see the pills. Further review revealed at this point both nurses were suspended pending the outcome of the investigation. Review of facility investigation revealed on 2/1/18 the police called the Administrator to say LPN #2 was requesting to speak with her at the police station. Continued interview revealed LPN #2 said she had done it and when asked what she had done she responded I took those pills and I'm sorry. What happens from here? Further review revealed the Administrator told LPN #2 was terminated and she would be reported to the Board of Nursing. Continued interview revealed LPN #2 was asked if she had taken any other pills and she responded This was the only time I've ever done that; I don't know what I was thinking. Review of facility investigation revealed Resident #3's personal physician as well as the Medical Director were informed of the diversion. Continued review revealed Resident #3 was informed of the situation and the facility reimbursed him for the medication. Facility investigation revealed all nurses were re-educated on narcotic counts with both nurses observing the medications and the count sheets when doing change of shift counts as well as both nurses observing and counting together when a resident brings medications from home. Interview with the DON and Administrator on 3/7/18 at 1:15 PM in the conference room revealed neither was in the facility when the diversion occurred. Review of the employee records of LPN #1 and LPN #2 revealed no previous disciplinary action for either of them.",2020-09-01
3274,"THE WATERS OF SMYRNA, LLC",445502,202 ENON SPRINGS ROAD EAST,SMYRNA,TN,37167,2018-01-16,609,E,1,0,POU411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to report all allegations of abuse to the State Survey Agency (SS[NAME]) In addition, the facility failed to ensure that the results of all investigations were reported to the SSA within 5 working days of the incident. This failure affected 3 residents ( #13,#15,#31) of 16 residents who were reviewed for abuse. The findings included: Review of facility policy, Abuse Prevention Program, updated 1/19/17, revealed .All alleged violations .MUST be reported to the Administrator and Director of Nursing, The Administrator is the Abuse Coordinator of the facility .When an alleged or suspected case of abuse or neglect is reported to the Administrator, the Administrator or person in charge of the facility will notify the following persons or agencies of such incident immediately: State Licensing and Certification Agency - TDH (Tennessee Department of Health.) .Abuse involving one resident upon another resident will be reported to TDH .The investigator will submit a final report of the conclusion of the investigation in writing within 5 working days of the incident .The Administrator is then responsible for forwarding a final report of the results of the investigation any corrective action taken to the Tennessee Department of Health (TDH) within the any of required timeframe allowed by the Tennessee Department of Health of the reported incident . Medical record review revealed Resident #13 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #13 scored 2 on the Brief Interview for Mental Status, indicating he was severely cognitively impaired Medical record review of Resident #13's Progress Notes revealed documentation of multiple allegations of resident-to-resident abuse, including on 6/6/17, when staff notified a nurse Resident #13 hit another resident in the head. Interview on 1/9/18 at 9:28 AM with the DON in the conference room confirmed the 6/6/17 allegation of physical abuse by Resident #13 had never been reported to the SS[NAME] She stated this allegation should have been reported, and she did not know why the previous Administrator, who was the Abuse Coordinator, had not reported it. Review of the facility investigation revealed a Witness Explanation of Incident dated 8/15/17 revealed a witness statement .a male resident alerted me there was an emergency in the dining room, that he is playing with her (female genitalia). I went to the dining room and (Resident #13) had his right hand up the pants of a female resident (Resident #14). She was motioning him to keep coming and was patting her private area. This nurse removed (Resident #13) from the area . Interview with the DON on 1/9/18 at 9:28 AM in the conference room confirmed the 8/15/17 incident was not reported to the state. Continued interview revealed although a male resident had alleged he observed sexual contact by Resident #13, the DON stated his allegation was not reported to the state, explaining although Resident #13 had put his hand up Resident #14's pants, there was no sexual contact - he was touching her leg. Review of a facility investigation record revealed on 11/5/17, Resident #13 was fondling a female resident's breast while she was sleeping in her wheelchair. Review of facility investigation records revealed this incident was reported to the SSA timely, However, the findings and conclusion of the investigation were not reported to the SSA within 5 days. Interview with the DON on 1/9/18 at 9:28 AM in the conference room confirmed the follow-up report for this allegation, due 11/10/17, was not submitted to the SSA in a timely manner. Continued interview revealed she related she could provide no evidence the findings of the investigation were reported to the SSA until 11/27/17. Further interview revealed she stated the findings should have been submitted within 5 working days and she did not know why the previous Administrator, who was responsible for reporting, did not finish the investigation or report the findings timely. Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE] revealed Resident #15 scored 1 on the BIMS, indicating he was severely cognitively impaired. Medical record review of Resident #15's Progress Notes included the following information: Medical record review of Progress Notes dated 8/5/17 revealed there were multiple aggressive behaviors noted today. Witnessed going into another patient's room and hit her . Medical record review of Progress Notes revealed a late entry on 9/3/17 for 9/2/17 which stated, .Reported to this nurse that resident hit at a family member and a resident . Medical record review of Progress Notes dated 9/3/17, revealed the .Resident hit resident in (room number) twice this AM . Medical record review of Progress Notes dated 9/24/17 revealed multiple entries including: 9/24/17 Resident has hit another resident, chased a family member, attempting to hit her, and hit two staff members, and groped breasts of another incapacitated resident. 9/24 .He was witnessed by another resident groping the breasts of an incapacitated resident who is unable to speak or remove herself from the situation .C Wing Nurse reported to this nurse that he kicked another resident. 9/24/17 11:30 AM .Resident was exhibiting repeated intrusive behaviors, wandering in and other of other resident's rooms .attempting to touch other residents . Interview with the Director of Nursing (DON) on 1/8/18 at 10:30 AM, the Director of Nursing (DON) was asked to provide all allegations of Resident #15 repeated abuse reported to the SSA from 8/5/17 - 9/24/17. Interview with the DON on 1/9/18 at 2:54 PM in her office revealed the Administrator was the facility Abuse Coordinator but because he was an interim administrator, she was the person to discuss questions with about specific instances of abuse. Continued interview revealed she stated the only allegation of abuse reported to the SSA for Resident #15 was on 12/18/17 when he hit Resident #16 in the face. Further interview confirmed none of the other allegations of resident-to-resident abuse documented to have occurred on 8/5/17, 9/2/17, 9/3/17, and 9/24/17 were ever reported to the SS[NAME] Continued interview revealed the DON stated, I don't know when asked whether these instances of resident-to-resident abuse should have been reported to the SSA, as well as Adult Protective Services and any other required state agencies. Further interview revealed she stated that I'll have to find the 'soft file' with the incident report to review each of the incidents and determine whether they should have been reported. Continued interview revealed the DON then stated that, as Abuse Coordinator, it was the previous Administrator's decision to not report these incidents to the SSA and she did not know why he had chosen to not report repeated instances of resident-to-resident abuse. Additional interview with the DON on 1/10/18 at 9:45 AM at the C-Wing Door confirmed she could not find the soft files she had referenced on 1/9/18 and had no additional information to show that each of the alleged incidents of resident-to-resident abuse had been reported. Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE] revealed Resident #31 had periodic confusion related to Dementia. Continued review revealed the resident had no behaviors during the assessment period. Medical record review of Progress Notes dated 6/3/17 revealed Resident #31 was involved in an incident of .physical aggression towards another resident . No specifics of this incident, which resulted in Resident #31 being hospitalized for [REDACTED]. Medical record review of Progress Notes dated 9/16/17 revealed Resident #31 was observed in the dining room with .her hand held back at another resident and the second resident stated Resident #31 hit her. When this nurse asked the resident if she hit her she held her hand up and said in the nose, in the nose, just once, just once. Will send resident to ER (emergency room ) for psych (psychiatric) evaluation . Medical record review of Progress Notes dated 9/21/17 revealed Resident #31 was .reported to have slapped male patient . Medical record review of Progress Notes revealed on 12/22/17 a nurse was notified Resident #31 'slapped' another resident in the face. Review of facility investigation files revealed this allegation of resident-to-resident abuse was reported timely to the SSA on 12/22/17. However, further review of the investigation file revealed no evidence the investigation was ever completed or the findings reported to the SSA within 5 working days of the incident. Review of facility records revealed no evidence these allegations of resident-to-resident abuse had been reported to the SS[NAME] Interview with the DON on 1/11/18 at 9:30 AM in the conference room confirmed these allegations of resident-to-resident abuse had not been reported to the SS[NAME] Continued interview revealed the DON then stated that, as Abuse Coordinator, it was the previous Administrator's decision to not report these incidents to the SSA and she did not know why he had chosen to not report repeated instances of resident-to-resident abuse.",2020-09-01
3369,NASHVILLE CENTER FOR REHABILITATION AND HEALING LL,445512,832 WEDGEWOOD AVENUE,NASHVILLE,TN,37203,2018-04-11,609,D,1,1,KI5Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to report allegations of abuse within the 2-hour time frame as required to the State Agency for 2 residents of 7 sampled residents (Resident #82 and Resident #83) reviewed for abuse. Findings include: Review of facility policy Abuse Reporting revised 11/23/17 revealed, .All alleged suspected violations .are required to be promptly reported to appropriate state agencies .as required by law .The facility must report abuse .immediately but not later than 2 hours . Medical record review revealed Resident #82 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a facility investigation involving Resident #82 with an occurrence date of 2/8/18 at 5:40 PM revealed an allegation of abuse. Continued review revealed the facility reported the allegation of abuse on 2/9/18 at 3:23 PM (8 hours past 2-hour timeframe). Medical record review revealed Resident #83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility investigation involving Resident #83 with an occurrence date of 2/25/18 at 11:00 AM revealed an allegation of abuse. Continued review revealed the facility reported the allegation of abuse on 2/25/18 at 4:41 PM (14 hours and 41 minutes past 2-hour timeframe). Interview with the Administrator on 4/11/18 at 4:00 PM in the Administrator's office confirmed the facility failed to report the allegations of abuse for Resident #82 and Resident #83 to the State Agency within the 2-hour time frame.",2020-09-01
605,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,225,E,1,0,DC3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to report an allegation of abuse for 1 resident (#1), failed to report 2 allegations of abuse timely for 2 residents (#3, #4), and failed to thoroughly investigate allegations of abuse for 3 residents (#1, #3, #4) of 5 residents reviewed for abuse. The findings included: Review of facility policy, Abuse Prevention and Intervention Strategies, dated 11/16 revealed .It is the policy of this facility to protect its residents from abuse .has implemented a program of abuse prevention and intervention strategies .Investigation: The facility will investigate all injuries of unknown origin and all allegations of mistreatment, neglect or abuse. All investigations will be conducted in a timely, thorough and objective manner .Any incidents of substantiated abuse and neglect are reported and analyzed and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State or Federal law . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility investigation dated 3/24/17 revealed the Director of Nursing (DON) had interviewed Resident #1 regarding statements of .(Licensed Practical Nurse (LPN) #3) .repositioning in bed .slammed her head . Further review of the facility investigation revealed 2 written statements, one was dated 3/31/17 signed by LPN #3 and the second was dated 4/5/17 signed by LPN #5. Interview with LPN #3 on 5/8/17 at 11:10 AM in the Social Worker's office revealed the LPN was aware of the allegations and wrote a statement of not transferring or repositioning Resident #1 on 3/24/17. Interview with the DON on 5/8/17 at 4:30 PM in the conference room revealed LPN #5 had informed the DON of the incident on 3/24/17. Interview with LPN #5 on 5/9/17 at 4:25 PM at the 1 East nursing station revealed he had been in Resident #1's room providing care and the resident repeatedly stated LPN #3 had .slammed me in the bed . and .grabbed me for no reason . Further interview revealed LPN #5 informed the DON the day of the incident. Further interview revealed LPN #5 checked the resident for any marks and found none. Further interview confirmed LPN #5 failed to document the resident's physical condition and the alleged incident on 3/24/17. Interview with the Administrator and the DON on 5/10/17 at 4:00 PM in the conference room confirmed the incident of alleged abuse occurred on 3/24/17. Further interview confirmed the facility failed to report the allegation of abuse to the State Agency. When the Administrator and DON were asked if other staff and residents were interviewed, were non-interviewable residents checked for safety, did the facility get statements on the day of the event, was Resident #1 physically and mentally checked out, did the facility complete a thorough investigation of the allegation, the Administrator stated .We steered in the wrong direction . Further interview confirmed the facility failed to complete a thorough investigation of the abuse allegation. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 had a Brief Interview of Mental Status (BIMS) of 10 indicating the resident was moderately cognitively impaired. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed the BIMS could not be conducted because the resident was rarely/never understood. Further review revealed the resident had trouble concentrating nearly every day and had no behavioral symptoms. Further review revealed the the resident had short and long term memory problems and the cognitive skills for daily decision making were severely impaired. Review of the facility investigation included an Occurence Report signed by the DON on 4/11/17 and revealed Resident #3 was slapped by Resident #5 on 4/8/17. Continued review revealed the investigation included a statement from Licensed Practical Nurse (LPN) #1 recounting the event, and skin assessments for Residents #3 and #5 on 4/11/17. Interview with the Administrator and the DON on 5/10/17 at 4:15 PM in the conference room confirmed the facility failed to report the allegation of abuse from 4/8/17 to the State Agency for Resident #3 until 4/14/17 and therefore was not reported in the required time frame. Continued interview with the Administrator and DON revealed the facility failed to conduct additional interviews with staff and interviewable residents, and failed to check non-interviewable residents for safety on the day of the incident. Further interview with the Administrator confirmed the facility failed to thoroughly investigate the allegation for Resident #3. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #4 had a BIMS of 7 indicating the resident was severely cognitively impaired. Review of the facility investigation included an Occurrence Report for Resident #4 and Resident #5. Further review revealed Resident #4 was hit by Resident #5 on 4/14/17. Continued review revealed the investigation included a statement recounting the incident, a skin assessment on Resident #4 dated 4/14/17, and the record of ongoing 15 minute checks of Resident #5 dated 4/11/17 to 4/14/17. Interview with the Administrator and DON on 5/10/17 at 4:20 PM in the conference room confirmed the facility failed to report the allegation of abuse from 4/14/17 to the State Agency until 4/21/17 and therefore was not reported in the required time frame. Continued interview with the Administrator and DON revealed the facility failed to conduct additional interviews with staff and interviewable residents and failed to check non-interviewable residents for safety on the day of the incident. Further interview with the Administrator confirmed the facility failed to thoroughly investigate the allegation of abuse for Resident #4.",2020-09-01
606,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,226,D,1,0,DC3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to report an allegation of abuse timely to the supervisor/administrator/abuse coordinator for 1 resident (#3) of 5 residents reviewed for abuse. The findings included: Review of facility policy, Abuse Prevention and Intervention Strategies, dated 11/16 revealed .It is the policy of this facility to protect its residents from abuse .has implemented a program of abuse prevention and intervention strategies .All investigations will be conducted in a timely, thorough and objective manner . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 had a Brief Interview of Mental Status (BIMS) of 10 indicating the resident was moderately cognitively impaired. Medical record review of the Initial Wound & Skin Record for Resident #3 dated 4/11/17 revealed .No bruises, marks or injuries noted on skin . Medical record review of a nurse's note dated 4/13/17 at 6:42 PM and written by the Director Of Nursing (DON) revealed .Late entry for 4/11/17. Resident was sitting in her room on 4/8/17 when another resident entered her room. Resident attempted to get him out of room and when she approached the resident, he slapped her in her face . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed the BIMS could not be conducted because the resident was rarely/never understood. Further review revealed the resident had trouble concentrating nearly every day and had no behavioral symptoms. Further review revealed the resident had short and long term memory problems and the cognitive skills for daily decision making were severely impaired. Review of the facility investigation revealed on 4/8/17 Resident #5 went into Resident #3's room and slapped Resident #3 on the face. Continued review of the facility investigation revealed an undated statement written by LPN #1 recounting the events of the incident on 4/8/17. Further review of the investigation revealed the occurrence report was not written until 4/11/17 by the DON. Interview with the Administrator and the DON on 5/10/17 at 3:55 PM in the conference room revealed they were not made aware of the incident involving Resident #5 hitting Resident #3 until 4/11/17. Further interview revealed it was the expectation of the administrator, who was also the abuse coordinator, for all allegations of abuse to be reported immediately to the supervisor and/or abuse coordinator. Continued interview revealed the Administrator confirmed LPN #1 failed to report the incident immediately to the supervisor and/or abuse coordinator.",2020-09-01
3343,LIFE CARE CENTER OF OLD HICKORY VILLAGE,445509,1250 ROBINSON ROAD,OLD HICKORY,TN,37138,2018-08-01,609,D,1,0,2NMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to report an allegation of abuse to the state agency within the required 2-hour time frame for 1 of 1 sampled residents in 1 allegation of abuse (Resident #1) Findings include: Review of facility policy Protection of Residents Reducing the Threat of Abuse & Neglect last revised 2/2018 revealed, .alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made .all alleged or suspected violation involving .abuse .will be immediately reported to the administrator and/or director of nursing . Medical record review revealed Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 5-day admission Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 14 indicating no cognitive impairment. Continued review revealed some short- and long-term memory problems. Further review revealed continuous Oxygen therapy was required. Continued review revealed pain assessment was required for pain management. Review of a facility investigation involving Resident #1 revealed an allegation of staff to resident abuse reported 7/15/18 at 8:30 AM. Continued review revealed the facility reported the allegation of abuse to the state agency on 7/15/18 at 5:39 PM. Interview with the Administrator on 7/30/18 at 12:50 PM in the private dining room confirmed the time line between the allegation of abuse and the reporting of the allegation to the state agency was outside of the 2-hour range for reporting.",2020-09-01
5324,CREEKSIDE CENTER FOR REHABILITATION AND HEALING,445516,306 W DUE WEST AVENUE,MADISON,TN,37115,2016-04-01,225,D,1,0,2CEQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to report to the State Agency and thoroughly investigate an unwitnessed fracture as an injury of unknown origin for 1 resident (#210) of 3 residents reviewed for accidents. The findings included: Review of the facility's Abuse Prevention Policy and Procedure revealed, .Investigation - All alleged violations involving mistreatment, abuse or neglect will be thoroughly investigated by the facility under the direction of the Administrator .Additionally, the facility will thoroughly investigate, under the direction of the Administrator, all injuries of unknown origin to determine if abuse or neglect was involved . Medical record review revealed Resident #210 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission/Interim Care Plan revealed the problem ADLS (activities of daily living) was dated 7/7/15, and identified Potential for ADL Decline as evidenced by increased need for assistance. Continued review of the Interim Care Plan revealed an approach for the problem of potential ADL decline, Complete .Lift Program Lift/Transfer Assessment Form and report findings to ADON (Assistant Director of Nurses) as per instructions of appropriate use - communicate findings to CNA. Medical record review of the Physical Therapy Screen dated 7/8/15 revealed, Pt (patient) is dependent for all moving. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment; and required extensive assistance (resident involved in activity, staff provide weight-bearing support) of 1 person for bed mobility and transfers. Medical record review of the Physical Therapy Screen dated 10/29/15 revealed, Total assist bed mobility, 2 person transfer .No changes in functional status at this time .per nsg (nursing). Medical record review of the Occupational Therapy Screen dated 10/29/15 revealed, Total care. Medical record review of a night shift Licensed Practical Nurse (LPN #2) entry in Departmental Notes dated 1/15/16 revealed, Received report from resident's care giver (CNA) of c/o (complaint) pain .guarding her left leg/foot .follow-up assessment .+2 [MEDICAL CONDITION] to left ankle region (more notable to lateral aspect), trace redness noted .pain only notable with position change .NP called .stat (medical term meaning now) xray (mobile) ordered. Medical record review of the stat mobile xray, dated 1/15/16 at 5:01 AM, revealed, SIGNIFICANT FINDINGS .Acute spiral mildly displaced fractures of the distal diaphyses and metadiaphyseal junctions of the tibia and fibula. Overlying soft tissue [MEDICAL CONDITION] and swelling .Impression: Acute mildly displaced fractures of the distal diaphyses and metadiaphyseal junctions of the tibia and fibula . Medical record review of the Physician's Telephone Orders dated 1/15/16 at 0615 (6:15 AM) AM, revealed 1. Send to the ER (emergency room ) .for ortho (orthopedic) evaluation and treatment of [REDACTED]. Medical record review of the ER xrays, dated 1/15/16 at 8:41 AM, revealed, Impression 1. Comminuted spiral fracture distal tibia metadiaphysis. No significant angulation or displacement. 2. Spiral [MEDICAL CONDITION] diaphysis extending to the distal metaphysis. Medical record review of the ER Physician's History and Physical dated 1/15/16 revealed, History of Present Illness: .severely demented .female who has contractures of her left knee and left hip .from nursing home with left tibia and fibula fracture. There is no real documentation when she suffered her fall. Per daughter she is non-ambulatory and in a wheelchair .Physical Examination: .Noted contracture of her left lower extremity with flexion contracture of her knee of approximately 90 degrees and a flexion contracture of the left hip .Assessment and Plan: .suffered an unfortunate event that was not witnessed, resulting in a left minimally displaced comminuted spiral pattern mid shaft tibia fracture, which extends intraarticularly with a posterior malleolus (ankle) fracture as well as minimally displaced comminuted fracture of her left distal fibular shaft . Medical record review of the Discharge/Aftercare Instructions dated 1/15/16 at 10:58 AM revealed, .you have fractured both the tibia and fibula bones .This injury often happens when the ankle is twisted strongly .This tears ankle ligaments. It also causes a break in the bones the ligaments hold together . Medical record review of a Progress Note dated 1/17/16, filed by the Medical Director revealed, .seen for readmission H&P (history and physical) .has returned to the facility .fracture sustained during a fall at the facility .General: Frail elderly female, sitting in wheel chair . Review of the facility's Resident Incident Report filed for Resident #210, dated 1/15/16 revealed, .Incident Type: Other, Type of Injury: Fracture, Location: Resident's room, Associate Involved: (CNA #5), Incident Reported by: Certified Tech, Report Prepared by: (LPN #2) . Review of the written statements (4 total) that accompanied the Incident Report revealed the first statement was recorded on a Fall Scene Investigation Report not dated or timed with the following: Upon arrival at 11:00 pm I checked on (Resident #210) and she was dry so there was no need to change her so on the next round at 1:00 AM she was wet and I go to change her she complains of pain in her left leg screaming 'it hurts' I finished changing her and immediately got the nurse to examine her. (signed by CNA #5 who was assigned to the resident's care on the night of 1/15/16) Review of the written statement (incorrectly dated 1/14/15) from CNA #3 assigned to Resident #210's unit revealed, While doing my first rounds I was in room [ROOM NUMBER]. I heard screaming. I peeped in the hall to see where it was coming from. As I was walking towards the screams (CNA #5) yelled out to go get the nurse because (Resident #210) was not acting like herself while she attempted to change her. I got (LPN #2). We all entered the room to assess the situation. She yelled and cried the whole time. Review of the written statement from LPN #2, signed and dated 1/15/16 revealed, Writer assessed resident (#210) at 0145 (AM) for c/o (complaint) of pain to L (left) (lower) ext (extremity) with findings of +1-+2 [MEDICAL CONDITION] of Left lower extremity. Trace pink color noted to left foot-with guarding of left foot with movement . Review of CNA #4's written statement revealed CNA #4 had been assigned to care for the resident on 1/14/16 on the evening shift, I had pt. (resident's last name) on 1/14/16 on the 3-11 shift pt. was put to bed but me and she was normal just the no, no, stop like she always does. Interview with the Director of Nursing (DON) on 3/30/16 at 9:35 AM, in the conference room, confirmed, I investigated the incident .the fracture occurred because the resident had [MEDICAL CONDITION] . Further interview revealed the DON denied the fracture being an injury of unknown origin. Interview continued and the DON stated she did not know why the Medical Director had documented the fracture occurred with a fall. Interview confirmed the DON had not completed a root cause analysis in an effort to determine the cause of the incident that lead to the spiral [MEDICAL CONDITION] and fibula bones of the lower left leg. Interview with the Nurse Practitioner (NP) on 3/30/16 at 11:00 AM, in the conference room, confirmed the NP (#3) had documented Resident #210 had a fall with [MEDICAL CONDITION] lower leg. Interview continued and the NP stated the information relayed to her contained a reference to the resident's foot becoming caught or something and she had thought a fall was involved in the injury; .wish I had not erased the telephone message the nurse left. Interview with the Administrator on 3/30/16 at 4:25 PM, in the conference room, revealed the Administrator stated she had completed the investigation of Resident #210's left lower leg fractures. Interview revealed she had not included the information provided on the x-ray report of 1/15/16 that stated the fracture was a spiral fracture both the tibia and fibula bones of the left lower leg. Interview continued and the Administrator stated the resident's [MEDICAL CONDITION] had led to the fractures. Further interview revealed, I'm not saying the fracture was spontaneous .when you are changing someone they have to be turned .it happened as care was being given, because of the [MEDICAL CONDITION]. Interview continued and the Administrator was asked if her statement meant the fractures were pathological and she said no. Interview continued with concurrent review of the written statement of the Certified Nurse Assistant #5 who was at the resident's bedside when the resident's first expressed pain. Interview confirmed the written statement did not include whether the CNA had turned the resident or began any hands on care of the resident prior to the pain being expressed by the resident. Interview continued and confirmed the Administrator had not conducted interviews with CNA #5 to clarify questions not addressed in the written statement. Interview confirmed the written statement of the CNA #4 who transferred the resident from the wheel chair to bed on the evening of 1/14/16 revealed the CNA had transferred the resident by herself. Interview confirmed the physical therapy staff and nursing staff had assessed Resident #210 as needing physical assistance of two for transfer in (MONTH) (YEAR) and again in (MONTH) (YEAR) and this need for 2 persons for safe transfer was not included in the care plan. Interview continued and confirmed the Administrator did not know why the NP and the Medical director documented the resident had a fall that resulted in the fractures of the left lower extremity. Interview continued and the Administrator confirmed she had not investigated the fracture as an injury of unknown origin and had not conducted a root cause analysis. Interview by telephone with the Medical Director (MD) on 3/31/16 at 11:45 AM revealed the MD received his information about Resident #210's fall on 1/15/16 from the NP and this was the reason he documented a fall in the Progress Note dated 1/17/16. Interview continued and the MD stated he had received a phone call from Nursing Administration on the previous day, 3/30/16, and had replied to inquiries about the cause of Resident #210's fractures, .[MEDICAL CONDITION] is beside the point, how did the fractures happen? Further interview confirmed the spiral fractures (of the tibia and fibula) indicated the ankle was twisted. Interview continued and the MD stated the fractures could have occurred as the resident was transferred to bed and the pain didn't happen until the care during the night .if the fractures possibly displaced at that time.",2019-04-01
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
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
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
4098,ELK RIVER HEALTH & REHABILITATION OF FAYETTEVILLE,445320,4081 THORNTON TAYLOR PARKWAY,FAYETTEVILLE,TN,37334,2016-12-07,223,D,1,0,Z5BS11,"**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 placed 1 (Resident #2) resident of 4 residents reviewed inside the secured unit against his will. The facility failed to provide a least restrictive alternative for the resident prior to being secluded from his room and familiar residents. The findings included: Review of a facility policy titled Abuse Prevention/Reporting Policy and Prevention dated 2013 revealed, .Residents must not be subjected to abuse by anyone .Abuse is defined as .unreasonable confinement .separation of a resident against the resident's will .When a resident is secluded for more than 1 hour the following must be documented in the resident's medical record: 1. The symptoms leading to the seclusion. 2. The root cause of the symptoms .3. Alternative interventions prior to the seclusion . Medical record review revealed Resident #2 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Continued review of a 14 day Minimum (MDS) data set [DATE] revealed the resident had disorganized thinking that fluctuated daily, had no behaviors, and did not wander. His Brief Interview for Mental Status score was 11/15 indicating moderate cognitive impairment. The resident required limited assistance of 1 person transfers, had no extremity impairments, and used a wheelchair for ambulation throughout the facility. Medical record review of the Risk of Elopement/Wandering Review assessment revealed on 8/19/16, 10/26/16, 11/10/16. and 11/30/16 Resident #2 was assessed as not at risk for elopement/wandering at this time. Continued review revealed documentation on 11/10/16 of .voices desire to go home but is aware of need for therapy services . Review of a facility investigation dated 9/29/16 revealed Resident #2 stated, .that he was sitting at the door of the locked unit trying to figure out the code to the door . Continued review revealed, .The resident is alert and oriented x (times) 3 with some confusion noted at times .The facility does have video cameras in the hallway .it was very clear by reviewing the camera by the locked unit door .the resident was not combative in any way .The resident was viewed self-propelling his wheelchair back into and back up the hallway . Continued review revealed the facility reviewed the video from 2:00 PM- 4:00 PM of the resident in the secured unit hallway and at the locked door. Review of a telephone statement made by Licensed Practical Nurse (LPN) #1 on 9/29/16 revealed on 9/18/16 another nurse reported to her the .pt. (patient) was sitting at doorway which is not unusual. The weekend supervisor .came to memory lane (secured unit) and stated (Resident #2) is trying to get out of the door. (LPN #1) then spoke with patient and took him to memory lane so he could be watched closer. He stayed in the back until his family arrived and they visited with him in his room .This was the 1st behavior episode that this nurse had been involved in with this patient. Telephone interview with LPN #1 on 12/6/16 at 12:30 PM revealed the LPN confirmed her written statement after it was read to her by the surveyor. The LPN confirmed she had taken Resident #2 to the secured unit after a nurse and the supervisor told her he was exit seeking. The LPN stated the nurse worked PRN (as needed) and the supervisor was new and neither one knew the resident sat at the door frequently. Continued interview revealed the LPN was caring for residents on the secured unit as well as residents on the unsecured unit and she placed Resident #2 in the secured unit so she could visualize him better. When asked if the resident wanted to be in the secured unit the LPN stated, He was upset at first and was ranting and raving and yelling that he wanted to call the cops. When I asked him why, he said because you got me back here. The LPN stated she told the resident I can't watch you if you get outside and roll down the hill into the road. The nurse stated, His family came to visit shortly after that, and they took him back to his room (unsecured unit) to eat lunch. When they were done visiting the family brought him back to me in the secured unit. Continued interview revealed the LPN stated the time frame was approximately 1:30 PM to 5:30 or 6:00 PM. During this time was when the resident was visualized on the video camera in the hallway by the door banging on it and pushing the buttons to try to get out. 2 PM-4 PM was quiet time for the resident's who lived in the secured unit. The LPN reported she explained that to the resident and encouraged him to take a nap in an empty room which he did for 45 minutes. The LPN was asked if she offered to take the resident outside and she stated, I don't remember him going outside. Medical record review revealed no documentation regarding the root cause of the symptoms that caused the resident to want to go outside, and no alternative interventions prior to placing the resident in the secured unit were found. Interview with the Director of Nursing (DON) on 12/6/16 at 12:45 PM in the Admission's Office confirmed Resident #2's room was #126 A and was not located in the secured unit. Continued review revealed the DON stated he tried to follow family out the door so the nurse put him in Memory Lane for a couple of hours. I personally didn't think he was trying to leave the grounds. I think he wanted to go outside cause he liked to sit outside. The DON was asked if anyone offered to take the resident outside, or sit with him, and the DON stated, I don't know, but we have hospitality aides here now, and Activities is here on the weekends too. The DON confirmed no other interventions were attempted prior to placing Resident #2 in the secured unit against his will. The facility failed to protect the resident from involuntary seclusion.",2019-11-01
2093,SIGNATURE HEALTHCARE OF GREENEVILLE,445351,106 HOLT COURT,GREENEVILLE,TN,37743,2018-05-16,600,D,1,0,OLZ611,"**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 3 residents (#5, #7, and #8) were free from abuse of 11 residents reviewed for abuse. The findings included: Review of facility policy Abuse, Neglect and Misappropriation or Property, last reviewed 11/16/17, revealed .It is (company) 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. Abuse includes physical abuse, mental abuse, verbal abuse and sexual abuse .For purposes of this policy, willful means non-accidental, or not reasonably related to the appropriate provision of ordered care and services .Verbal abuse is use of any oral, written or gestured language that includes any threat, or any frightening, disparaging or derogatory language, to residents or their families, or within their hearing distance, regardless of age, ability to comprehend, or disability . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 scored a 8 (moderately cognitive impaired) on the Brief Interview for Mental Status (BIMS). Medical record review of a psychiatric consult dated 4/17/18 revealed Resident #5 with behaviors including yelling out, verbal aggression towards staff, and reports of physical aggression at times. Review of a facility investigation dated 4/24/18 revealed administration received a report of an allegation of verbal abuse by Licensed Practical Nurse (LPN) #4 directed toward Resident #5. Continued review revealed LPN #4 was sitting at the nurse's desk and Resident #5 was sitting nearby in her wheelchair and was yelling. Further review revealed the resident was attempting to stand, which made her chair alarm go off and LPN #4 stood up, point at the resident, and told her to sit down and shut up. Continued review revealed the resident told LPN #4 You go to hell and LPN #4 replied you first. Further review revealed LPN #4 stated .I hate that woman .I'm tired of the yelling all the time . Continued review of a witness statement from Registered Nurse (RN) #4 revealed RN #4 overheard LPN #4 tell Resident #5 loudly to sit down and shut up. Further review of the witness statement revealed the resident told LPN #4 to go to hell, LPN then #4 told the resident to go first and LPN #4 stated I hate you I hate you you're a hateful old woman. Continued review of a written statement from LPN #4 revealed .Resident (#5) was screaming 'help' per usual and standing up against lap buddy which caused the w/c (wheelchair) to alarm. I said 'sit down' .I'm going to say I told you so when you flip that w/c over because I already told you what could happen .(Resident #5) said 'you go to hell, G .D .you' .She continued screaming and again I said 'sit down and stop it' .looked at (another nurse) and said 'I hate that woman' . Further review revealed LPN #4 was terminated on 5/2/18 due to substantiated verbal abuse. Interview with the Administrator on 5/15/18 at 5:00 PM, in the Admissions Office, confirmed LPN #4 partially admitted the allegation but stated she meant to say she hated the resident's behavior not the resident. Telephone interview with Registered Nurse (RN) #4 on 5/15/18 at 5:45 PM revealed she was at the nurses' station and overheard LPN #4 .being very rude and nasty .(RN #4) was flabbergasted . Continued interview revealed .(LPN #4) yelled at (Resident #5) to 'shut up' .(the resident) then told the nurse to .'go to hell' .(LPN #4) replied ' .you first' .(LPN #4) then stated 3 times ' .I hate her (Resident #5)' . Interview with the interim Director of Nursing (DON) on 5/16/18 at 8:10 AM, in the Admissions Office, revealed she felt it was best to terminate LPN #4. Continued interview revealed LPN#4 denied the allegation at first and then admitted to telling the resident to stop yelling. Telephone interview with LPN #4 on 5/16/18 at 9:10 AM revealed around 6:00 PM she was sitting at the nurses' station and several residents were sitting in front of the nurses' desk, including Resident #5. Continued interview revealed .(Resident #5) was yelling and attempting to stand up in her wheelchair .(LPN #4) asked the resident to please stop and (the resident) cursed and told her (LPN #4) to shut up .listened to the yelling about 30 minutes and (LPN#4) was getting nervous with all the screaming .kept telling the resident to sit down . Further interview revealed LPN #4 .'hated the woman's (Resident #5) behavior' . Interview with the Administrator and the interim DON on 5/16/18 at 9:55 AM, in the Admissions Office, confirmed LPN #4 was terminated for verbal abuse of Resident #5 and confirmed the facility failed to protect Resident #5 from verbal abuse. Telephone interview with RN #5 on 5/17/18 at 3:30 PM revealed Resident #5 was screaming and .one point (LPN #4) stood up pointing at (Resident #5) to sit down and shut up .(Resident #5) then said to (LPN #4) to go to hell .(LPN#4) said you go first .(LPN #4) then sat down and said I hate that woman . Telephone interview with LPN #5 on 5/18/18 at 6:00 PM revealed Resident #5 was yelling and told LPN #4 .you go to hell .(LPN #4) replied you go to hell first . 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 scored a 0 (severely cognitive impaired) on the BIMS. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with readmission date of [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Significant Change MDS dated [DATE] revealed Resident #6 scored a 4 (severely cognitive impaired) on the BIMS. Continued review revealed the resident was independent with ambulation with wheelchair use and required assistance of 1 for Activities of Daily Living (ADLs). Medical record review revealed on 4/28/18 at approximately 5:30 PM Resident #6 was hallucinating, got up from her supper tray, and proceeded to look for a dead man lying in the hall. Continued review revealed Resident #6 picked up another resident's supper tray that was on a table in the hall and headed toward the table with it. Further review revealed the resident was close to 2 other resident's heads so a nurse grabbed onto the tray to prevent Resident #7 from hitting the other resident's with it. Continued review revealed Resident #6 was very upset, begun to yell, and then let go of the tray and punched the nurse. Further review revealed the nurse stepped back and Resident #6 then punched Resident #7 in the head. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Significant Change MDS dated [DATE] revealed Resident #8 scored a 0 (severely cognitive impaired) on the BIMS. Review of a facility investigation dated 5/6/18 at 7:30 PM revealed a nurse observed Resident #6 standup from her wheelchair with her oxygen intact and stretch the oxygen tubing a short distance from her chair to where she was standing. Continued review revealed Resident #8 walked up the hall, raised the tubing so she could walk beneath the tubing, turned around, and then started to walk underneath the tubing again. Further review revealed Resident #6 stated .I am tired of you getting into my business . then shoved Resident #8 causing her to fall to the floor. Continued review revealed the residents were separated and both assessed for any injury, with no injuries noted. Interview with Certified Nursing Assistant (CNA) #3 on 5/16/18 at 9:30 AM, in the behavior unit, Resident #8 was walking under the oxygen tubing of Resident #6, which was pulling the oxygen tubing. Further interview revealed Resident #6 told Resident #8 to get away but Resident #6 walked under the oxygen tubing again and Resident #6 pushed Resident #8 to the floor. Continued interview revealed Resident #8 gets .hyper .(Resident #6) doesn't want people to get close to her .(Resident #8) had not gone under the oxygen tubing before but sometimes will do things for attention . Interview with the Administrator and interim DON on 5/16/18 at 11:30 AM, in the Admissions Office, confirmed the facility failed to protect Resident #7 and Resident #8 from a resident to resident altercation with Resident #6.",2020-09-01
2094,SIGNATURE HEALTHCARE OF GREENEVILLE,445351,106 HOLT COURT,GREENEVILLE,TN,37743,2018-05-16,609,D,1,0,OLZ611,"**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 allegations of abuse were reported timely to the Administrator and to the State Survey Agency for 1 residents (#7) of 11 residents reviewed for abuse. The findings included: Review of facility policy Abuse, Neglect and Misappropriation or Property, last reviewed 11/16/17 revealed .It is (company) policy to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property, and to assure that all alleged violations of federal or State laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property are investigated and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies . 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 scored a 0 (severely cognitive impaired) on the BIMS. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with readmission date of [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Significant Change MDS dated [DATE] revealed Resident #6 scored a 4 (severely cognitive impaired) on the BIMS. Medical record review revealed on 4/28/18 at approximately 5:30 PM Resident #6 was hallucinating, got up from her supper tray, and proceeded to look for a dead man lying in the hall. Continued review revealed Resident #6 picked up another resident's supper tray that was on a table in the hall and headed toward the table with it. Further review revealed the resident was close to 2 other resident's heads so a nurse grabbed onto the tray to prevent Resident #7 from hitting the other resident's with it. Continued review revealed Resident #6 was very upset, begun to yell, and then let go of the tray and punched the nurse. Further review revealed the nurse stepped back and Resident #6 then punched Resident #7 in the head. Interview with the Administrator and the interim Director of Nursing (DON) on 5/16/18 at 10:00 AM, in the Admissions Office, revealed the facility discovered the alleged incident on 5/6/18 (8 days later) while doing a medical record review. Continued interview confirmed the facility staff failed to report the incident timely to the Administrator and to the State Survey Agency 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
1742,BEECH TREE HEALTH AND REHABILITATION,445292,"240 HOSPITAL LANE, PO BOX 300",JELLICO,TN,37762,2019-02-26,600,D,1,0,MIJV11,"**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 prevent a resident to resident altercation for 2 residents (#5 and #6) of 6 residents reviewed for abuse. The findings included: Review of facility policy, Abuse Prohibition/Investigative dated 11/2016, revealed .This facility will prohibit abuse, neglect, misappropriation of resident property .Abuse; is the willful infliction of injury, unreasonable confinement, intimidation .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Actions to prevent abuse include identifying, correcting and intervening in situations in which abuse are more likely to occur . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #5's admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 had short and long term memory loss. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #6's annual MDS dated [DATE] revealed the resident scored a 5 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Review of a facility investigation dated 2/24/19 at 8:45 PM revealed Resident #5 and Resident #6 were in the day room and Resident #5 was cleaning the table where Resident #6 was sitting drinking a cup of coffee. Further review revealed Resident #5 tried to take the cup of coffee away from Resident #6, but Resident #6 would not let go of the cup so Resident #5 slapped Resident #6 in the face. Continued review revealed while staff attempted to redirect Resident #5, both residents struck each other again. Further review revealed the residents were separated and were placed on every 15 minute checks. Interview with the Director of Nursing (DON) on 2/26/19 at 11:20 AM, in the conference room, revealed Resident #5 was a compulsive cleaner. Further interview revealed Resident #6 was trying to eat a snack when Resident #5 took Resident #6's cup to clean. Further interview revealed neither resident was injured and the facility placed both residents on 15 minutes checks until Resident #5 was sent to inpatient psychiatric facility the next day. Interview with Licensed Practical Nurse (LPN) #2 on 2/26/19 at 12:10 PM, at the 300 Unit Nurses Station, revealed Resident #5 was always cleaning something and Resident #6 will sit in the day room and does not like others in his space. Telephone interview with the DON on 2/27/19 at 10:00 AM revealed the facility was aware Resident #6 did not like others in his space and Resident #5 intruded into Resident #6's space. Further interview confirmed the facility failed to prevent a resident to resident altercation between Resident #5 and Resident #6.",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
4209,MCKENDREE VILLAGE,445491,4347 LEBANON ROAD,HERMITAGE,TN,37076,2016-12-29,225,E,1,0,OJT511,"**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 thoroughly investigate an injury of unknown origin for 1 resident (#1) and allegations of abuse for 2 residents (#3, #4) of 4 residents reviewed. The findings included: Review of facility policy Abuse Recognition, Prevention and Reporting, revised 6/2016 revealed, .The Administrator .will be responsible for assuring that any reports of abuse are appropriately investigated .members of the interdisciplinary team, such as the Social Worker, may provide follow up support to the resident reporting the allegation of abuse to support their well being .The Administrator .will take steps .to prevent further potential abuse and protect the resident while the investigation is in progress .All facility employees are responsible for reporting immediately to their supervisor, Administrator or Director of Nursing any allegation of .abuse of residents . Review of facility policy Accident/Incident Reporting, effective 11/2012 revealed, .All .incidents involving residents .shall be investigated and reported to the Administrator .The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the .incident .The following data .shall be included .The date and time the .incident took place .The circumstances surrounding the .incident .The name (s) of witnessess and their accounts of the .incident .the injured person's account of the .incident .The time the injured person's Attending Physician was notified .The date/time the injured person's family was notified and by whom .any corrective action taken .Follow-up information . Medical record review revealed Resident #1 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 the resident had short and long term memory loss and was severely cognitively impaired, and had behaviors of inattention that fluctuated. Review of facility investigation dated 10/17/16 revealed Resident #1 had a scratch to her right temple/eye area, and the resident reported to her family member that a boy hit her on Saturday, 10/15/16. Continued review revealed the family member reported the incident to Licensed Practical Nurse (LPN) #2 on 10/15/16 around lunch time. Further review revealed no documentation of a skin assessment on Resident #1 or on any other non-interviewable residents, and no statements from other residents were included in the facility investigation. Medical record review revealed no documentation of a scratch to Resident #1's right temporal/eye area in the Nurse's Notes, no documentation of an allegation of abuse in the Social Service Progress Notes, and no documentation the physician was notified. Interview with Registered Nurse (RN) #1 on 12/29/16 at 9:52 AM, in the 2 East Quiet Room revealed the RN stated, The scratch happened on the weekend and the nurse did not report it. I found out because a CNA (Certified Nurse Aide) came and told me about it on Monday 10/17. Continued interview when asked where a skin assessment for the resident was located, and the documentation the physician was notified of an injury of unknown origin, the RN stated, It should be in the chart, and I should have done a nurse's note, but I can't promise I did. Further interview confirmed there was no skin assessment for Resident #1 included in the facility investigation, no skin assessments on other residents, or any resident statements included in the facility investigation. Interview with LPN #2 on 12/29/16 at 10:20 AM, in the 2 East Quiet Room confirmed the family member of Resident #1 pointed out a scratch to the right eye area of the resident to the LPN on 10/15/16. Continued interview confirmed the LPN failed to report the injury of unknown origin and stated, I don't know if it got busy out here and it was a tiny injury. Interview with the Administrator on 12/29/16 at 1:15 PM in the Conference Room confirmed the facility failed to thoroughly investigate an injury of unknown origin for Resident #1 and the facility investigation was incomplete. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Further review of an Admission MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 3 indicating he was severely cognitively impaired. Review of facility investigation dated 8/18/16 revealed an anonymous hand written letter to the Director of Nursing (DON) and Administrator dated 8/16/16 reporting Resident #3 was hit in the head with something thrown at him by CNA #3 on 8/14/16. Continued review of the facility investigation included a statement from 2 CNA's who had no knowledge of the incident, and 1 statement from a CNA who assisted CNA #3 with dressing and placing the resident in a wheelchair in the common area after the alleged incident occurred. Further review of the facility investigation revealed there was no follow up regarding the alleged incident from Resident #3, the nurse caring for the resident, or any other facility staff members. Medical record review revealed no documentation of an assessment of the resident, notification of the family, or the physician for the allegation of abuse. Continued review revealed no follow up by Social Services. Interview with the Social Services Director on 12/28/16 at 12:38 PM, in the Conference Room confirmed she did not follow up with Resident #3 after an allegation of abuse was identified. Interview with the Administrator on 12/29/16 at 1:15 PM, in the Conference Room confirmed the facility failed to thoroughly investigate an allegation of abuse for Resident #3, and the facility investigation was incomplete. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #4's cognitive skills for daily decision making were severely impaired, never/rarely made decisions, and speech was unclear with slurred or mumbled words. Continued review revealed Resident #4's bed mobility required extensive assistance. Further review revealed Resident #4 was always incontinent of bladder and bowel. Medical record review of Nurses Notes dated 10/17/16 and signed by LPN #1 revealed, .noted pt (patient) and CNT (CNA) leaving dining room and pt crying .this writer started talking to pt and pt reported 'she pulled my arm (Lt) (left)'. Reported to (RN #2) after she spoke c (with) pt & and got same story. (RN #3) unit supervisor notified . Interview with RN #3 on 12/29/16 at 2:15 PM in the Conference Room, with the Administrator present, was shown the nurses note written by LPN #1 on 10/17/16. RN #3 stated, I don't remember anything about this. Interview with the Administrator on 12/29/16 at 2:25 PM, in the Conference Room confirmed the nurses note written by LPN #1 on 10/17/16 was not followed up on, and the facility failed to investigate an alleged allegation of physical abuse for Resident #4. Review of a facility investigation dated 11/5/16 revealed Resident #2 reported that CNA #4 appeared frustrated and used profanity while providing care to Resident #4. Further review of the facility investigation revealed no documentation of statements from CNA #4 and CNA #5. Medical record review revealed no documentation of follow up by Social Services, and no documentation the physician or family was notified. Interview with the Social Services Director on 12/28/16 at 12:38 PM, in the Conference Room, with the DON present, confirmed she failed to follow-up with Resident #4 after the alleged incident of verbal abuse. Interview with the Administrator on 12/29/16 at 2:25 PM in the Conference Room confirmed there was no written statement from CNA #4 who allegedly made an inappropriate comment to Resident #4 on 11/5/16. Continued interview confirmed there was no documentation of the conversation with CNA #4 by phone regarding the incident. Further interview with the Administrator confirmed there was no written statement from CNA #5 who initially reported the allegation of verbal abuse. The Administrator confirmed the facility failed to thoroughly investigate an allegation of verbal abuse for Resident #4.",2019-11-01
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
1471,AHC CUMBERLAND,445262,4343 ASHLAND CITY HIGHWAY,NASHVILLE,TN,37218,2017-09-13,309,E,1,0,F0U711,"**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 provide care by failing to follow physician's orders [REDACTED].#12, #10, #3, #14, #17) and failed to follow the facility policy for 1 resident (#12) of 17 residents reviewed. The findings included: Review of facility policy, Controlled Drug Accountability Procedure, effective 7/2014, revealed .Each dose administered is to be signed out by the nurse on the controlled drug record and on the patient's eMAR (Medication Administration Record). Follow-up documentation for effectiveness should be accomplished on the eMAR also .The count of each controlled substance must be audited at every shift change by the nurse coming on duty and the nurse going off duty. Visual checks of the entire medication card for missing medications and the record sheet must be done by both nurses .Both nurses must sign the Narcotic Control Record indicating the count has been completed; the date, time, number of medication cards, and the number of controlled drug record sheets must be documented .If the count is incorrect the Director of Nursing (DON) must be notified immediately. No exchange of med cart keys should be done and the off-going nurse should not leave the facility . Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #12 scored 1 on the Brief Interview for Mental Status (BIMS) indicating she was severely impaired cognitively. Medical record review of physician's orders [REDACTED].#12 was ordered [MEDICATION NAME]/APAP 5/325 milligrams (mg) 1/2 tablet every 6 hours as needed for pain. Review of the Controlled Drug Record revealed [MEDICATION NAME] was signed out on 8/31/17 and below it were 2 tablets signed out on 8/27/17 or 8/28/17 by Licensed Practical Nurse (LPN #1). Continued review revealed 1/2 tablet was signed out on 6/26/17, 7/14/17, 7/17/17, 7/25/17, and 7/31/17 and 1/2 wasted was documented but there was no signature by the second nurse. Further review revealed 1 tablet signed out on 8/7/17, 8/23/17, 8/25/17, 8/26/17, 8/31/17 but the other had not been changed from 1/2 tablet. Observation of Resident #12 on 9/13/17 at 11:50 AM revealed her seated in her wheelchair in front of the overbed table with a finished lunch tray on it. Her arms were crossed; she was leaning to the left; and was asleep. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual MDS dated [DATE] revealed Resident #3 scored 13 on the BIMS indicating she had slight cognitive impairment. Medical record review of physician's orders [REDACTED].#3 was ordered [MEDICATION NAME] 5/325 mg every 6 hours as needed. Review of the Controlled Drug Record revealed Resident #3 had [MEDICATION NAME] signed out on 9/6/17 at 4:00 PM and again at 8:00 PM, not 6 hours apart by LPN #2. These doses were not documented on the Medication Administration Record (MAR) as being administered. Review of the facility investigation revealed the Administrator interviewed Resident #3 and she stated she had not had any pain medication in over a week. Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #15 scored 7 on the BIMS, indicating she was moderately cognitively impaired. Medical record review of physician's orders [REDACTED].#15 was ordered [MEDICATION NAME]/APAP 5-325 mg every 6 hours as needed for pain. Continued review of orders revealed this was discontinued 6/9/17. Review of the Controlled Drug Record revealed [MEDICATION NAME]/APAP signed out on 8/26/17 at 5:00 PM and 11:00 PM and 8/31/17 at 4:00 PM and 10:00 PM by LPN #2. Review of the facility investigation revealed the Administrator determined the order was discontinued and the medication was still signed out. Observation of Resident #15 on 9/13/17 at 11:40 AM revealed she was sitting in the dining room eating lunch with no complaints of pain. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of nursing notes dated 9/1/17 revealed Resident #14 was alert but confused. Medical record review of physician's orders [REDACTED].#14 was ordered [MEDICATION NAME]/APAP 10/325 mg every 6 hours as needled. Review of the Controlled Drug Record revealed on 9/6/16 Resident #14 had received [MEDICATION NAME]/APAP at 10:10 AM then it was signed out at 4:00 PM and 9:00 PM by LPN #2. Review of the facility investigation revealed the DON determined the medication was given at too short an interval. Observation of Resident #14 on 9/13/17 at 11:47 AM revealed him sitting on the side of the bed eating lunch. He said he was not in pain but the pain medication helped him. Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #17 scored 15 on the BIMS indicating he was alert, oriented, and able to make his needs known. Medical record review of physician's orders [REDACTED].#17 was ordered [MEDICATION NAME]/APAP 5-325 mg every 6 hours as needed for pain. Review of the Controlled Drug Record revealed [MEDICATION NAME] signed out on 9/6/17 at 10:10 AM then at 4:00 PM and 9:00 PM by LPN #2. Review of the facility investigation revealed the DON determined the medication was given at too short an interval. Observation of the resident on 9/13/17 at 2:40 PM revealed Resident #17 resting in bed. He stated he had no pain currently and his pain medications usually control the pain. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with the Administrator on 9/12/17 at 2:20 PM in the Administrator's office confirmed LPN #2 signed out medications more often than ordered by the Physician. Interview with the DON on 9/13/17 at 10:30 AM in the DON's office confirmed nurses failed to obtain a second signature when wasting narcotics for Resident #12 so did not follow facility policy. Continued interview the DON also confirmed on 9 occasions 1 tablet was signed out to be administered instead of the 1/2 tablet thus failing to follow physician's orders [REDACTED]. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) revealed Resident #10 had a Brief Interview for Mental Status of 4 indicating she was severely cognitively impaired. Further review revealed the resident had no impairment of the lower extremities and was not steady, only able to stabilize with staff assistance with moving from seated to standing position, moving on/off toilet and surface-to-surface transfer. Medical record review of a Clinical Note dated 5/18/17 revealed [MEDICAL CONDITION] in right ankle. Resident #10 expressed facial grimaces when the nurse touched the ankle and declined to get out of bed. Medical record review of a Physician assessment dated [DATE] revealed .Pt's (patient's) rt (right) ankle swollen, erythemoatous, possible deformity noted. Very painful (with) palpitation. Pt doesn't recall any injury to ankle. Was called last night regarding pain to pts hip/ankle, ordered uric acid level for today which is (negative) will get xray . Medical record review of a Clinical Note dated 5/19/17 revealed the Nurse Practitioner (NP) ordered an xray of the resident's right ankle. The findings showed comminuted and mildly displaced acute [MEDICAL CONDITION] and fibula above the joint. NP ordered for the resident to be sent to emergency department (ED). Medical record review of a Radiology Report dated 5/19/17 revealed .There are comminuted angulated and mildly displaced acute fractures of the distal tibia and distal fibula, well above the joint space. The bones are osteopenic. There appears to be narrowing of the ankle joint. No there acute fractures seen. No other incidental findings .Acute [MEDICAL CONDITION] tibia and fibula . Medical record review of an ED report dated 5/19/17 revealed Resident #10 had a .tib-fib (tibia-fibula) fracture . which was splinted. Resident to follow-up with Physician within 5 to 7 days. Review of a medical record report dated 7/21/17 revealed Resident #10 had a follow-up appointment with an Orthopedic Specialist. Further review revealed .She was seen on (MONTH) 19, (YEAR), when x-rays at nursing facility showed a right distal tibia fracture. She was placed in a splint, but unfortunately never followed up until this week. She is here with her daughter. I questioned her daughter why they never brought her back even with the followup information that I clearly showed her and that the daughter had with her today and the daughter says she just thought the nursing home would do it .when we touched her right leg, she started screaming .There is a procurvatum deformity at the right distal tibia and equinus flexion contracture of the ankle .Right distal third extraarticular tib-fib fracture sustained 2 months ago, was seen in the ER and told to followup and has not until now .patient is not an operative candidate. Will have to balance the orthopedic treatment for [REDACTED]. She may have a nonunion of the tibia that we treat with bracing long term .we will put her in a short leg cast for some stability at the fracture site. Hopefully this will stimulate some healing .will see her back in a month. We can cut cast off, get another set of x-rays and check on her symptoms. She may be a candidate for a molded removable splint, that may be a good long term option for her . Review of the medical records from (MONTH) (YEAR) until Sept (YEAR) revealed Resident #10 was never seen by social services. Review of a medical record dated 3/6/17 by social services revealed .(Resident #10) received mental health services on this date. A clinical note has been provided and will be scanned into the system for staff review. This social worker will assist (Resident #10) with any social services needs as they arise . Interview with the Social Worker (SW) #1 on 9/12/17 at 4:30 PM in his office revealed he was responsible for making all follow-up appointments. SW #1 stated he was not aware Resident #10 had a fracture. SW #1 confirmed he did not make Resident #10 a follow-up as ordered from the ED Physician. SW #1 then stated he had not seen Resident #10 from timeframe (MONTH) (YEAR)-July (YEAR). Interview with the Administrator on 9/12/17 at 4:42 PM in her office confirmed the facility failed to ensure Resident #10 received a follow-up orthopedic appointment as ordered. Interview with the Administrator on 9/13/17 at 12:45 PM revealed she expected Social Services to have contact with residents at least quarterly if not more. The Administrator confirmed Resident #10 had not been assessed by Social Services since (MONTH) (YEAR)",2020-09-01
401,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-11-13,224,D,1,1,UJ6N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation review, review of police report, and interview, the facility failed to ensure 1 resident (#101) was free from misappropriation of property of 3 residents reviewed for abuse of 29 sampled residents. The findings included: Review of the facility policy Abuse Prevention Program, updated 1/19/17, revealed .prevent resident abuse .theft .misappropriation of resident property .the deliberate .use of a resident's belongings or money without the resident's consent . Medical record review revealed Resident #101 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #101 had a Brief Interview for Mental Status score of 12, indicating the resident was minimally cognitively impaired. Continued review revealed no behavioral symptoms, hallucinations or delusions and the resident was independent with activities of daily living. Review of a facility investigation revealed Resident #101's daughter discovered several charges to the resident's bank account she believed to be fraudulent and reported the suspicious charges to the facility on [DATE]. Review of Resident #101's Bank Statement dated 8/18/17 revealed a check charge in the amount of $309.15, along with several other charges totaling approximately $1,439. Review of a police report dated 8/18/17 revealed an officer of the local police department interviewed Resident #101 at the facility. Continued review revealed the resident told the officer she kept several checks in a bottom drawer in her room and she did not give permission to anyone to use them. Further review revealed, through the officer's investigation, it was discovered Certified Nursing Assistant (CNA) #5 was identified through surveillance footage to be the person writing the stolen check at a local store. Review of CNA #5's signed statement dated 8/18/17 revealed the CNA confirmed she stole a check from Resident #101 without her consent and used the funds for her own purpose. Interview with Resident #101 on 11/6/17 at 9:40 AM, in the resident's room, confirmed she had been .robbed .a few months ago . Interview with the Administrator on 11/8/17 at 11:44 AM, in the Director of Nursing office, confirmed the facility failed to prevent the misappropriation of property for Resident #101.",2020-09-01
660,"AGAPE NURSING AND REHABILIATION CENTER, LLC",445162,505 N ROAN STREET,JOHNSON CITY,TN,37604,2018-03-14,600,D,1,0,2X2811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation, and interview the facility failed to ensure two residents (#2, #3) were free from abuse of 10 residents reviewed for abuse. The findings included: Review of the facility policy, Abuse Protocol, dated 11/2016, revealed .Each resident has the right to be free from abuse .2. Abuse means the willful infliction of injury . Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 day Minimum Data Set ((MDS) dated [DATE] revealed resident Brief Interview for Mental Status (BIMS) score of 10 indicating resident with moderately impaired cognition. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed resident Brief Interview for Mental Status (BIMS) score of 6 of 15 indicating resident with severe cognitive impairment. Review of a facility investigation dated 12/19/17 revealed .nurse notified of an altercation .upon entering room this nurse was told by CNA on staff that she had witnessed resident in bed #2 being hit by her mother. CNA on staff had separated the altercation .resident in bed #2 stated that resident in bed #1 had hit her in the face with a closed fist more than once .Resident in bed #1 stated resident in bed #2 mother stated to daughter be good, you need to stay here and proceeded to slap daughter. Resident in bed #2 proceeded to hit her mother. Resident in bed #2 stated she couldn't stand to see resident in bed #2 slap her mother, so she went over there and slapped resident in bed #2. Resident in bed #1 stated she got me, pulled my hair and bit my hand and when she did that I slapped the hell out of her . Review of facility investigation statements and interview with the Assistant Director of Nursing (ADON) on 3/13/18 at 9:51 AM, in the activity room, confirmed resident #2 had been smacked by her mother. Continued interview revealed resident #3's hair was pulled and her hand had been bitten by resident #2.",2020-09-01
491,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2018-02-14,600,D,1,0,CEZ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation, and interview the facility failed to prevent abuse for 1 (Resident #2) of 4 residents reviewed for abuse. The findings included: Review of the facility policy Abuse Prevention Program Updated 1/19/17 revealed .It is the policy of this facility to prevent resident abuse . Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set ((MDS) dated [DATE] for Resident #9 revealed a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. Continued review revealed the resident exhibited no behaviors during the review period. Resident #2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of an MDS dated [DATE] for Resident #2 revealed the resident was rarely/never understood. Continued review revealed no behaviors were exhibited during the review period. Observation on 2/12/18 at 10:25 AM, of Resident #2, in her room on the secure unit revealed the resident seated on the side of her bed. Continued observation revealed the resident was awake and alert, however did not answer questions appropriately. Review of the facility investigation dated 1/19/18 revealed .At 12:53 PM (Resident #2) was struck four times on the left shoulder by (Resident #9) after she wondered into his room .Upon attempting to enter (resident #9's) room, she (Resident #2) backed out; he followed her out, and then struck her four times on the left shoulder with an open hand . Review of a Progress Note dated 1/19/18 at 3:06 PM, for (Resident #3) revealed .Resident opened door to (Resident #9's) room attempting to enter. Resident began backing out of room at which time (Resident #9) struck 3-4 times making contact to left shoulder . Interview on 2/14/18 at 12:00 PM, with[NAME]Lowhorn DON, in the conference room confirmed Resident #9, did willfully hit Resident #2 in attempt to remove her from his room, and the facility failed to prevent abuse for one resident #2.",2020-09-01
4773,CREEKSIDE CENTER FOR REHABILITATION AND HEALING,445516,306 W DUE WEST AVENUE,MADISON,TN,37115,2016-08-11,323,D,1,0,S2LI11,"**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 supervise a resident to prevent a fall for 1 resident (#1) of 3 residents reviewed for falls. The findings included: Review of facility policy, Falls Management, revealed .the facility strives to reduce the risk for falls and injuries by promoting the implementation of the Risk Reduction: Falls and Injuries Programs. Residents are assessed for the fall risk factors. The interdisciplinary team works with the residents and family to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence . Medical record review revealed Resident #1 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 #1 scored 15/15 on the Brief Interview for Mental Status indicating he was alert, oriented, and could make his wants known. Continued review of the MDS revealed Resident #1 required extensive assistance of 2 people for bed mobility and transfers; and was dependent on 1 person for bathing. Further review revealed Resident #1 was always incontinent of bowel and bladder. Medical record review of the Certified Nursing Aide's (CNA) care card dated 10/23/15, in use on 7/5/16 revealed .2 staff members needed for bed mobility. Resident is difficult to turn and is unable to assist with turning. Resident has rigid body position r/t (related to) Parkinson's Disease . Medical record review of the Care Plan dated 6/24/16 revealed a problem of Resident requires assist with ADLs (Activities of Daily Living) with an approach of .Extensive assist of 2 for bed mob (mobility) . Medical record review of the care plan problem with the onset date of 6/6/14 and revised on 7/5/16, revealed a problem of I am at risk for falls d/t (due to) weakness, Parkinson's Disease, communication deficit, vision deficit, medications that increase risks, hx (history) of previous falls, incontinence .7/5/16 Fall . with approaches of .Mat to floor beside bed for prevention of serious injury r/t falls. Fall risk assessment completed and reviewed quarterly and prn (as needed) .7/5/16 .CNA training, 2 person assist . Review of the facility investigation dated 7/5/16 at 12:11 PM revealed .During bath time resident lost upward seated balance and required staff to physically assist him to floor to prevent fall. Skin tear right small toe. Small bruise to left upper arm. Bruises bilaterally to inner thighs . Review of Post-Incident Actions dated 7/5/16 revealed .Per CNA resident was being bathed on bed and began to lose his balance leaning over to his left side and needed to be assisted to floor to prevent him from falling from bed . with immediate post-incident action to .utilize 2 technicians during bath time to assist with balance and mobility . Review of the Employee Investigation Interview Form completed by the nurse to whom the incident was reported and dated 7/5/16, revealed .Called to rm (room) .by ( CNA #1) that resident was in floor at BS (bedside). upon entering rm noted resident lying on floor on right side noted resident to have a sm (small) skin tear to right sm toe noted a sm bruise on left upper arm also bilateral groin noted to be bruised. Resident lifted back to bed with lift sheet by 6 CNA . Review of a Personnel Consultation Form dated 7/5/16 revealed CNA #1 .was changing resident by herself. Care guide calls for 2 person assist with bed mobility . Medical record review of a Physician's Progress Notes dated 7/5/16 revealed .He is seen today because nursing notes he had a fall in his room today. He states he was being bathed and rolled off the bed. He states he hit his head and scratched his right foot, fifth toe. He states he was picked back up and put in bed. He denies any severe pain to his face but does state he is sore . Continued review of the progress note revealed a skin assessment of bilateral upper thighs with small ecchymosis and right foot fifth toe with small abrasion 1/2 cm (centimeter) in diameter on lateral side. Further review revealed the physician diagnosed Resident #1 with superficial bruising of lower leg; contusion of right lower leg; contusion of left lower leg. Continued review revealed facial series x-ray were within normal limits. Review of the Employee Investigation Interview Form completed by the Director of Regional Operations dated 7/5/16 revealed .I misunderstood (named nurse) statement as she now states he rolled to the floor. I was understanding her to state resident was lowered to the floor . Review of the Investigation/Response to a Concern/Comment Report dated 7/6/16 and completed by the Administrator, revealed .Spoke with son about incident. Explained difference in language used by staff as slid out of bed vs (versus) a fall. A slide is still a fall by interpretation . Continued review revealed .Interview with resident with son at BS. He (Resident #1) stated .She was cleaning me up, had me on my right side facing the windows. I started falling and yelled for help. I don't know where she was. But I heard her call for help after I yelled . Interview with Resident #1 on 8/10/16 at 1:15 PM, in the resident's room revealed the CNA was giving him a bath and rolled him over on his right side. Continued interview revealed she left him to answer a knock on the door and was not sure if she left the room or not. Further interview revealed he was so far over he started rolling and could not stop. Further interview revealed he was already on the floor when the CNA said Hold on then I'm in trouble now and 6 people picked him up and put him in bed. Continued interview revealed he hurt all over the next day. Interview with CNA #1 on 8/10/16 at 2:20 PM on the Capitol Hill unit, revealed .I was giving (Resident #1) his bath and had turned him on his side facing the window .he began to shake and fell off the bed, landing on the floor on his right side . Further interview revealed it was her first time to care for him and she did not know he required 2 people for bed mobility. Continued interview revealed CNAs can find information on the amount of assistance residents need with ADLs in the computer on the care guide. Further interview revealed CNA #1 stated she did not look at the care guide before providing care for Resident #1 on 7/5/16. Interview with the Administrator on 8/10/16 at 3:35 PM in the conference room revealed CNA #1 turned Resident #1 over on his right side and when the CNA turned to get something he fell off the bed to the right of the bed by the wall. Further interview with the Administrator confirmed CNA #1 failed to follow the care guide and the facility policy to ensure 2 person assist was provided resulting in a fall from the bed to the floor.",2019-08-01
841,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-06-12,609,J,1,0,HPNL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation, employee files and interviews the facility failed to follow the facility policy related to reporting abuse immediately to the supervisor. The findings include: Review of the facility policy, Abuse, Neglect and Exploitation of Residents, undated, revealed .It is the policy of the facility that acts of abuse directed against residents are absolutely prohibited .All personnel (including volunteers) in all departments will be alert to indicators of suspected or actual abuse, neglect and exploitation. The resident is assisted to safety and is protected against (further) harm, and if abuse is suspected, personnel will report their observations to their supervisor immediately and without delay . Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 01, indicating severe cognitive impairment. Further review revealed no restraints were used for Resident #2. Review of the facility investigation and a Respiratory Therapist (RT #1) initial written statement dated 5/2/19 revealed I walked over to 2A's nsg (nursing) station at approximately 4:45 AM to discuss this [MEDICAL CONDITION] Care. As I arrived in the common area, I saw (Resident #2) sitting in his wheelchair. He was secured (restrained) to the chair with a pink and grey gait belt. The belt was wrapped around (Resident #2's) chest and the wheelchair. I talked briefly with him. He said the word '[***] ' and motioned his hand as to point to the nurses station. When I looked at the nsg station the (AP) was the only person sitting there. The gait belt was obviously tightly secured because he could not lift his back off of the back of the wheel chair. Review of the RT #1's employee file on 6/12/19 revealed RT #1 received training on abuse and reporting abuse upon hire in (MONTH) 2019. Interview with the Director of Nursing (DON) on 6/11/19 at 8:00 AM in the conference room revealed the DON was informed of the alleged abuse on 5/2/19 around 9:00 AM by Licensed Practical Nurse (LPN) #5. Continued interview revealed by the time the DON informed the Administrator, the RT #1 had already reported it to the Administrator. Continued interview when asked when staff are to report abuse the DON confirmed all staff were expected to report suspected or witnessed abuse immediately. Interview with the Administrator on 6/11/19 at 8:15 AM in the conference room revealed the Administrator was informed on 5/2/19 around 10:00 AM by RT #1 of Resident #2 being secured (restrained) in his wheelchair with a gait belt around his chest. Continued interview revealed the Administrator reported the allegation to the State Agency as soon as he was aware of the allegation. Further interview when asked when staff were to report abuse the Administrator stated, Immediately, I expect them to notify me as soon as it happens. Interview with the RT #1 on 6/11/19 at 1:15 PM in the conference room revealed she reported for work on 5/2/19 around 5:30 AM to educate the night shift nurses on [MEDICAL CONDITION] care. Continued interview revealed when she went to station 2A around 5:45 AM and she observed Resident #2 sitting in a wheelchair with his back facing the nurses station. Resident #2 hollered (yelled) come here and motioned for the RT (#1) to come over to him. RT #1 went over to Resident #2 and he pointed at a gait belt that was around his chest, and said look what that [***] did to me, pointing toward the nurses station where the (AP) was sitting. Further interview, when asked how was the gait belt placed on Resident #2 she confirmed the gait belt was around the upper part of Resident #2's chest snuggly, and attached to the wheelchair. When asked to explain snugly, RT #1 replied, he could not raise his back off the back of the wheelchair. Continued interview revealed RT #1 went inside the nurses station and spoke to the AP related to the training she was doing and the AP spoke hatefully saying, I don't have time to do the training. The RT left nurses station 2A and went to the 400 hall. Further interview revealed the RT reported her observation of Resident #2 with a gait belt around his chest securing (restraining) Resident #2 to his wheelchair to LPN #5 (Unit Manager for 200 Hall) when she (LPN #5) arrived at the facility at 7:30 AM. Continued interview revealed RT #1 reported her observation of Resident #2 in his wheelchair with a gait belt around his chest to the Administrator during the morning stand up meeting around 9:00 to 9:30 AM on 5/2/19. She stated, I guess I should have called someone and reported it sooner, I don't know, I just told (LPN #5) as soon as she got here. Interview on 6/11/19 at 1:45 PM with LPN #5 at nurses station 2A revealed she reported for work on 5/2/19 at 7:30 AM. Continued interview revealed she stated, the (RT #1) reported to me that (Resident #2) was sitting in his wheelchair at the nurses station with a gait belt around his chest, secured (restrained) to the wheelchair; I went immediately and assessed (Resident #2) and he was in the bed with no restraint on and no injuries noted. Continued interview with LPN #5 revealed I reported to the DON around 8:30 AM (RT #1) witnessed (Resident #2) being in a wheelchair with a gait belt around his chest, secured to the wheelchair. Validation of the IJ removal plan to remove the IJ was completed on 6/12/19 through review of the facility documentation, observations and interviews. Surveyor verified the IJ removal by: 1. Review of the personnel file for the AP revealed abuse training was appropriately provided at orientation and as needed. Continued review revealed the facility obtained background checks and reference checks with no negative findings. Immediately following the incident of 5/2/19 the AP was suspended pending investigation. Further review revealed the AP was terminated on 5/2/19 following review of video footage confirming application of a gait belt as a restraint by the AP to Resident #2. 2. Review of resident audits for all the residents on the secured unit. 3. Review of the restraint policy and abuse policy was done and the policies were appropriate. In-service education was completed for all staff on 5/3/19 to 5/6/19 as evidenced by sign-in rosters and staff interviews. Verification through interviews of internal audits initiated 6/12/19 to ongoing every 2 weeks then weekly for 3 months to assess for restraint use. 4. Presentation of all audits to the Quality Assurance Committee (QAC) monthly for 3 months; with the first presentation at the 6/12/19 meeting.",2020-09-01
309,TENNOVA LAFOLLETTE HEALTH AND REHAB CENTER,445115,200 TORREY ROAD,LAFOLLETTE,TN,37766,2018-05-03,602,D,1,0,IO8511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility investigation, observation, and interview, the facility failed to prevent misappropriation of a narcotic patch for 1 resident (#1) of 6 residents reviewed for misappropriation of property. The findings included: Review of the facility policy Abuse Prevention Program dated 8/17 revealed .Our residents have the right to be free from abuse, neglect, misappropriation of resident property .Protect our residents from abuse by anyone . Medical record review revealed Resident #1 was admitted to the facility on [DATE], and was readmitted on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. Review of the facility's investigation dated 4/8/18 at 5:30 PM, revealed Resident #1 called for LPN #2, and reported the other nurse had told her she was sent to change her pain patch. When LPN #2 checked the patch she discovered the pain patch missing but the [MEDICATION NAME] (clear dressing) was intact. When the facility was able to contact LPN #1 she stated she was trying to replace the torn [MEDICATION NAME] covering the patch, and accidently removed the patch with the torn [MEDICATION NAME]. She had discovered it in her scrub pocket late that night when doing laundry. On 4/9/18 at approximately 7:00 AM, LPN #1 reported to the Director of Nurses office, and was escorted to HR (Human Resources). At this time LPN #1 returned the patch to the facility. The facility noted the LPN had red eyes and unusual speech patterns. She was taken to the lab for a drug screen, which was failed due to urine failing to have a temperature with in the acceptable range. This was considered a positive and LPN #1 was terminated. Observation and interview with Resident #1 on 5/1/18 at 10:00 AM, in her room revealed on Sunday morning 4/8/18, LPN #1 was a new nurse her hair was blue, she asked me to stand up and I told her I couldn't. She said I'll have to put your pain patch on in the bed. I told her I didn't think it was time for it to be changed, but she said (LPN #2) said it was. She took off the old patch and folded it up in a small piece of gauze. Then she put something on my back, but when (LPN #1) checked she said she didn't put a new patch on. Interview with LPN #2 on 5/1/18 at 10:15 AM, on the 200 Central Hall revealed Resident #1 told her that girl told me you sent her in here to change my patch. I asked her if the girl had blue hair and she said yes that's her. I checked her patch. There was a [MEDICATION NAME] with the date and her (LPN #1's) initials but no patch. The old patch had been removed but she did not put on a new patch. Continued interview revealed somewhere between 9:45 AM, and 10:00 AM, she had observed LPN #1 flipping through my MAR (Medication Administration Record), and around 10:00 AM, (LPN #1) told me (Resident #4) wanted her 12:00 PM, pain pills and asked me if I had given them. She asked me if I wanted her to take the medicine to her and I told her no. Then about 11:30 AM, she told me (Resident #6) wanted a pain pill, and asked me if I wanted her to take it to him, again I told her no. Further interview revealed she had reported both incidents to the RN supervisor. She stated I went and told (RN #1) that she kept asking me if I wanted her to give my residents their pain medications. Interview with RN #1 on 5/1/18 at 12:10 PM, via telephone revealed, (LPN #2) came to me and said (Resident #1) had stated (LPN #1) had removed her patch. The [MEDICATION NAME] was there but there was not patch. It was dated and (LPN #1's) initials were on it. She identified her as the blue haired girl. (LPN #1) was working as a CNA (certified nurse aide) that day; she had no business in the MAR, or dealing with the medications. I told her to just be a CNA for today, and to forget about passing medication, just to do patient care. I had to redirect her a couple of times. She took the [MEDICATION NAME] (pain medication) patch off and kept it. Further interview revealed (LPN #1) had been complaining of being sick, and not long after she took the patch off, she said she was sick, and asked to leave and he had told her to go ahead and leave. Interview with LPN #1 on 5/1/18 4:30 PM, via telephone revealed When I took off the old [MEDICATION NAME], the patch must have come off with it. I reapplied the new [MEDICATION NAME] initialed and dated it. I didn't realize the patch was still on the old [MEDICATION NAME] until I found it in my scrub pocket. Further interview revealed LPN #1 stated as a CNA I should have reported to the nurse, but I am used to being the nurse and I had never worked as a CNA before. I didn't think anything about fixing the [MEDICATION NAME]. Review of facility documents, Daily Assignment Sheets for 3/29/18 through 4/8/18 revealed LPN #1 had worked as a CNA on 3/29, 3/30, 3/31, 4/1, 4/7 and 4/8/2018. Interview with CNA #2 on 5/2/18 at 8:45 AM, in the conference room revealed at approximately 2:00 PM, she (LPN #1) was in (Resident #1's) room, I walked down the hall, the resident's back was towards the door, and she (LPN #1) was standing at her back, as I walked by I heard her say (LPN #2) told me to come in and change your patch. Interview with the Administrator on 5/2/18 at 1:48 PM, in the conference room confirmed the facility failed to prevent misappropriation of a narcotic patch for Resident #1.",2020-09-01
3047,CORNERSTONE VILLAGE,445483,2012 SHERWOOD DRIVE,JOHNSON CITY,TN,37601,2018-07-12,609,D,1,1,O7K511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility records review, and interview, the facility failed to report an allegation of misappropriation for 1 resident's (#183) monies to the Department of Health Incident Reporting System (IRS) in the required timeframe. The findings included: Review of the facility Abuse policy, undated, revealed Misappropriation .the Department of Health will be immediately notified of the alleged event by the Administrator .HOW QUICKLY MUST YOU REPORT? .2. Within 24 hours (if there is not serious bodily injury) after forming your reasonable suspicion . Medical record review revealed Resident #183 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the resident was re-admitted to the facility on [DATE], following a 6 day stay in the hospital. Review of the facility's Incident file, pertaining to the allegation of misappropriation of monies for Resident #183, revealed the resident had disclosed a theft in the morning of Thursday 11/29/17, to the wound care nurse. Continued review revealed the resident was interviewed by the Administrative Assistant, the Director of Nursing and the Social Service Director on 11/29/17 and reasonable suspicion the theft had occurred was established. Further review revealed the facility reported the incident to the Department of Health on Tuesday, 12/6/17, a delay of 6 days. Interview with the Administrator on 7/11/18 at 3:35 PM, in the conference room, confirmed the required timeframe for reporting had not been met.",2020-09-01
839,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-06-12,550,J,1,0,HPNL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, facility video footage review, and interview the facility failed to ensure 1 resident (Resident #2) of 3 residents reviewed was treated with respect, dignity, and quality of life when restrained with a gait belt to his wheelchair. The findings include: Review of the facility policy, Abuse, Neglect and Exploitation of Residents, undated, revealed .It is the policy of the facility that the acts of abuse directed against residents are absolutely prohibited .unlawful restraint is intentionally or knowingly using a physical or chemical restraint . Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 01, indicating severe cognitive impairment. Further review revealed no restraints were used for Resident #2. Medical record review of Resident #2's (MONTH) 2019 Order Summary Reports revealed no order for a restraint. Review of the facility's video footage on 5/2/19 and interview with the Administrator on 6/11/19 at 11:52 AM in the conference room confirmed the Alleged Perpretrator (AP) restrained Resident #2 to his wheelchair by putting a gait belt around his chest and fastening the gait belt to the back of the wheelchair, restraining Resident #2 in his wheelchair. Interview with the Administrator revealed the AP, Certified Nursing Assistant (CNA) #3 and CNA #4 were identified by the Administrator on the video footage. Further review of the facility's video footage revealed CNA #4 was standing at the nurses station facing the AP and Resident #2 and it appeared that CNA #3, wearing a pink shirt, was in the sideline of the camera then CNA #3 walked by the AP and Resident #2 after the gait belt was applied. Further review revealed the facility's video footage did not show removal of the gait belt. Interview with the Administrator revealed the video footage containing conversation between the Respiratory Therapist (RT) and Resident #2 was unavailable due to the system rolls over video footage after 14 days, and some video footage is self-erased. Interview with the Director of Nursing (DON) on 6/11/19 at 8:00 AM in the conference room revealed the DON was informed of the abuse on 5/2/19 around 9:00 AM by Licensed Practical Nurse (LPN) #5. Continued interview revealed by the time the DON informed the Administrator, the Respiratory Therapist (RT) had already reported it to the Administrator. Continued interview revealed when asked when staff were to report abuse the DON confirmed all staff were expected to report suspected or witnessed abuse immediately. Interview with the Administrator on 6/11/19 at 8:15 AM in the conference room revealed the Administrator was notified on 5/2/19 around 10:00 AM by RT #1 of Resident #2 being restrained in his wheelchair with a gait belt around his chest. Continued interview revealed the Administrator reported the allegation to the State Agency as soon as he was aware of the allegation. Further interview when asked when staff were to report abuse the Administrator stated, Immediately, I expect them to notify me as soon as it happens. Interview on 6/11/19 at 1:45 PM with LPN #5 at nurses station 2A revealed she reported for work on 5/2/19 at 7:30 AM. Continued interview revealed she stated, RT (#1) reported to me that (Resident #2 ) was sitting in his wheelchair at the nurses station with a gait belt around his chest, secured to the wheelchair; I went immediately and assessed Resident #2 and he was in the bed with no restraint on and no injuries noted. Continued interview with LPN #5 stated, I reported to the Director of Nursing around 8:30 AM the RT witnessed Resident #2 being in a wheelchair with a gait belt around his chest, secured (restrained) to the wheelchair. Interview with RT #1 on 6/11/19 at 1:15 PM in the conference room revealed on arrival to the facility on [DATE] around 5:30 AM she observed Resident #2 sitting in a wheelchair yelling come here. and look what that [***] did to me. RT #1 stated the resident had a gait belt around the upper part of the chest, attached to the wheelchair, and fitted snugly against the resident's chest. Continued interview revealed RT #1 reported what she saw to the Administrator around 9:00 to 9:30 AM on 5/2/19. She stated, I guess I should have called someone and reported it sooner, I don't know, I just told (LPN #5) as soon as she got here. Validation of the IJ removal plan was completed on 6/12/19 through review of the facility documentation, observations and interviews. Surveyor verified the IJ removal plan by: 1. Review of the personnel file for the AP revealed abuse training was appropriately provided at orientation and as needed. Continued review revealed the facility obtained background checks and reference checks with no negative findings. Immediately following the incident on 5/2/19 the AP was suspended pending investigation. Further review revealed the AP was terminated on 5/2/19 following review of video footage confirming application of a gait belt as a restraint by the AP to Resident #2. 2. Review of resident audits for all the residents on the secured unit. 3. Review of the restraint policy and abuse policy was completed and the policies were appropriate. In-service education was completed for all staff on 5/3/19 to 5/6/19 as evidenced by sign-in rosters and staff interviews. Verification through interviews of internal audits initiated 6/12/19 to ongoing every 2 weeks then weekly for 3 months to assess for restraint use. 4. Presentation of all audits to the Quality Assurance Committee (QAC) monthly for 3 months; with the first presentation at the 6/12/19 meeting.",2020-09-01
2351,MANCHESTER HEALTH CARE CENTER,445391,395 INTERSTATE DRIVE,MANCHESTER,TN,37355,2019-08-07,609,D,1,1,1TH511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, grievance report review, and interviews, the facility failed to immediately report an allegation of abuse for 1 resident (#33) of 24 residents reviewed for abuse. The findings include: Review of the facility policy FREEDOM OF ABUSE, NEGLECT AND EXPLOITATION STANDARD revised 11/2017, revealed .Report allegations or suspected abuse .immediately to: Administrator, Other Officials in accordance with State Law .Reporting-All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint, allegation .of resident abuse .investigation can be undertaken promptly .The Director of Nursing Services, Administrator, or designee will .Ensure that all alleged violations involving abuse .are reported immediately, but not later than 2 hours after allegation is made . Medical record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum (MDS) data set [DATE] revealed Resident #33's Brief Interview for Mental Status score was 11 of 15, indicating the resident had moderate cognitive impairment. Review of a GRIEVANCE/CONCERN/COMMENT REPORT dated 8/5/19, not timed, revealed .(Resident #33) .Person Reporting: Dtr (Daughter) .I have witnessed tech, (Certified Nurse Assistant (CNA) #2) .talk ugly to my Dad. He has verbalized that he is scared of her. She is hateful . Continued review revealed the grievance form was signed by the Social Service Director. Interview with the Social Service Director on 8/7/19 at 9:00 AM, in the conference room, revealed on 8/5/19 a grievance was turned in by Resident #33's daughter. Continued interview revealed the Resident's daughter reported to the Social Service Director that CNA #2 had been hateful and the resident was scared of CNA #2. Further interview confirmed the Social Service Director reported the grievance to the Director of Nursing (DON) the morning of 8/6/19 (1 day later). Interview with the Administrator on 8/7/19 at 12:15 PM, in the Administrator's office, confirmed the facility failed to report an allegation of abuse to the Administrator and the State Survey Agency within 2 hours.",2020-09-01
2352,MANCHESTER HEALTH CARE CENTER,445391,395 INTERSTATE DRIVE,MANCHESTER,TN,37355,2019-08-07,610,D,1,1,1TH511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, grievance report review, and interviews, the facility failed to initiate an immediate investigation of an allegation of abuse for 1 resident (#33) of 24 residents reviewed for abuse. The findings include: Review of the facility policy FREEDOM OF ABUSE, NEGLECT AND EXPLOITATION STANDARDS, revised 11/2017, revealed .This facility will conduct a comprehensive investigation of any employee suspected of abuse .of residents and will implement disciplinary action according to company policy. Any employee, who is accused of resident abuse .will be suspended at the time of allegation, pending further investigation .INVESTIGATION: OF ALLEGED ABUSE .When .reports of abuse .occur, an investigation is immediately warranted .All alleged violations involving .abuse .will be thoroughly investigated by the facility under the direction of the Administrator and in accordance with state and federal law . Medical record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum (MDS) data set [DATE] revealed Resident #33's Brief Interview for Mental Status score was 11 of 15, indicating the resident had moderate cognitive impairment. Review of a GRIEVANCE/CONCERN/COMMENT REPORT dated 8/5/19 revealed .(Resident #33) .Person Reporting: Dtr (Daughter) .I have witnessed tech, (Certified Nurse Assistant (CNA) #2) .talk ugly to my Dad. He has verbalized that he is scared of her. She is hateful . Continued review revealed the grievance form was signed by the Social Service Director. Interview with the Administrator on 8/6/19 at 5:17 PM, outside the conference room, confirmed he had been made aware of the allegation of abuse to Resident #33 reported by the resident's daughter on 8/5/19. Interview with the Social Service Director on 8/7/19 at 9:00 AM, in the conference room, confirmed the grievance was turned in by Resident #33's daughter on 8/5/19. Further interview confirmed an investigation was not initiated by the facility at time the grievance was reported on 8/5/19. Interview with the Administrator and Director of Nursing (DON) on 8/7/19 at 12:15 PM, in the Administrator's office, revealed the DON was made aware of the grievance the morning of 8/6/19. Continued interview revealed an investigation was not initiated until the evening (unknown time) of 8/6/19 (1 day later). Further interview revealed the facility did not initiate an immediate investigation and the facility failed to follow the facility policy.",2020-09-01
404,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-11-13,314,D,1,1,UJ6N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, interview, and observation, the facility failed to ensure weekly skin assessments were completed for 2 (#30, #106) residents of 5 residents reviewed for pressure ulcers of 29 residents reviewed. The findings included: Review of the facility policy, Skin Integrity Guideline, undated, revealed .Licensed nurse will be responsible for performing a skin evaluation/observation weekly, utilizing the Weekly Skin Review . Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of the Braden Scale dated 8/16/17 revealed .score 13.0 .moderate risk . Medical record review of the Weekly Skin Review dated 8/21/17 revealed .elbows and heels clear . Medical record review of the Weekly Skin Review dated 9/4/17 revealed .Treatment in progress for wounds to coccyx and right hip .Top of right foot, red nonblanchable area 3 (centimeters) x (by) 2 (centimeters) .and purple nonblanchable area to bottom of left heel . Medical record review of a Physician's Order dated 9/4/17 revealed .Apply skin prep to red area to top of right foot Q (every) shift until healed .red non blanchable area .apply skin prep to left heel Q shift .for purple non blanchable area . Medical record review of a Physician's Progress Note dated 9/5/17 revealed .area red and nonblanchable on the top of his right foot and a purple discolored area on the bottom of his heel .he said that he often crosses his feet and he feels like this is what has happened . Medical record review of the Progress Note dated 9/12/17 revealed .Right dorsal foot 2.0 (cm) x 2.4 (cm) unblanchable red area .left foot is 2.0 (cm) x 2.0 (cm) red area now nonblanchable appearing now since initial onset which appeared more bruise in appearance. Skin prep continues . Medical record review of the Progress Notes dated 9/16/17 revealed .Resident .refuses to turn and reposition. Resident request that his feet be placed on pillows . Interview with the Wound Care Nurse on 11/8/17 at 8:20 AM, at the Nursing Station, confirmed there was no documentation a skin assessment had been performed the week of 8/28/17, prior to the identification of the red nonblanchable area to the top of the right foot and the purple area on the left heel. Medical record review revealed Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #106 was severely cognitively impaired and required extensive assistance of two person physical assist for bed mobility, transfers, dressing, and personal hygiene, and was totally dependent of two or more physical assist for toileting. Further review revealed Resident #106 was at risk for developing a pressure ulcer, did not have a pressure ulcer at the time of the assessment, and was always incontinent of urine and bowel. Medical record review of Resident #106's plan of care dated 8/29/17 revealed .at increased risk for alteration in skin integrity .impaired mobility . Medical record review revealed a weekly skin assessment was not completed for the week of 10/8/17 - 10/14/17. Medical record review of the weekly skin sheet dated 10/16/17 revealed .open areas .R (right) lateral (side) ankle 1.8 (cm) x 1.6 (cm) x 0.8 (cm) .yellow slough (devitalized tissue) . Medical record review of the Wound report dated 10/27/17 revealed .right ankle .granulation noted to edges of wound with white slough in center .pressure ulcer .unstageable .size of wound .1.9 (cm) x 1.9 . Interview with Registered Nurse (RN) #1 on 11/8/17 at 11:01 AM, in the nursing office, confirmed the facility failed to complete a weekly skin assessment on Resident #106 the week of 10/8/17 - 10/14/17. Interview with Nurse Practitioner (NP) #1 on 11/9/17 at 1:49 PM, in the conference room, confirmed due to the resident's overall condition the development of a pressure ulcer was unavoidable. Observation of Resident #106's right ankle wound on 11/9/17 at 3:42 PM, with RN #1, Licensed Practical Nurse #1, and NP #1 in the resident's room revealed Resident #106 was lying in bed on an air mattress. Continued observation revealed an open area to the right outer ankle approximately the size of a quarter. Further observation revealed the wound bed was red with pink edges. Continued observation revealed RN #1 obtained measurements of the wound which were 2.5 centimeters (cm) x 2.5 cm x 0.5 cm.",2020-09-01
4462,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2016-09-06,502,D,1,0,T33N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, interview, and pharmacy data review, the facility failed to follow physician orders [REDACTED].#4) of 9 residents reviewed. The findings included: Medical record review revealed Resident #4 was admitted on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Consultant Pharmacist Recommendation to Physician form dated 10/19/15 revealed .resident is currently taking [MEDICATION NAME] Sprinkles 125 mg 8 capsules at bedtime. The usual monitored tests are [MEDICATION NAME] Acid .Please consider ordering baseline labs and repeat every six months . Further review revealed the hand written notation .CMP (Comprehensive Metabolic Panal) + (and) [MEDICATION NAME] level q (every) 6 months . Medical record review of the laboratory data revealed no laboratory results for a CMP and [MEDICATION NAME] level in 10/2015. Interview with the DON on 8/25/16 at 12:25 PM, in the BOM office confirmed the facility failed to write the phone order for the 10/19/15 accepted pharmacy recommendation for lab work and failed to obtain the lab work. Interview with Resident #4's Physician on 8/25/16 at 3:00 PM, in the second floor dayroom confirmed the writing on the 10/19/15 pharmacy recommendation was his and his expectation was for the facility staff to write a telephone order and .do what was ordered .",2019-09-01
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
1011,SPRING CITY CARE AND REHABILITATION CENTER,445209,331 HINCH STREET,SPRING CITY,TN,37381,2019-10-23,600,D,1,1,UOSR11,"**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 2 residents (#10 and #53) were free from abuse of 24 residents reviewed for abuse. The findings include: Review of the facility policy, Abuse, Neglect and Misappropriation of Property revised 5/8/19 revealed .Abuse .includes physical abuse .Willful as used in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Physical abuse .includes, but not limited to, hitting, slapping, pinching, kicking . Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nurse's note dated 7/9/19 revealed .increased behaviors noted this shift toward staff when trying to redirect resident or provide care . Medical record review of Resident #10's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Medical record review revealed Resident #231 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #231's Quarterly MDS dated [DATE], revealed the resident was rarely understood. Review of the facility Event Report dated 8/2/19, revealed Resident #231 approached Resident #10 in her wheelchair and struck him with an open hand. Continued review revealed no injury occurred. Interview with Certified Nursing Assistant (CNA) #1 on 10/22/19 at 2:45 PM, in the conference room, confirmed on 8/2/19 she observed Resident #231 in her wheelchair pushing herself by the shower room in the 300 hallway. Continued interview confirmed Resident #231 pushed her w/c up to Resident #10 and struck Resident #10 on the arm with her (Resident #231) hand. Interview with CNA #2 on 10/22/19 at 3:00 PM, in the conference room confirmed on 8/2/19 she observed Resident #231 push her w/c up to Resident #10 and slapped him on the arm. Further interview confirmed Resident #231 had become agitated with staff and residents prior to the incident on 8/2/19 . Interview with the Nurse Consultant on 10/23/19 at 3:25 PM, in the conference room, confirmed there was a resident to resident altercation between Resident #231 and Resident #10 on 8/2/19. Medical record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 1 indicating severe cognitive impairment. Medical record review of Resident #41's nurse's note dated 8/12/19 revealed .had a negative interaction with another resident back on the gate (gated) community .they were in each other's personal space . Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE], revealed Resident #53 had a Brief Interview for Mental Status score of 1 indicating severe cognitive impairment. Medical record review of the facility Event Report dated 8/12/19 revealed .this resident (Resident #41) .yelled 'get the hell over there' .this resident (Resident #41) .reached up and smacked the other resident (Resident #53) .across the right cheek .certified nursing assistant (CNA) .immediately separated both residents .when .asked .why she (Resident #41) smacked the other resident (Resident #53) .resident (Resident #41) .stated 'she got in my face' . Continued review revealed no injuries were noted. Interview with the Facility Administrator on 10/23/19 at 11:17 AM, in the conference room, confirmed the facility failed assure Resident #53 was free from abuse.",2020-09-01
1069,SIGNATURE HEALTHCARE OF ELIZABETHON REHAB & WELLNE,445217,1200 SPRUCE LANE,ELIZABETHTON,TN,37643,2019-10-02,600,D,1,1,IXRK11,"**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 abuse for 1 resident #22 of 8 residents reviewed for abuse of 29 sampled residents The findings include: Review of the facility policy, Abuse, Neglect and Misappropriation of Property revised 5/8/19 revealed It is the organization's intention to prevent the occurrence of abuse .Abuse .includes physical abuse .willful .means non-accidental .Willful as used in the definition of abuse' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #22's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 5 indicated the resident had severe cognitive impairment and required extensive assistance for bed mobility, toileting, transfer, dressing and toileting. Medical record review revealed Resident #173 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #173's Significant Change MDS dated [DATE] revealed the resident had a BIMS score of 7, indicated the resident had severe cognitive impairment, coded with hallucinations and delusions, required extensive assistance for dressing, limited assistance for toileting and hygiene and supervision for locomotion, bed mobility, transfer and locomotion. Medical record review of Resident #173's care plan dated 2/12/19 revealed .Resident is a threat to self and/others .history of physical and verbal abuse . rejection of care, urinates in inappropriate places R/T (related to) Dementia, Depression, history of [MEDICAL CONDITION] .Goal .Resident will not harm self or others . Medical record review of Resident #173's nurse's note dated 7/4/19, revealed at 9:50 PM, Certified Nursing Assistant (CNA) was summoned to the room by resident (#173), who told him that he had beat up his roommate (#22). Roommate (Resident #22) said resident had hit him twice in the face and roommate's urinary catheter was pulled out. No injuries were noted to resident. Residents were separated and monitored. Contacted Director of Nursing (DON), MD (Medical Doctor), new orders to send out for behavioral modification and psych evaluation. Contacted both families. Resident had on roommates's shoes and refused to remove them, saying they were his. Resident left facility via EMS (Emergency Medical Services) at 11:18 PM. Medical record review of Resident #173's Psychiatric note dated 7/15/19, revealed the resident had continued inappropriate and bizarre behavior and had to move his roommate (Resident #22) out because of the resident's behavioral disturbances. Interview with CNA #1 on 10/1/19 at 2:20 PM, in the conference room, confirmed she was working as a CNA on the 200 hall on 7/3/19. Continued interview confirmed another CNA called for her and she went into the room while the other CNA separated Resident 173 and Resident #22. Further interview confirmed staff took Resident #173 out of the room and staff cleaned up Resident #22 because his catheter had been pulled out and and there was blood on Resident #22. Further interview confirmed Resident #22 told the CNA that Resident #173 had hit him in the face. Continued interview confirmed she was not aware of any other incidents of aggression. Further interview confirmed it was at the end of her shift and she left shortly after the incident. Interview with CNA #2 on 10/1/19 at 3:10 PM by phone, revealed he worked from 6 PM-10 PM on the day of the incident (7/3/19). Further interview confirmed he was passing ice and went in to resident's room and the lights were off, he turned the lights on and saw Resident #173 standing by Resident #22 in his bed. Further interview confirmed blood was on Resident #22's sheet and the urinary catheter had been removed from Resident #22. Continued interview confirmed Resident #173 stated that he had beat the hell out of him (resident #22). Further interview confirmed Resident #22 stated to the CNA that Resident #173 had hit him. Continued interview confirmed Resident #22 was checked for any injuries and no marks or injuries were found. Further interview confirmed the residents were separated he was unsure what room the residents were sent to. Further interview confirmed he was not aware of either residents having aggressive behavior prior to this event. Review of a statement by the DON dated 10/2/19 revealed .This nurse spoke with resident (#173) the next day on 7/4/19 about incident the night before. He had told me that his roommate left because he beat him up & there was blood all over the place but didn't remember much about the night except he went to jail & they released him . I had also spoke to the other resident (Resident #22)who stated to just forget it ever happened .I spoke with (Resident #173)'s daughter on 7/5/19 from home in regards to his behaviors & explained he may be more appropriate in a behavior unit if his behaviors continued with refusing care, etc .",2020-09-01
2199,HARRIMAN CARE & REHAB CENTER,445368,240 HANNAH ROAD,HARRIMAN,TN,37748,2017-11-08,353,D,1,1,78KG11,"**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 sufficient staffing to meet the needs of 2 residents (#18 and #59) of 17 residents reviewed. The findings included: Review of the facility policy, Introduction to Restorative Nursing Process dated 7/2010 revealed .The most successful Restorative Nursing programs are evidenced by the presence of a solid nursing/therapy team .This provides the foundation for superior resident care delivery and seamless transition through the rehabilitation and restorative continuum . Medical record review revealed Resident #18 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's ( #18) was cognition was intact, required 2 person assist for most of her activities of daily living and had functional limitation in range of motion (ROM) to bilateral upper and lower extremities. Medical record review of the Restorative Nursing Program for ROM/Exercise dated 7/11/17 revealed Resident #18 was to receive passive range of motion and active range of motion six times a week. Medical record review of the Restorative Nursing Report dated 9/2/17 revealed Resident #18 received ROM once in the month of (MONTH) (YEAR) and refused services 3 times during the month of September. Continued review revealed in (MONTH) (YEAR) Resident #18 received ROM services 3 times and refused ROM services 3 times in the month of October. Observation on 11/8/17 at 12:15 PM in Resident #18's hallway revealed the resident in an electric wheel chair, and talking to staff and peers. Interview with the Restorative Certified Nursing Assistant on 11/6/17 at 2:15 PM confirmed Resident #18 was to receive range of motion services 6 times a week and that she was pulled in to staffing and staff were unable to provide restorative services which includes range of motion services. Interview with Restorative Licensed Practical Nurse on 11/6/17 at 2:37 PM in the conference room confirmed .She is to get range of motion 6 times a week but receives it 1-2 times a week .They keep pulling us to the floor or sending us home .Need to be able to get job done and take care of patients .She comes to me and says I need range of motion . Continued review revealed LPN #3 and restorative CNAs are placed into staffing to provide care to the residents and are unable to perform restorative needs such as ROM. Interview with CNA #2 on 11/7/17 at 8:47 AM in the 500 hallway, confirmed .We need more CNAs on floor especially on Resident #18 shower days . Interview with CNA #1 on 11/8/17 at 8:35 AM in the conference room, confirmed .Some days not enough staff . Interview with RN #3 on 11/8/17 at 1:08 PM in the conference room, confirmed .A couple residents had to wait 15-20 mins to be changed .They (CNAs) stay busy . Medical record review revealed Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 11/6/17 at 10:30 AM, in Resident #59's room revealed the resident was in the bed and not able to move the left arm or leg. Medical record review of the Restorative Nursing Report dated from 10/7/17 to 10/31/17 revealed Resident #59 received ROM services from Restorative Nursing on 2 days 10/10/17 and 10/31/17. Interview with the Restoratve LPN on 11/8/17 at 2:50 PM in the conference room, revealed .it's (ROM) suppose to be done 6 times a week but we can't always get to her .we get pulled to work the floor .or sent home .",2020-09-01
1526,GREEN HILLS CENTER FOR REHABILITATION AND HEALING,445267,3939 HILLSBORO CIRCLE,NASHVILLE,TN,37215,2019-07-16,609,D,1,0,RDJP11,"**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 report an allegation of abuse to a state agency within the 24 hour time frame for 1 (Resident #1) of 3 residents reviewed. The findings include: Review of the facility policy Abuse and Neglect revised 7/2018 revealed .The facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment including injuries of unknown origin, and misappropriation of property to the administrator, State Survey Agency and law enforcement officials and adult protective services in accordance with Federal and State law through established procedures. Timeline for reporting is as follows .If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, a report is made no later than 24 hours after the facility is notified of the allegation . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the care plan dated 7/6/18 revealed .I am at risk for falls r/t (related to) Confusion, Deconditioning, Gait/balance problems, Incontinence, Psychoactive drug use, Unaware of safety needs . Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a Brief Mental Interview for Mental Status (BIMS) score of 0 which indicated severe cognitive impairment. Continued review revealed Resident #1 required supervision with setup only when walking in room. Interview with Resident Care Specialist #5 (RCS) on 7/16/19 at 1:30 PM in the Director Of Nursing (DON) office revealed Registered Nurse #5 (RN) stated .I just came out of this room, what the hell is wrong with you . to Resident #1. Continued interview with RCS #5 revealed she left the room and saw the DON coming toward the room and told her .RN #5 was off the chain . Continued interview with RCS #5 revealed she did not report what she heard RN #5 said to Resident #1. Continued interview with RCS #5 revealed .I didn't explain to her (DON) what was going on. I got on the elevator . Continued interview with RCS #5 revealed she did not report the verbal abuse to the DON until a later time during a conversation. Continued interview with RCS #5 confirmed .I told the DON I knew I should have said something but I was so upset at the time . Continued interview with RCS #5 confirmed .you are suppose to report it (verbal abuse) to your immediate supervisor . Continued interview with RCS #5 revealed she had knowledge of the facility's policy and procedures for abuse. Interview with DON on 7/16/19 at 7:04 PM in her office revealed the DON confirmed .my expectation of staff is to stop it immediately and report it to the abuse coordinator, myself, or the immediate supervisor. Continued interview revealed .I shared that expectation with her (RCS #5) when she shared with me the incident .",2020-09-01
4682,HILLCREST HEALTHCARE CENTER,445316,111 E PEMBERTON STREET,ASHLAND CITY,TN,37015,2016-08-17,323,E,1,0,7BRH11,"**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 3 of 3 (Resident #1, 15 and 105) sampled residents reviewed for risk of elopement. The findings included: 1. The facility's Risk of Elopement policy documented, .In our facility, elopement refers to the ability of a resident who is not capable of protecting him or herself successfully leave the facility unsupervised or unnoticed and enter into harm's way .The staff will assess and identify residents who are at risk for harm due to unsafe wandering or risk of elopement on admission, quarterly, and as needed . 2. 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 the resident was non-verbal, had a cognitive summary score of 14 indicating the resident was cognitively intact and required supervision in locomotion on the unit after one person physical assist with the use of a wheelchair. Review of the resident's elopement risk assessments from 6/11/15 to present revealed two quarterly elopement risk assessments dated 6/20/16 and 3/20/16 which both indicated the resident was not at risk for elopement. The facility was unable to provide documentation of additional elopement risk assessments having been completed. Observations on the D Hall on 8/16/16 at 4:10 PM revealed, Resident #1 propelled to the door leading to a gated courtyard and was banging on the key-coded door, which had a 15 second lock delay, attempting to get outside. 3. Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS dated [DATE] revealed the resident had clear speech, had a cognitive summary score of 14 indicating the resident was cognitively intact, transferred with supervision after one person physical assist, ambulated with supervision and required supervision in locomotion on the unit after one person physical assist with the use of a wheelchair. Review of the resident's elopement risk assessments from 6/11/15 to present revealed a quarterly elopement risk assessment dated [DATE] and an annual assessment dated [DATE] which both indicated the resident was not at risk for elopement. The facility was unable to provide documentation of additional elopement risk assessments having been completed. The Social Services Director's (SSD) progress note dated 7/18/16 documented, .met with resident concerns the resident stating she wanted to leave the facility . Observations in Resident #15's room on 8/16/16 at 11:30 AM revealed, the resident appropriately dressed, sitting at the bedside in a wheelchair. Interview with the resident revealed she was alert and oriented to person, place and time and able to transfer herself and get around in her wheelchair without staff assistance. Telephone interview with Resident #15's power of attorney (POA) on 8/16/16 at 11:10 AM revealed, in the middle of (MONTH) (2016) the resident had been threatening to leave the facility. 4. Medical record review revealed Resident #105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] revealed the resident had no speech, rarely/never made self understood, sometimes understands, displayed no wandering behavior and had supervision during ambulation on the unit after one person physical assist. Review of the resident's elopement risk assessment dated [DATE] revealed the resident did not require interventions to reduce risk for elopement. The facility was unable to provide documentation of additional elopement risk assessments having been completed. A staff in-service sign-in sheet dated 7/21/16 documented, .(Named Resident #105) is to wear a bracelet for the anti-wander device . Observations of Resident #1 on 8/16/16 at 2:00 PM, 2:25 PM and 2:45 PM revealed, the resident was neatly dressed and wearing tennis shoes, ambulating independently up and down the halls of the facility with an anti-wander device bracelet intact on her left wrist. 5. Interview with the Director of Nursing (DON) on 8/17/16 at 3:25 PM in the DON office, when asked how often the residents' elopement risk assessments were suppose to be completed, the DON stated, Everyone at admission, then quarterly and prn (as needed). I'm not sure if the quarterly assessments are done on everyone or just those determined to be at risk. That would be a social services question. Interview with the SSD on 8/17/16 at 3:45 PM in the SSD office, when asked if the elopement risk assessments were to be completed quarterly on everybody, the SSD stated, Yes. When asked are you the one responsible, the SSD stated, Yes. Interview with the DON on 8/17/16 at 3:50 PM in the DON office, when asked about Resident #15 having threatened to leave the facility, the DON stated, She had the one episode last month. (Named Resident #15's Family Member) called me at home and said (Named Resident #15) was going to leave the building .I called the charge nurse and we put her on 15 minute checks that night . When asked about Resident #105's elopement risk assessment which documented intervention was not required to reduce risk for elopement, the DON stated, She should have had another assessment. We had to go with the wanderguard with her.",2019-08-01
4743,"COLLIERVILLE NURSING AND REHABILITATION, LLC",445495,490 WEST POPLAR AVENUE,COLLIERVILLE,TN,38017,2016-08-23,322,D,1,0,VCF211,"**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 medications were administered correctly via percutaneous endoscopic gastrostomy (PEG) tube for 2 of 2 (Resident #2 and 4) of the 3 residents reviewed for PEG medication administration. The findings included: 1. The facility's Medication Administration Enteral (PEG) Tubes policy documented, .The nursing care center assures the safe and effective administration of enteral formulas and medications .PR[NAME]EDURES .Verify tube placement .Unclamp tube and use the following procedures .Insert a small amount of air into the tube with the syringe and listen to stomach with stethoscope for gurgling sounds .Aspirate stomach contents with syringe. Check residual. Allow stomach contents to go back into stomach .Allow medication to flow down tube via gravity .Give gentle boosts with the plunger (approximately 1-inch down) if the medication will not flow by gravity .Do not push medications through the tube . 2. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician re-admission orders [REDACTED]. Observations in Resident #2's room on 7/20/16 beginning at 8:00 AM, revealed Nurse #4 did not check for stomach content residual before administering the ordered medications. 3. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician recertification orders dated 6/2016 revealed Resident #4 was to receive the following medications via PEG tube: Vitamin C 500 mg one tablet daily, a Multivitamin with minerals one tablet daily, [MEDICATION NAME] 10 mg/milliliter (ml) 10 ml daily and Acidophilus one capsule daily. Observations in Resident #4's room on 7/20/16 beginning at 9:20 AM, revealed Nurse #5 did not instill air and listen to the resident's abdomen with the stethoscope or check for stomach content residual before first pushing 30 ml of water to flush the PEG tube. Nurse #5 then, keeping the syringe barrel and plunger together, pulled the plunger back to get the 1st medication into the syringe, attached the syringe to the PEG tube and pushed the medication through the tube followed by pushing 5 ml of water through the tube. Nurse #5 continued to push each medication, following each with 5 ml of water until the 4 medications were administered. Nurse #5, having administered the ordered medications, pushed 30 ml of water through the PEG tube as a final flush. 4. Interview with the Director of Nursing (DON) on 7/20/16 at 9:55 AM, in the conference room, when asked if nurses should have aspirated for residual before giving medications via PEG tube, stated, Yes. The DON was then asked if nurses should auscultate to check placement then check for residual before giving medications via PEG tube, the DON stated, Oh yeah. The DON was then asked if medications and flushes should be allowed to flow through the PEG tube by gravity, the DON stated, Yes and confirmed the nurses should be following the facility's policy.",2019-08-01
1417,SUMMIT VIEW OF ROCKY TOP,445259,204 INDUSTRIAL PARK RD,ROCKY TOP,TN,37769,2017-06-28,312,D,1,1,YWM011,"**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 basic oral hygiene to a totally dependent resident for 1 resident (#79) of 35 residents reviewed for oral hygiene. The findings included: Review of a facility policy Mouth Care dated (MONTH) 2007, revealed .the purposes of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent infections of the mouth .the following should be recorded in the resident's medical record .date and time the mouth care was provided . Medical record review revealed Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 6/26/17, at 8:43 AM, in the resident's room, revealed Resident #79 lying in bed with eyes closed. Continued observation revealed the resident's mouth had dried saliva around the lips. Observation and interview with Licensed Practical Nurse (LPN) #15 on 6/26/17, at 8:50 AM, confirmed the resident had dried saliva around the mouth. Observation on 6/26/17, at 3:24 PM, in the resident's room, revealed the dried saliva was still around the mouth. Interview with LPN #15 on 6/26/17, at 3:25 PM, at the nursing station, confirmed the Certified Nurse Aide (CNA) .do mouth care sometimes and the nurses do mouth care sometimes .I don't know if he had mouth care today or not . Interview with Unit Manager (UM) #1 on 6/27/17, at 8:55 AM, at the front desk, confirmed she expected mouth care to be given and .mouth care is given as needed and every 2-4 hours with swabs .",2020-09-01
4742,"COLLIERVILLE NURSING AND REHABILITATION, LLC",445495,490 WEST POPLAR AVENUE,COLLIERVILLE,TN,38017,2016-08-23,205,E,1,0,VCF211,"**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 written information regarding the facility's bed-hold policies to the resident, a family member or legal representative at the time of transfer to the hospital for 3 of 3 (Resident #1, 2 and 3) residents reviewed. The findings included: 1. The facility's BED HOLD POLICY last revised 9/1/95 documented, .This policy will be explained to the resident and responsible party upon admission and will be posted at each nurse's station so it can be reviewed by resident, family, or friends before transfer to the hospital or therapeutic leave . 2. Closed medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the NURSE'S NOTES for (MONTH) (YEAR) revealed Resident #1 was transferred and discharged to the hospital on [DATE] and had not returned to the facility as of 7/25/16. 3. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the NURSE'S NOTES for (MONTH) (YEAR) revealed Resident #2 was transferred and discharged to the hospital on [DATE] and returned to the facility 5/20/16. Review of the NURSE'S NOTES for (MONTH) (YEAR) revealed the resident was transferred and discharged to the hospital on [DATE] and returned to the facility on [DATE]. 4. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the NURSE'S NOTES for (MONTH) (YEAR) revealed Resident #3 was transferred and discharged to the hospital on [DATE] and returned to the facility on [DATE] and was again transferred and discharged to the hospital on [DATE] and returned on 7/13/16. 5. Interview with the Administrator on 7/19/16 at 8:30 AM, in the conference room, when asked for a copy of the facility's bed-hold policy, stated, .We QA'd (Quality Assurance review conducted) the bed-hold policy. It was not transferred with the residents on discharge . 6. The facility's newly developed BED HOLD POLICY, effective date 7/12/16, documented, .If you are transferred out of the facility to the hospital or for an overnight therapeutic leave, we will provide written information about our bed hold policy to you . 7. Interview and observation with Licensed Practical Nurse (LPN) #1 on 7/25/16 at 11:20 AM, at the 3rd floor nursing station, when asked if the bed-hold policy was sent to the hospital with the resident at time of transfer, LPN #1 stated, .Not as far as I know . Observation of the file containing the transfer forms in use revealed the Nursing Home to Hospital Transfer Form did not include the bed-hold policy. 8. Interview and observation with LPN #2 and LPN #3 on 7/25/16 at 11:25 AM, at the 2nd floor nursing station, when asked if the bed-hold policy was sent to the hospital with the resident at time of transfer, LPN #2 stated, No, I've never sent it out. Observation of the file containing the transfer forms in use revealed the Nursing Home to Hospital Transfer Form which did not include the bed-hold policy and another multi-page transfer form with carbon-copy pages, which had the facility s new BED HOLD POLICY attached. When asked if they had received in-services on use of the new transfer form, LPN #2 stated, No. LPN #3 also stated, No.",2019-08-01
4681,HILLCREST HEALTHCARE CENTER,445316,111 E PEMBERTON STREET,ASHLAND CITY,TN,37015,2016-08-17,280,D,1,0,7BRH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observation and interview, the facility failed to revise the care plan in a timely manner with a change in the resident's condition for 1 of 32 (Resident #105) sampled residents reviewed. The findings included: The facility's Care Planning policy documented, .Our facility develops and maintains an individualized comprehensive care plan for each resident .Care plans are revised as changes in the resident's condition dictate . Medical record review revealed Resident #105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A staff in-service sign-in sheet dated 7/21/16 documented, .(Named Resident #105) is to wear a bracelet for the anti-wander device . Resident #105's comprehensive care plan documented, .I am a wanderer and at risk for elopement AEB (as evidenced by) being disoriented to place, having an impaired safety awareness, wandering aimlessly throughout the facility. Date Initiated: 08/16/2016 Created on: 08/16/2016 .Interventions .Be sure my wanderguard bracelet or anklet is in place . Observations of Resident #1 on 8/16/16 at 2:00 PM, 2:25 PM and 2:45 PM revealed, the resident was neatly dressed and wearing tennis shoes, ambulating independently up and down the halls of the facility with an anti-wander device bracelet (wanderguard) intact on her left wrist. Interview with the Director of Nursing (DON) on 8/17/16 at 4:45 PM in the Staff Development Office, the DON confirmed Resident #105 had started wearing the wanderguard bracelet on 7/21/16 and the care plan had not been revised until 8/16/16. When asked how soon after a change in a resident's status the facility updated their care plan, the DON stated, Normally on a daily basis. Definitely weekly.",2019-08-01
4426,CREEKSIDE CENTER FOR REHABILITATION AND HEALING,445516,306 W DUE WEST AVENUE,MADISON,TN,37115,2016-10-24,332,L,1,0,CT4U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observation of medication pass, and interview, the facility failed to ensure the medication error rate was less than 5% for the facility with 21 medications given more than one hour before and one hour after the scheduled time with 32 medications observed during medication pass for a medication error rate of 65%. The facility's failure to ensure safe medication administration placed all residents in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Administrator (NHA) was informed of the Immediate Jeopardy on 10/24/16 at 3:25 PM in the Conference Room. F332 is Substandard Quality of Care. The findings included: Review of facility policy, Medication Administration, revised 3/16/15 revealed, .Administer medications within 60 minutes of the scheduled time .for example, if the medication is ordered for 8:00 a.m., it must be give between 7:00 a.m. and 9:00 a.m. in order to be considered timely . The Medical Director of the facility is the physician of record for all the residents. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation and interview with Licensed Practical Nurse (LPN) #1 on 10/11/16 at 1:15 PM, in Resident #2's room revealed the LPN checked the resident's blood sugar and was administering a bolus tube feeding scheduled at 12:00 PM. Interview with the LPN confirmed the tube feeding was administered a little late, but I get it all done. Medical record review revealed a physician's orders [REDACTED]. The scheduled administration time was 9:00 PM. Medical record review of the Medication Administration Record [REDACTED] 10/8 administered at 10:26 PM 10/9 administered at 10:30 PM 10/10 administered at 11:43 PM 10/11 administered at 10:32 PM 10/12 administered at 12:33 AM on 10/13 10/13 administered at 11:32 PM 10/14 administered at 11:41 PM 10/18 administered at 12:30 AM on 10/19 10/19 administered at 11:25 PM Interview with the DON on 10/19/16 at 4:05 PM, in the conference room revealed the DON was unaware [MEDICATION NAME] was being administered consistently late to Resident #2. Continued interview with the DON confirmed the facility failed to follow the policy to administer medications within the 60 minute time frame before and after the scheduled time resulting in medication errors for Resident #2. Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR indicated [REDACTED] Tylenol ([MEDICATION NAME]) 650 mg due at 9:00 AM Aspirin 81 mg due at 9:00 AM [MEDICATION NAME] (antidepressant) 40 mg due at 9:00 AM [MEDICATION NAME] (over-active bladder) 5 mg due at 9:00 AM [MEDICATION NAME] ([MEDICAL CONDITION]) 1000 mg due at 9:00 AM Floastor ([MEDICATION NAME]) 250 mg due at 9:00 AM Observation during medication pass which began at 11:00 AM, revealed LPN #7 administered all of the medications at 11:10 AM. Medical record review revealed Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR indicated [REDACTED] a. blood glucose check at 7:30 AM b. Humalog Insulin according to the blood glucose at 7:30 AM c. [MEDICATION NAME] (antacid) 150 milligrams (mg) due at 9:00 AM d. [MEDICATION NAME] ([MEDICAL CONDITION]) 600 mg due at 9:00 AM e. [MEDICATION NAME] ([MEDICAL CONDITION]) 250 mg due at 9:00 AM f. [MEDICATION NAME] (antibiotic)100 mg due at 10:00 AM g. Eliquis (anticoagulant) 10 mg due at 10:00 AM h. [MEDICATION NAME] (steroid) 5 mg due at 10:00 AM Observation during the medication pass revealed Registered Nurse (RN) #3 administered all of the medications and completed the blood glucose check at 11:15 AM. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR indicated [REDACTED] a. [MEDICATION NAME] (diuretic) 37.5/25 mg at 8:00 AM b. [MEDICATION NAME] (diuretic) 40 mg at 9:00 am c. [MEDICATION NAME] (cardiac) 240 mg at 9:00 AM d. Potassium Chloride (replacement) 20 milliequivalents at 9:00 AM e. [MEDICATION NAME] (stool softener) 100 mg at 10:00 AM f. [MEDICATION NAME] (antibiotic) 100 mg at 10:00 AM g. [MEDICATION NAME] (antibiotic) 2 grams intravenously at 10:00 AM Observation during the medication pass revealed RN #3 administered all of the medications at 12:05 PM. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR indicated [REDACTED] a. [MEDICATION NAME] (antihypertensive) 40 mg at 9:00 AM b. [MEDICATION NAME] (prevent blood clotting) 30 mg due at 9:00 AM Observation during the medication pass revealed RN #3 administered both medications at 11:45 AM. Interview with RN #3 on 10/19/16 at 12:30 PM on the IBW hall revealed she was aware she was late administering her medications but also stated .I would rather my residents be safe . Continued interview revealed RN #3 stated medications are signed off as soon as they are administered because to wait until the end of med pass would be too confusing and difficult to remember if any medications were held. Interview with the Director of Nursing (DON) on 10/19/16 at 4:05 PM, in the conference room revealed she was aware medications were being administered outside the 2 hours window (60 minutes before and 60 minutes after the scheduled time) allotted for medication administration. Continued interview with the DON confirmed medications, blood glucose monitoring, and insulin were administered at times greater than the 2 hours window allowed. Further interview with the DON confirmed it was a medication error for medications to be administered more than 1 hour before or 1 hour after the scheduled time. Refer to F157 K, F224 L SQC, F281 L, F282 [MI]",2019-10-01
4423,CREEKSIDE CENTER FOR REHABILITATION AND HEALING,445516,306 W DUE WEST AVENUE,MADISON,TN,37115,2016-10-24,224,L,1,0,CT4U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observation of medication pass, and interview, the facility failed to prevent resident neglect when it failed to complete blood glucose monitoring at specified times; failed to administer insulin at scheduled times; failed to administer cardiac, blood pressure, and anti-[MEDICAL CONDITION] medications within the scheduled time frame; failed to notify physician of abnormal blood glucose values; failed to follow physician's orders to recheck blood glucose after an abnormal value was found; and failed to document interventions for 12 residents (#2,# 3,# 6,# 5, #7, #8, #9, #10, #4, #11, #12, #13 ) of 12 residents reviewed for medications. These failures placed all diabetic residents 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 of a resident). The Administrator (NHA) was informed of the Immediate Jeopardy on 10/24/16 at 3:15 PM in the Conference Room. F224 is Substandard Quality of Care The findings included: Review of facility policy, Medication Administration, revised 3/16/15 revealed, .Administer medications within 60 minutes of the scheduled time . Review of facility policy, Diabetes, Nursing care of the Adult Diabetes Mellitus Resident, undated, revealed, .The purpose of this guideline is .Prevent recurrence of [MEDICAL CONDITION]/[DIAGNOSES REDACTED] (high and low blood sugars). Recognize, assist and document the treatment of [REDACTED].obtain pre-meal fingerstick blood glucose within 60 minutes (maximum) of anticipated meal .The physician should be notified when the blood sugar falls above his/her specified blood sugar range and/or above 400 mg/dL (milligrams per deciliter) . Review of facility policy, Guidelines for Medications, undated, revealed .All blood sugars that are less than 60 or greater than 400 must be rechecked in 15 minutes and documented . The Medical Director of the facility is the physician of record for all the residents. Medical record review revealed Resident #2 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 had a Brief Interview for Mental Status (BIMS) of 4/10 due to the inability of the resident to complete the interview, indicating the resident was severely cognitively impaired. She received 51% or more of her calories, 500 cc (cubic centimeters) or more of fluid through a feeding tube, and received 7 injections of insulin during the previous 7 days. Medical record review of a Physician's Order for Resident #2 dated 6/4/16 revealed, .ACCUCHECKS (finger stick for blood sugar) BEFORE BOLUS FEEDINGS AND SSI (sliding scale insulin) AS FOLLOWS: 0-59 = CALL MD (Medical Doctor) 60-150=0, 151-200=2u (units), 201-250=4u, 251-300=6u, 301-350=8u, 351-400 = 10u .NOTIFY MD AND RECHECK IN 15 MINUTES . The scheduled time was 6 AM, 12 PM, 6 PM, and 12 AM daily. Medical record review of the 6/2016 Medication Administration Record [REDACTED]. Continued review revealed blood sugars were checked 1-4 hours late 2 times for the month of 6/16. Interview with Licensed Practical Nurse (LPN) #3 on 10/18/16 at 2:20 PM in the conference room revealed he called Nurse Practitioner (NP) #2 on 6/4/16 regarding Resident #2's blood sugar of 211 and was told to hold the SSI dose of 4 units. The LPN confirmed he did not write an order to hold the 4 units of insulin and he did not administer the dose per the sliding scale protocol. Medical record review of Resident #2's 7/2016 MAR indicated [REDACTED]. The time frame excludes the window of time which is allowable to administer medication 60 minutes before or 60 minutes after the scheduled time. Medical record review of Resident #2's 9/2016 MAR indicated [REDACTED]. Medical record review of the 10/2016 MAR for Resident #2 revealed blood sugars were checked 17 minutes-4 hours and 35 minutes late 8 times from 10/1-10/20/16 and checked 1 hour and 26 minutes early on 10/8/16. Medical record review of Resident #2's Physician's Orders for Resident #2 dated 9/22/16 revealed an order for [REDACTED]. The scheduled administration time was 9:00 PM. Continued medical record review of the 9/2016 MAR indicated [REDACTED]. There was no documentation the blood sugar was re-checked in 15 minutes after administration of the 10 units of SSI. The blood sugar was not checked at 6:00 PM per order and the 21 units of [MEDICATION NAME] was not administered at 9:00 PM on 9/22/16 per order. The blood sugar was 327 at 12:00 AM on 9/23 and no SSI was administered; the blood sugar was 560 at 6:00 AM and no SSI was administered, the blood sugar was not re-checked in 15 minutes, and the physician was not notified. Continued review revealed no physician orders to hold accuchecks, [MEDICATION NAME], or SSI in Resident #2's medical record. Medical record review of an e-MAR (electronic Medication Administration Record) narrative Administration Record note for Resident #2 dated 9/22/16 at 7:20 PM by Registered Nurse (RN) #2 revealed, .ACCUCHECK .scheduled for 09/22/2016 6:00 PM. verbally ordered to hold insulin per NP #1 . Continued review of a note dated 9/22/16 at 9:44 PM by RN #2 revealed, .[MEDICATION NAME] .scheduled for 09/22/2016 9:00 PM. Ordered to hold per NP #1 . Continued review revealed the blood glucose was 327 at 1:50 AM and a note dated 9/23/16 at 1:50 AM by LPN #5 revealed, .insulin held as ordered . The blood glucose was 560 at 5:16 AM and a note on 9/23/16 at 5:16 AM from LPN #5 revealed, .insulin held for lab work this am . Review of a physician's order dated 9/22/16 revealed A1C (blood test to determine average glucose over 3 months) in AM. Interview with NP #1 on 10/12/16 at 12:38 PM in the conference room revealed, when asked if insulin needed to be held prior to drawing A1C labwork, the NP stated, Absolutely not. Continued interview with the NP revealed she was aware the insulin had not been given to Resident #2 when she rounded (visited residents) on 9/23/16. The NP denied giving a verbal order to Registered Nurse (RN) #2 to hold insulin on the resident on 9/22/16. She stated, I only met (RN #2) the one time during shift change. (LPN #4) and I had been dealing with (Resident #2's) [MEDICAL CONDITION] (high blood sugar) issues during that day. I absolutely did not give a verbal order to hold insulin and no one called me when it was 560. What I wanted done was to wait until 7 PM to give the next tube feeding bolus as the previous one was given around 2 or 3 PM. I was here when the blood sugar was 501 and (LPN #4) gave 10 units, rechecked it and it was still high. I believe we may have given another 10 units of insulin after that. It makes no sense to hold insulin when the blood sugars had been high that day. Further interview and medical record review with the NP confirmed there was no written telephone order and no computerized order by LPN #4 to give another 10 units of insulin, no order to hold the [MEDICATION NAME] dose at 9:00 PM, and no order to hold any SSI (Sliding Scale Insulin - specific amount of insulin administered according to blood glucose result) at 12:00 AM or 6:00 AM. Interview with LPN #4 on 10/12/16 at 2:05 PM, in the conference room revealed she notified NP #1 on 9/22/16 when Resident #2's blood sugar was 501 and was told to give 10 units of insulin, wait 30 minutes and re-check it again. The LPN stated when she re-checked the blood glucose 30 minutes later the blood glucose was higher than 501 and the NP told her to give an additional 12 units of insulin and recheck it after that. Continued interview with LPN #4 revealed she checked it after administering 12 units and the blood glucose was in the 300's and stated she notified the NP and was told to go ahead and give the tube feeding now. The LPN was not sure of the exact time but stated it was around 2 or 3 in the afternoon. Further interview with LPN #4 revealed I told (RN #2) I didn't give the 6 o'clock tube feeding, and to give it at 7 PM because the 12 o'clock dose was given later in the afternoon because of the blood sugars. Continued interview with LPN #4 confirmed she failed to write an order to administer an additional 12 units of insulin on 9/22/16; failed to document the results of the blood sugars when she rechecked them twice; and failed to document she had notified the NP for a blood glucose of 501 and higher for Resident #2. Telephone interview with RN #2 on 10/12/16 at 3:20 PM revealed, The NP was rounding when I was taking over the cart around 6:30 or 7 PM. She told me to hold 1 dose of insulin for (Resident #2) because her blood sugar had been low. I don't know why the other nurse held the insulin as it is not indicated for an A1C. Continued interview with RN #2 confirmed he did not write a telephone order to hold 1 dose of insulin and did not put an order in the computer and stated, I didn't know how to make it a physician's order in the computer. Telephone interview with LPN #5 on 10/18/16 at 4:00 PM revealed, (RN #2) gave me report to hold the insulin for lab work in the morning. I should have looked to see the order myself, and I did not call the Doctor when (Resident #2's) sugar was 560. I was just going on what I was told. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission MDS dated [DATE] revealed the resident was severely cognitively impaired, had impairments to all extremities, received insulin 1 time over the previous 7 days, received 51% or greater of his calories, and 501 cc per day of fluid through a feeding tube. Medical record review of a telephone physician's order dated 9/22/16 revealed, .Accuchecks before meals and at bedtime . The scheduled time of administration was 7:30 AM, 12:00 PM, 5:00 PM, and 9:00 PM. The order did not include sliding scale insulin (SSI) orders. Medical record review of the 9/16 MAR indicated [REDACTED]. Medical record review revealed no telephone physician orders regarding accuchecks, SSI, or administration time changes. Medical record review of the Physician's Recapitulation Orders for 9/2016 revealed an order dated 9/23/16 for accuchecks with SSI. The scheduled times were 10:00 AM, 2:00 PM, 6:00 PM and 10:00 PM. Medical record review of the 9/2016 and 10/2016 MAR indicated [REDACTED] 9/24 scheduled at 10:00 AM checked at 3:05 PM 9/24 scheduled at 2:00 PM checked at 4:20 PM 9/25 scheduled at 10:00 AM checked at 3:38 PM 9/25 scheduled at 2:00 PM checked at 5:33 PM 9/25 scheduled at 10:00 PM checked at 11:23 PM 9/26 scheduled at 10:00 AM checked at 12:39 PM 9/26 scheduled at 2:00 PM checked at 3:28 PM 9/26 scheduled at 10:00 PM checked at 5:20 AM on 9/27 9/28 scheduled at 10:00 AM checked at 11:19 AM 9/28 scheduled at 2:00 PM checked at 4:04 PM 9/28 scheduled at 10:00 PM checked at 11:36 PM 9/29 scheduled at 10:00 AM checked at 3:19 PM 9/29 scheduled at 2:00 PM checked at 3:20 PM 10/4 scheduled at 2:00 PM checked at 6:08 PM Medical record review of a physician's telephone order dated 9/12/16 revealed, .[MEDICATION NAME] HCL (used to treat low blood pressure) 5 mg tab (tablet) give one tab PT (per tube) before meals; BP (blood pressure) to be checked prior to administration, Hold for BP (systolic greater than 120 or diastolic greater than 80) .The order was written by LPN #4 and signed by NP #1. Medical record review of the Electronic Physician's Order dated 9/12/16 for [MEDICATION NAME] 5 mg revealed it was entered into the computer by LPN #4 at 7:00 PM. The electronic order contained a special requirement to check the blood pressure prior to administration and to hold if the systolic blood pressure was less than 120. Medical record review of 9/2016 MAR indicated [REDACTED].[MEDICATION NAME] HCL 5 MG TABLET give one tablet per tube before meals. CHECK BP (blood pressure) . There were no blood pressure parameters transcribed onto the MAR. Medical record review of the 9/2016 MAR indicated [REDACTED]. 9/12 at 10:00 PM. BP 149/90 9/13 at 10:00 AM. BP 152/82 9/13 at 2:00 PM. BP 125/64 9/13 at 6:00 PM BP 122/80 9/13 at 10:00 PM. BP 124/53 9/14 at 10:00 AM. BP 134/70 9/14 at 2:00 PM. BP 130/70 9/14 at 6:00 PM. BP 134/70 9/14 at 10:00 PM. BP 129/82 9/15 at 10:00 AM. BP 126/75 9/15 at 2:00 PM. BP 128/75 9/16 at 10:00 AM. BP 120/100 9/16 at 2:00 PM. BP 118/88 Continued review of an Electronic Physician's Order dated 9/16/16 revealed LPN #3 removed the parameter to hold the [MEDICATION NAME] 5mg if the systolic blood pressure was less than 120 on 9/16/16 at 5:01 PM. The original parameters from the 9/12/16 order to hold the medication if the systolic BP was greater than 120 or the diastolic BP was greater than 80 was not entered into the computer or transcribed onto the MAR. Medical record review of the MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 10/19/16 at 4:05 PM, in the conference room revealed the DON was aware medications were being administered outside the 2 hour window, 60 minutes before and 60 minutes after the scheduled time allowed for medication administration. Continued interview with the DON confirmed administering medications greater than the 2 hour window was a medication error and stated It's not acceptable. The DON confirmed the blood pressure parameters for the 9/12/16 [MEDICATION NAME] 5mg order for Resident #3 had been entered into the computer incorrectly and the medication was administered to the resident when it should not have been. Continued interview confirmed the correct blood pressure parameters should have been entered on 9/16/16 and were not. Further interview revealed the DON confirmed when a blood sugar or blood pressure was not documented prior to administering or holding insulin or a blood pressure medication as ordered it was a medication error. The DON confirmed the facility failed to check blood sugars as scheduled, failed to follow the facility policy to administer medications within the 2 hour window, failed to enter BP orders into the computer correctly, and failed to document blood sugars and/or blood pressure readings, resulting in significant medication errors for Resident #2 and #3. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for (MONTH) (YEAR) revealed: a. on 7 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window b. on 4 occasions insulin was administered 1 1/2 - 2 hours past the scheduled window. c. on 6 occasions [MEDICATION NAME] was administered 1 1/2 - 3 hours past the scheduled window. Medical record review of physician's admission orders [REDACTED]. Continued review revealed if the blood glucose was greater than 400 the nurse was to notify the physician. Medical record review of the blood glucose monitoring record and the MAR indicated [REDACTED]. Continued review revealed no documentation the blood glucose was rechecked in 15 minutes per physician orders and facility policy. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a History and Physical from the hospital dated 9/14/16 revealed Resident #6 was admitted for a blood sugar which was .measurable high . Continued review revealed the blood glucose in the Emergency Department was 500 and significant ketosis was present. Medical record review of the Medication Administration Record [REDACTED] a. on 22 occasions blood glucose monitoring was completed from 1 1/2 - 7 hours past the scheduled window of 60 minutes after the scheduled time b. on 12 occasions insulin was administered 1 1/2 - 7 hours past the scheduled window c. on 7 occasions [MEDICATION NAME] (antibiotic) was administered 2 - 8 1/2 hours past the scheduled window. Medical record review of the MAR for (MONTH) (YEAR) revealed: a. on 33 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window b. on 2 occasions insulin was administered 1/2 - 1 1/2 hours past the scheduled window c. on 4 occasions [MEDICATION NAME] (antidepressant) was administered 2 - 3 hours past the scheduled window d. on 4 occasions [MEDICATION NAME] (antidepressant) was administered 1/2 - 3 hours past the scheduled window e. on 9 occasions [MEDICATION NAME] (anti-anxiety) was administered 1 1/2 - 4 hours past the scheduled window Medical record review of physician's admission orders [REDACTED]. Continued review revealed the order stated if the resident's blood glucose was greater than 400 the nurse was to administer 10 units of insulin and notify the physician. Medical record review of the blood glucose monitoring sheets and the Medication Administration Record [REDACTED] a. 9/20/16 blood glucose 593 at 9:00 PM b. 9/24/16 blood glucose 405 at 9:00 PM c. 9/29/16 blood glucose 421 at 1:00 PM d. 9/29/16 blood glucose 423 at 5:00 PM e. 10/4/16 blood glucose 405 at 6:15 PM Continued review revealed no documentation the physician was notified of any of these abnormal blood glucose results. Further review revealed no documentation the blood glucose was rechecked in 15 minutes on each of these occasions per physician order and facility policy. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for (MONTH) (YEAR) revealed: a. on 7 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window b. on 4 occasions insulin was administered 1 1/2 - 2 hours past the scheduled window. c. on 6 occasions [MEDICATION NAME] was administered 1 1/2 - 3 hours past the scheduled window. Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for (MONTH) (YEAR) revealed: a. on 18 occasions blood glucose monitoring was completed 1 1/2 - 3 hours past the scheduled window b. on 16 occasions insulin was administered 2 1/2 - 8 hours past the scheduled window c. on 5 occasions [MEDICATION NAME] (cardiac) was administered 3 1/2 - 6 hours past the scheduled window d. on 9 occasions [MEDICATION NAME] (blood pressure) was administered 1 1/2 - 3 hours past the scheduled window e. on 5 occasions [MEDICATION NAME] (blood pressure) was administered 1 1/2 - 3 hours past the scheduled window f. on 3 occasions [MEDICATION NAME] (antianxiety) was administered 1 1/2 - 2 1/2 hours past the scheduled window Medical record review of the physician's admission orders [REDACTED]. If BS (blood sugar) > (greater than) 400 notify MD and recheck in 15 minutes . Medical record review of the blood glucose monitoring record and the MAR indicated [REDACTED]. Continued review revealed no documentation the physician was notified of the abnormal blood glucose result and no documentation the blood glucose was rechecked after 15 minutes per physician orders and facility policy. Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for (MONTH) (YEAR) revealed: a. on 54 occasions blood glucose monitoring was completed 1 1/2 - 8 1/2 hours past the scheduled window b. on 18 occasions [MEDICATION NAME] (blood pressure) was administered 1 1/2 - 5 hours past the scheduled window c. on 13 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 5 1/2 hours past the scheduled window d. on 14 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 4 1/2 hours past the scheduled window e. on 3 occasions [MEDICATION NAME] (cardiac) was administered 1 1/2 - 2 1/2 hours past the scheduled window f. on 1 occasion [MEDICATION NAME] ([MEDICAL CONDITION]) and [MEDICATION NAME] (antacid) were administered 10 1/2 hours past the scheduled window Medical record review of the MAR for (MONTH) (YEAR) revealed: a. on 31 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window b. on 4 occasions insulin was administered 2 - 5 hours past the scheduled window c. on 20 occasions [MEDICATION NAME] was administered 1 1/2 - 7 /12 hours past the scheduled window d. on 11 occasions [MEDICATION NAME] was administered 2 - 3 hours past the scheduled window e. on 13 occasions [MEDICATION NAME] was administered 1 1/2 - 5 hours past the scheduled window. Medical record review of physician's admission orders [REDACTED]. Continued review revealed if the blood glucose was greater than 400 the nurse was to notify the physician and recheck the blood glucose in 15 minutes. Medical record review of the blood glucose monitoring record and the MAR indicated [REDACTED]. Continued review revealed there was no documentation the physician was notified of the abnormal blood glucose result. Further review revealed no documentation the blood glucose was rechecked in 15 minutes per physician orders and the facility policy. Medical record review revealed Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for (MONTH) (YEAR) revealed: a. on 30 occasions blood glucose monitoring was completed 1 1/2 - 7 hours past the scheduled window b. on 20 occasions insulin was administered 1 1/2 - 7 hours past the scheduled window c. on 43 occasions [MEDICATION NAME] (antianxiety) was administered 1 1/2 - 5 hours past the scheduled window. d. on 16 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 5 hours past the scheduled window e. on 16 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 5 hours past the scheduled window Medical record review of the MAR for (MONTH) (YEAR) revealed: a. on 13 occasions blood glucose monitoring was completed 1 1/2 - 4 hours past the scheduled window b. on 6 occasions insulin was administered 1 1/2 - 3 1/2 hours past the scheduled window c. on 19 occasions [MEDICATION NAME] was administered 1 1/2 - 2 1/2 hours past the scheduled window d. on 8 occasions [MEDICATION NAME] was administered 1 1/2 - 3 1/2 hours past the scheduled window e. on 8 occasions [MEDICATION NAME] was administered 1 1/2 hours - 3 1/2 hours past the scheduled window Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for (MONTH) (YEAR) revealed: a. on 47 occasions blood glucose monitoring was completed 1 1/2 - 7 hours past the scheduled window. Medical record review of the MAR for (MONTH) (YEAR) revealed: a. on 34 occasions blood glucose monitoring was completed 1 1/2 - 7 1/2 hours past the scheduled window. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for (MONTH) (YEAR) revealed: a. on 21 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window Medical record review revealed Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED] a. blood glucose check at 7:30 AM b. Humalog Insulin according to the blood glucose at 7:30 AM c. [MEDICATION NAME] (antacid) 150 milligrams (mg) due at 9:00 AM d. [MEDICATION NAME] ([MEDICAL CONDITION]) 600 mg due at 9:00 AM e. [MEDICATION NAME] ([MEDICAL CONDITION]) 250 mg due at 9:00 AM f. [MEDICATION NAME] (antibiotic)100 mg due at 10:00 AM g. Eliquis (anticoagulant) 10 mg due at 10:00 AM h. [MEDICATION NAME] (steroid) 5 mg due at 10:00 AM Observation during the medication pass which began at 11:00 AM, revealed RN #3 administered all of the medications and completed the blood glucose check at 11:15 AM. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR indicated [REDACTED] a. [MEDICATION NAME] (diuretic) 37.5/25 mg at 8:00 AM b. [MEDICATION NAME] (diuretic) 40 mg at 9:00 am c. [MEDICATION NAME] (cardiac) 240 mg at 9:00 AM d. Potassium Chloride (replacement) 20 milliequivalents at 9:00 AM e. [MEDICATION NAME] (stool softener) 100 mg at 10:00 AM f. [MEDICATION NAME] (antibiotic) 100 mg at 10:00 AM g. [MEDICATION NAME] (antibiotic) 2 grams intravenously at 10:00 AM Observation during the medication pass revealed RN #3 administered all of the medications at 12:05 PM. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR indicated [REDACTED] a. [MEDICATION NAME] (antihypertensive) 40 mg at 9:00 AM b. [MEDICATION NAME] (prevent blood clotting) 30 mg due at 9:00 AM Observation during the medication pass revealed RN #3 administered both medications at 11:45 AM. There were 21 medications given more than 1 hour before or 1 hour after the scheduled time with 32 medications observed during medication pass for a medication error rate of 65%. Interview with RN #3 on 10/19/16 at 12:30 PM on Hall #1 revealed she was aware she was late administering her medications but also stated .I would rather my residents be safe . Continued interview revealed RN #3 stated medications are signed off as soon as they are administered because to wait until the end of med pass would be too confusing and difficult to remember if any medications were held. Interview with the Director of Nursing (DON) on 10/19/16 at 4:05 PM in the conference room revealed she was aware medications were being administered outside the 2 hours window (60 minutes before and 60 minutes after the scheduled time) allotted for medication administration. Continued interview with the DON confirmed medications, blood glucose monitoring, and insulin were administered at times greater than the 2 hours window allowed. Further interview with the DON confirmed it was a medication error for medications to be administered more than 1 hour before or 1 hour after the scheduled time. Refer to F157 K",2019-10-01
5828,TENNESSEE VETERANS HOME,445270,PO BOX 10299,MURFREESBORO,TN,37129,2015-11-10,328,D,1,0,09ZM11,"**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 correctly transcribe a physicians order for the use of oxygen, failed to follow the facility policy for transcribing and reviewing physician orders [REDACTED].#4) of 5 residents reviewed. The findings included: Review of a facility policy titled, Transcription of Physician order [REDACTED].Guidelines have been established to ensure physician orders [REDACTED].The licensed nurse is responsible to clarify any physician order [REDACTED].or confusing prior to transmission to the pharmacy or transcription on the medication administration record .Information must not be added in to any order .The night shift charge nurse .completes a 24 hour chart check each night indicating that all orders for the preceding 24 hours period orders have been properly transcribed and executed .any issue or discrepancies shall be addressed at this time and communicated to ensure 100% of all physician orders [REDACTED]. If discrepancies are found they are to be corrected by the .nurses. This will serve as a triple check of all orders. Review of a facility policy titled, Oxygen Policy dated 2/20/13 revealed, .Oxygen will only be administered with a physician's orders [REDACTED]. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was seen in the Emergency Department on 9/2/15 with a [DIAGNOSES REDACTED]. Medical record review of a Significant Change Minimum (MDS) data set [DATE] revealed the resident was severely cognitively impaired, had symptoms of inattention and altered level of consciousness that fluctuated for 1-3 days, needed extensive assistance from 2 people for activities of daily living, did not ambulate, used a wheel chair for mobility and had received oxygen therapy within the previous 14 days while in the facility. Medical record review of a Physician's Telephone Orders sheet dated 9/2/15 at 1:20 AM documented, .Oxygen at 2-5 Liters per mask to keep 02 Sats (saturation of oxygen in the blood) above 90%. (MONTH) also use nasal cannula . The indication was documented as decreased 02 Sats. Review of a Nurses Note dated 9/2/15 at 6:50 AM documented .Late entry: New orders for oxygen at 2-5 liters per mask or PNC (per nasal cannula) to keep O2 sats above 90% . Review of a MAR (Medical Administration Record) dated 9/2015 documented Oxygen at 2-5 liters per mask to keep 02 sats above 90%. (MONTH) also use nasal cannula. 9/2/15 Continued review revealed on the date and time next to the hand written order was written PRN (as needed) indicating the oxygen was an 'as needed' order instead of a continuous order. Further review of the MAR revealed the resident did not receive oxygen on 9/7/15 on the 3-11 PM shift, or on 9/10/15 on the 11 PM-7 AM shift as ordered by the physician. Continued review of the MAR revealed the order on 9/2/15 was incorrectly transcribed as a PRN order. Further review of the MAR revealed a hand written, undated order to Change 02 tubing and humidifier bottle every Sunday night and PRN. The date and time next to the order indicating when the tubing was to be changed documented 7p-7a and PRN. Continued review revealed the oxygen tubing and humidifier bottle was not documented as changed on 9/13/15 and 9/27/15. Review of the MAR dated 10/2015 revealed the Oxygen order dated 9/2/15 remained as an active PRN order and was incorrectly transcribed from the 9/2/15 physician's orders [REDACTED]. Review of the 11/2015 recapitulation orders for Resident #4 documented an order dated 9/2/15 for Oxygen at 2-5 liters per mask to keep 02 sats above 90%. (MONTH) also use nasal cannula. Review of the MAR dated 11/2015 revealed the Oxygen order dated 9/2/15 remained as an active PRN order and was incorrectly transcribed from the 9/2/15 order. Continued review revealed the resident did not receive oxygen on 11/3/15 during the 7 AM- 3 PM shift, 11/4/15 during the 3-11 PM shift, or 11/5/15 during the 11 PM-7 AM shift as ordered by the physician. Observation of Resident #4 on 11/9/15 at 3:00 PM in the resident's room revealed the resident was sleeping in her bed and had a nasal cannula in her nose. The resident was sleeping with her mouth open, snoring and grunting. The cannula was attached to the oxygen concentrator at her bedside. Further observation revealed the ball in the cylinder indicating how many liters of oxygen the resident was using was on the very bottom line indicating there was no oxygen flowing. Further observation revealed the concentrator on/off switch was in the off position. The resident was not receiving any oxygen via the nasal cannula. Interview with Licensed Practical Nurse (LPN) #2 on 11/9/15 at 3:15 PM in the resident's room confirmed she was the nurse taking care of the resident that day. When asked if the resident had an order for [REDACTED]. When asked if the resident was receiving oxygen now, the LPN checked the concentrator and confirmed it was not turned on and the resident was not receiving oxygen as ordered. When asked how long the resident had gone without oxygen, the LPN stated, I'm not sure. Two other nurses put her to bed, but I don't know when. Interview and observation with LPN #3 on 11/9/15 at 3:20 PM at the West nurses station confirmed she and LPN #1 had laid the resident down in bed between 1:45 PM and 2:00 PM. When asked if she had placed the oxygen on the resident LPN #3 stated, I put the cannula in her nose and (named LPN #1) hooked it to the concentrator. When asked if the concentrator was turned on she stated, I didn't turn it on, I assumed (named LPN #1) did. When asked if the resident had an order for [REDACTED]. The LPN was asked if she had checked the resident's sats to determine how many liters to use, she stated No, but I will right now. The surveyor and the LPN then went to the resident's room where LPN #3 checked the saturation of oxygen in the residents blood using a hand held O2 sat monitor. After observing the monitor for approximately 2-3 minutes, the monitor showed a consistent wave form and showed the O2 sat to be 88% on room air. When the LPN was asked if the resident required oxygen, she stated she sure does. Continued interview with the LPN confirmed the resident had required oxygen as her O2 sat was 88%, was ordered oxygen, and was without oxygen for approximately 1 1/2 hours. Interview with LPN #1 on 11/9/15 at 3:30 PM at the West nurses station when asked if she assisted with laying Resident #4 down between 1:45 PM and 2:00 PM stated Yes I did. When asked if she had turned on the oxygen concentrator, the LPN stated, I'm pretty sure I did. When asked if she was positive, LPN #1 stated, I think I did. I heard the concentrator was on in her room. When asked if the resident's roommate also used oxygen, LPN #1 stated, Yes. I guess it was (named resident's roommate) that I heard when I thought (named Resident #4) was on. Interview with Registered Nurse (RN) #4 on 11/10/15 at 11:20 AM in the Corporate Conference Room confirmed the telephone physician's orders [REDACTED]. (MONTH) also use nasal cannula was a continuous order and not a PRN order. The RN also confirmed PRN was transcribed incorrectly on the the MAR for 9/2015, 10/2015, and 11/2015 and was not on the original physician's telephone order dated 9/2/15. Interview with the Director of Clinical Services on 11/10/15 at 1:00 PM in the Corporate Conference Room confirmed the resident's oxygen tubing and humidifier bottle were not documented as changed 2 times during the month of 9/2015 per facility policy. Continued interview confirmed the 9/2/15 physician telephone order for oxygen at 2-5 liters per mask to keep O2 sats above 90%. Further interview confirmed the use of a nasal cannula was not a PRN order and should have been clarified. Continued interview confirmed the resident did not receive oxygen therapy during 2 shifts in 9/2015, 2 shifts in 10/2015 and 3 shifts in 11/2015 per the physician's orders [REDACTED].>",2018-11-01
4821,HOLSTON MANOR,445295,3641 MEMORIAL BLVD,KINGSPORT,TN,37664,2016-07-26,333,D,1,0,VE6H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observation, and interview the facility failed to follow proper procedure for medication administration for 1 resident (#6) of 8 residents observed. The findings included: Review of facility policy, General Procedures to Follow for All Medications, undated revealed .After administration, return to cart and document administration in Medication Adiministration Record (MAR) or Treatment Adminsitration Record (TAR). If resident refuses medication, document refusal on MAR indicated [REDACTED] Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum (MDS) data set [DATE] revealed Resident #6 was cognitively intact. Medical record review of the Medication Administration Record [REDACTED]. Observation on 6/28/16 at 9:15 AM, on the over the bed table in the resident's room revealed a medication cup containing 2 pills. Interview with Resident #6 on 6/28/16 at 9:15 AM, in her room confirmed . (nurse name) left them there .I took most of them, but I wanted to wait till I had something to eat before I took the rest of them . Interview with Licensed Practical Nurse (LPN) #1 on 6/28/16 at 9:20 AM, confirmed .those look like some of her morning medications .[MEDICATION NAME] and Calcium .yes (nurse name) .LPN #4 .worked last night .no we are not supposed to leave the medications in the room if the resident does not take them . Interview with the Director of Nursing on 6/30/16 at 3:00 PM, in the conference room confirmed the facility had failed to follow the proper procedure for medication administration.",2019-07-01
4210,MCKENDREE VILLAGE,445491,4347 LEBANON ROAD,HERMITAGE,TN,37076,2016-12-29,312,D,1,0,OJT511,"**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 incontinence care in a timely manner for 1 resident (#4) of 3 residents reviewed. Review of facility policy, Resident Care Rounds, dated 10/15/13 revealed, .All nursing service personnel shall follow daily work assignments and perform assigned duties in accordance with professional standards of practice and facility policy .Call lights are to be answered timely and address the resident with respect. If unable to accomplish the task needed, ask a coworker to assist or the nurse for assistance . Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #4's cognitive skills for daily decision making were severely impaired, never/rarely made decisions, and speech was unclear with slurred or mumbled words. Continued review revealed Resident #4's bed mobility required extensive assistance. Further review revealed Resident #4 was always incontinent of bladder and bowel. Observation on 12/29/16 at 9:20 AM in Resident #4's room revealed the resident was in bed and a wet brief and bed pad was on the floor on the left side of the bed. Continued observation at 9:30 AM revealed Resident #4 turned on the call light. Further observation at 9:33 AM revealed two staff members entered Resident #4's room and the call light was turned off. The two staff members exited the room. Observation on 12/29/16 at 9:43 AM in Resident #4's room revealed the wet brief and bed pad was still on the floor on the left side of the bed. Observation on 12/29/16 at 10:25 AM in Resident #4's room revealed the resident was in bed covered with a sheet, the wet brief and bed pad were on the floor, and the resident gown was beside it. Continued observation revealed Resident #4 turned on the call light at 10:26 AM as the surveyor exited the room. Further observation on 12/29/16 at 10:29 AM revealed CNA #1 in Resident #4's room as the surveyor re-entered the room. The resident pointed to the dirty linen pile on the floor and CNA #1 stated, He just did that. Continued interview with CNA #1 when asked if she saw the resident place the linens on the floor revealed, No. The CNA was informed by the surveyor that the observation was first made of the wet brief and bed pad on the floor at 9:20 AM. CNA #1 stated she was not aware of it and had been helping other residents at that time. Interview with the Medical Records Clerk on 12/29/16 at 10:37 AM in her office, when asked if she remembered answering the call light in Resident #4's room that morning revealed, Yes. Continued interview revealed, His diaper and pad were on the floor so I went and told a tech. Further interview revealed the Medical Records Clerk did not know the tech's name but she could locate her. Observation on 12/29/16 at 10:40 AM in Resident #4's room with the Medical Records Clerk revealed CNA #1 was present in the room. The Medical Records Clerk identified CNA #1 as the tech she had told earlier that the resident needed to be changed. Further interview with CNA #1 at 10:41 AM, when asked if the Medical Records Clerk had told her earlier that morning the resident needed to be changed revealed the CNA stated, Yes. Continued interview with CNA #1 confirmed the resident had not been changed in a timely manner. Interview with the Administrator on 12/29/16 at 1:45 PM, in the Conference Room revealed the Administrator stated, My expectation is for the residents to be changed in a timely manner and certainly not an hour. Continued interview revealed the Administrator confirmed the facility failed to provide incontinence care for Resident #4 in a timely manner and failed to provide the care and assistance the resident required.",2019-11-01
2198,HARRIMAN CARE & REHAB CENTER,445368,240 HANNAH ROAD,HARRIMAN,TN,37748,2017-11-08,318,D,1,1,78KG11,"**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 range of motion services to meet the needs of 2 residents (#18 and #59) of 17 residents reviewed. The findings included: Review of the facility policy, Introduction to Restorative Nursing Process dated 7/2010 revealed .The most successful Restorative Nursing programs are evidenced by the presence of a solid nursing/therapy team .This provides the foundation for superior resident care delivery and seamless transition through the rehabilitation and restorative continuum . Medical record review revealed Resident #18 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's (#18) cognition was intact, required 2 person assist for most of her activities of daily living and had functional limitation in range of motion (ROM) to bilateral upper and lower extremities. Medical record review of the Restorative Nursing Program for ROM/Exercise dated 7/11/17 revealed Resident #18 was to receive passive range of motion and active range of motion six times a week. Medical record review of the Restorative Nursing Report dated 9/2/17 revealed Resident #18 received ROM once in the month of 9/2017 and refused services 3 times during the month of September. Continued review revealed in 10/2017 Resident #18 received ROM services 3 times and refused ROM services 3 times in the month of October. Interview with Restorative Certified Nursing Assistant on 11/6/17 at 2:15 PM in the conference room, confirmed Resident #18 was to receive range of motion services 6 times a week and that she was pulled in to staffing and unable to provide restorative services which includes range of motion services. Interview with Restorative Licensed Practical Nurse on 11/6/17 at 2:37 PM in the conference room, confirmed .She (Resident #18) is to get range of motion 6 times a week but receives it 1-2 times a week .They keep pulling us to the floor or sending us home .Need to be able to get job done and take care of patients .She comes to me and says I need range of motion . Interview with the Director of Nursing on 11/8/17 at 9:10 AM in the chapel confirmed the facility failed to provide range of motion services to Resident #18. Medical record review revealed Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] revealed Resident #59 was cognitively intact, required staff assistance with transfers, dressing, toileting, hygiene, and bathing. Observation on 11/6/17 at 10:30 AM, in Resident #59's room revealed the resident was in the bed and not able to move the left arm or leg. Medical record review of the Occupational Therapy note dated 10/6/17 revealed the long and short term goal was for the resident to participate in Range Of Motion (ROM) with the Restorative Nursing program. Medical record review of the Restorative Nursing Report dated from 10/7/17 to 10/31/17 revealed Resident #59 received ROM services from Restorative Nursing on 2 days 10/10/17 and 10/31/17. Interview with the Restorative LPN on 11/8/17 at 2:50 PM in the conference room, revealed .it's (ROM) suppose to be done 6 times a week but we can't always get to her .",2020-09-01
2646,MT JULIET HEALTH CARE CENTER,445439,2650 NORTH MT JULIET ROAD,MOUNT JULIET,TN,37122,2019-03-13,695,D,1,1,O5E111,"**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 respiratory care consistent with professional standards for the safe handling, cleaning, and storage of oxygen tubing for 2 Residents (#24, #33) of 6 residents on oxygen. The findings include: Facility policy review,Oxygen Concentrator, dated 11/2017, revealed .change tubing weekly and as needed; document in medical record . Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 2/20/19 revealed .oxygen prn (as needed) . Medical record review of the Clinical Notes Report, Nursing, General, dated 3/12/19, revealed .MD notified of residents need for O2 (oxygen) use at hs (hour of sleep), new orders received . Observation of Resident #24 on 03/12/19 at 7:49 AM in the room revealed oxygen at 2 (Liters Per Minute) LPM per nasal cannula (NC), unlabeled. Further observation of resident on 03/12/19 at 8:43 AM in his room revealed resident eating breakfast unassisted sitting in bed, no oxygen in use. Oxygen tubing is looped under bagged nebulizer hanging on concentrator, undated. Observation on 3/13/19 at 8:05 AM in the room revealed resident sitting upright in bed, no oxygen in use. Oxygen tubing is looped under nebulizer in bag hanging on concentrator,undated. Interview of Resident #24 on 03/12/19 at 1:40 PM in the room revealed oxygen per NC is used at night only. Medical record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician progress notes [REDACTED].O2 2L N/C prn .humidify O2 @ all times . Medical record review of Clinical Notes Report, Nursing, General, dated 3/9/19 revealed .resident reporting not feeling well throughout day and at 5 pm reporting chest pains, nitro given x2 .O2 84%, resident had taken her O2 off placed back on .15 minutes later O2 87%. Dr.[NAME]notified .resident reported feeling somewhat better .VS (vital signs) at 7:30 pm O2 94% . Medical record review of Physician's telephone order dated 3/12/19 revealed .Oxygen By Shift at 2 LPM Continuous . Medical record review of Clinical Notes Report, Nursing, General, dated 3/12/19, revealed .Oxygen tubing change every 1 week .Oxygen Filter Every 1 Week, clean with water .Change Humidfier Bottle Every 2 Weeks .Oxygen (O2) at 2 L/min per nasal cannula PRN (Max 3 Doses), apply if O2 Sats below 90% . Review of Quarterly MDS dated [DATE] and Comprehensive MDS dated [DATE] revealed no oxygen in use at the time of either MDS. Observation of Resident #33 on 3/11/19 at 8:05 PM in the room revealed resident on 2 LPM oxygen per NC, tubing undated. Further observation on 03/12/19 at 7:44 AM in the room revealed resident on oxygen per NC at 2 LPM, tubing undated. Observation on 03/12/19 at 8:44 AM in the room revealed resident sitting up in bed eating breakfast without NC oxygen, tubing at bedside on side rail and laying on the bed, undated.Observation of resident on 03/12/19 at 10:05 AM in the room revealed resident in the bathroom being assisted by a CNA, oxygen is off and NC tubing is over the side rail and laying in the bed, undated. Interview with Licensed Practical Nurse (LPN) #3 on 3/13/19 at 9:28 AM in the hallway confirmed .oxygen tubing should be changed once a week and should be labeled with a piece of tape with the date on it .should be in a bag for storage when it's not being used by resident .",2020-09-01
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
4427,CREEKSIDE CENTER FOR REHABILITATION AND HEALING,445516,306 W DUE WEST AVENUE,MADISON,TN,37115,2016-10-24,333,L,1,0,CT4U11,"**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 8 (Resident #2, #3, #4, #5, #7, #8, #9, #10) residents of 12 residents reviewed were free from significant medication errors; failed to ensure blood glucose monitoring was completed as ordered; failed to ensure insulin was administered at scheduled times; failed to administer medications to control blood pressure, behaviors, and [MEDICAL CONDITION] within the scheduled time frame; and failed to administer antibiotics as ordered. These failures placed all residents in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Administrator (NHA) was informed of the Immediate Jeopardy on 10/24/16 at 3:25 PM in the Conference Room. F333 is Substandard Quality of Care. The findings included: Review of facility policy, Medication Administration revised 3/16/15 revealed, .Administer medications within 60 minutes of the scheduled time .for example, if the medication is ordered for 8:00 a.m., it must be give between 7:00 a.m. and 9:00 a.m. in order to be considered timely . Review of facility policy, Diabetes, Nursing Care of the Adult Diabetes Mellitus Resident, undated, revealed, .The purpose of this guideline is .Prevent recurrence of [MEDICAL CONDITION]/[DIAGNOSES REDACTED] (high and low blood sugars). Recognize, assist and document the treatment of [REDACTED].obtain pre-meal fingerstick blood glucose within 60 minutes (maximum) of anticipated meal .The physician should be notified when the blood sugar falls above his/her specified blood sugar range and/or above 400 mg/dL (milligrams per deciliter) . The Medical Director of the facility is the physician of record for all the residents. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician's Order dated 6/4/16 revealed, .ACCUCHECKS (finger stick for blood sugar) BEFORE BOLUS FEEDINGS AND SSI (sliding scale insulin) AS FOLLOWS: 0-59 = CALL MD 60-150=0, 151-200=2u (units), 201-250=4u, 251-300=6u, 301-350=8u, 351-400 = 10u .NOTIFY MD AND RECHECK IN 15 MINUTES . The scheduled time was 6 AM, 12 PM, 6 PM, and 12 AM daily. Medical record review of the 6/2016 Medication Administration Record [REDACTED]. Continued review revealed blood sugars were checked 1-4 hours late 2 times for the month of 6/2016. Interview with Licensed Practical Nurse (LPN) #3 on 10/18/16 at 2:20 PM, in the conference room stated he called Nurse Practitioner (NP) #2 on 6/4/16 regarding the blood sugar of 211 for Resident #2 and was told to hold the SSI dose of 4 units. Continued interview with the LPN confirmed he did not write an order to hold the 4 units of insulin, and he did not administer the dose per the sliding scale protocol. Medical record review of the 7/2016 MAR indicated [REDACTED]. Medical record review of the 9/2016 MAR indicated [REDACTED]. Medical record review of Resident #2's Physician's Orders dated 9/22/16 revealed an order for [REDACTED]. The scheduled administration time was 9:00 PM. Medical record review of the 9/2016 MAR for Resident #2 revealed [MEDICATION NAME] 21 units was not administered on 9/22/16 at 9:00 PM per physician's order. Continued medical record review of the 9/2016 MAR indicated [REDACTED]. The blood sugar was not checked at 6:00 PM per order. The blood sugar was 327 at 12:00 AM on 9/23 and no SSI was administered; the blood sugar was 560 at 6:00 AM and no SSI was administered. Medical record review revealed NO physician orders to hold accuchecks, [MEDICATION NAME], or SSI for Resident #2 on 9/22 and 9/23/16. Interview with NP #1 on 10/12/16 at 12:38 PM, in the conference room confirmed there were no written telephone orders or computerized orders to hold the [MEDICATION NAME] dose at 9:00 PM, and no order to hold any SSI at 12:00 AM or 6:00 AM on 9/22 and 9/23 for Resident #2. Interview with LPN #4 on 10/12/16 at 2:05 PM, in the conference room revealed she notified NP #1 on 9/22/16 when Resident #2's blood sugar was 501 and was told to give 10 units of insulin, wait 30 minutes and re-check it again. Continued interview with the LPN revealed when she re-checked the blood glucose 30 minutes later the blood glucose was higher than 501 and the NP told her to give an additional 12 units of insulin and recheck it after that. Further interview with LPN #4 revealed she checked it after administering 12 units and the blood glucose was in the 300's. Continued interview with the LPN confirmed she failed to write an order to administer an additional 12 units of insulin to the resident on 9/22/16. Telephone interview with RN #2 on 10/12/16 at 3:20 PM confirmed he did not write a telephone order to hold Resident #2's [MEDICATION NAME] 21 units of insulin and did not put an order in the computer on 9/22/16. Telephone interview with LPN #5 on 10/18/16 at 4:00 PM revealed (Named RN #2) gave me report to hold the insulin for lab work in the morning. I should have looked to see the order myself, and I did not call the Doctor when the sugar was 560. I was just going on what I was told. Continued interview with the LPN confirmed she failed to administer SSI per the physicians order to Resident #2 on 9/23 at 12:00 AM and 6:00 AM. Medical record review of the 10/2016 MAR indicated [REDACTED]. Medical record review of a physician's order dated 7/25/16 for Resident #2 revealed, [MEDICATION NAME] (blood pressure medication, used for Hypertension) 10 MG (milligrams) CAPSULE GIVE ONE CAPSULE PER [DEVICE] EVERY 8 HOURS The scheduled time of administration was 6:00 AM, 2:00 PM, and 10:00 PM. Medical record review of the 7/16 MAR indicated [REDACTED]. Medical record review revealed no physician orders to hold the [MEDICATION NAME] on 7/25 or 7/27, and no physician orders with parameters to hold the [MEDICATION NAME] for a blood pressure of 102/58. Medical record review of the 8/16 MAR indicated [REDACTED]. Medical record review revealed no physician orders for parameters to hold the [MEDICATION NAME] if the systolic blood pressure was less than 110. Continued review revealed no physician orders to hold the [MEDICATION NAME] on 8/19 or 8/22/16. Medical record review of the 9/2016 MAR indicated [REDACTED]. Medical record review revealed no physician's order to hold the [MEDICATION NAME] on 9/16/16 at 6:00 AM for Resident #2. Interview with NP #2 on 10/24/16 at 12:20 PM, in the conference room revealed, I don't give parameters for calcium channel blockers ([MEDICATION NAME] is a calcium channel blocker), and I did not give any orders for blood pressure medicines to be held. Medical record review of the 10/2016 MAR indicated [REDACTED] 10/12 scheduled for 10:00 PM; administered at 12:33 AM on 10/13 10/13 scheduled for 2:00 PM; administered at 4:23 PM 10/13 scheduled for 10:00 PM; administered at 11:32 PM 10/14 scheduled for 10:00 PM; administered at 11:41 PM 10/15 scheduled for 2:00 PM; administered at 3:14 PM Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a telephone physician's order dated 9/22/16 revealed, .Accuchecks before meals and at bedtime . The scheduled time of administration was 7:30 AM, 12:00 PM, 5:00 PM, and 9:00 PM. The order did not include sliding scale insulin (SSI) orders. Medical record review of the 9/2016 MAR indicated [REDACTED]. Medical record review revealed no telephone physician orders regarding accuchecks, SSI, or administration time changes. Medical record review of the physician's recapitulation orders for 9/2016 revealed an order dated 9/23/16 for accuchecks with SSI. The scheduled times were 10:00 AM, 2:00 PM, 6:00 PM and 10:00 PM. Medical record review of the 9/2016 and 10/2016 MAR indicated [REDACTED] 9/24 scheduled at 10:00 AM checked at 3:05 PM 9/24 scheduled at 2:00 PM checked at 4:20 PM 9/25 scheduled at 10:00 AM checked at 3:38 PM 9/25 scheduled at 2:00 PM checked at 5:33 PM 9/25 scheduled at 10:00 PM checked at 11:23 PM 9/26 scheduled at 10:00 AM checked at 12:39 PM 9/26 scheduled at 2:00 PM checked at 3:28 PM 9/26 scheduled at 10:00 PM checked at 5:20 AM on 9/27 9/28 scheduled at 10:00 AM checked at 11:19 AM 9/28 scheduled at 2:00 PM checked at 4:04 PM 9/28 scheduled at 10:00 PM checked at 11:36 PM 9/29 scheduled at 10:00 AM checked at 3:19 PM 9/29 scheduled at 2:00 PM checked at 3:20 PM 10/4 scheduled at 2:00 PM checked at 6:08 PM Medical record review of a physician's telephone order dated 9/12/16 revealed, .[MEDICATION NAME] HCL (used to treat low blood pressure) 5 mg tab (tablet) give one tab PT (per tube) before meals; BP (blood pressure) to be checked prior to administration, Hold for BP (systolic greater than 120 or diastolic greater than 80) .The order was written by LPN #4 and signed by NP #1. Medical record review of the Electronic Physician's Order dated 9/12/16 for [MEDICATION NAME] 5 mg revealed it was entered into the computer by LPN #4 at 7:00 PM. The electronic order contained a special requirement to check the blood pressure prior to administration and to hold if the systolic blood pressure was less than 120. Medical record review of 9/2016 MAR indicated [REDACTED].[MEDICATION NAME] HCL 5 MG TABLET give one tablet per tube before meals. CHECK BP (blood pressure) . There were no blood pressure parameters transcribed onto the MAR. Medical record review of the 9/2016 MAR indicated [REDACTED]. 9/12 at 10:00 PM. BP 149/90 9/13 at 10:00 AM. BP 152/82 9/13 at 2:00 PM. BP 125/64 9/13 at 6:00 PM BP 122/80 9/13 at 10:00 PM. BP 124/53 9/14 at 10:00 AM. BP 134/70 9/14 at 2:00 PM. BP 130/70 9/14 at 6:00 PM. BP 134/70 9/14 at 10:00 PM. BP 129/82 9/15 at 10:00 AM. BP 126/75 9/15 at 2:00 PM. BP 128/75 9/16 at 10:00 AM. BP 120/100 9/16 at 2:00 PM. BP 118/88 Continued review of an Electronic Physician's Order dated 9/16/16 revealed LPN #3 removed the parameter to hold the [MEDICATION NAME] 5mg if the systolic blood pressure was less than 120 on 9/16/16 at 5:01 PM. The original parameters from the 9/12/16 order to hold the medication if the systolic BP was greater than 120 or the diastolic BP was greater than 80 was not entered into the computer or transcribed onto the MAR. Medical record review of the MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 10/19/16 at 4:05 PM, in the conference room revealed the DON was aware medications were being administered outside the 2 hour window, 60 minutes before and 60 minutes after the scheduled time allowed for medication administration. Continued interview with the DON confirmed administering medications greater than the 2 hour window was a medication error and stated It's not acceptable. The DON confirmed the blood pressure parameters for the 9/12/16 [MEDICATION NAME] 5mg order for Resident #3 had been entered into the computer incorrectly and the medication was administered to the resident when it should not have been. Continued interview confirmed the correct blood pressure parameters should have been entered on 9/16/16 and were not. Further interview revealed the DON confirmed when a blood sugar or blood pressure was not documented prior to administering or holding insulin or a blood pressure medication as ordered it was a medication error. The DON confirmed the facility failed to check blood sugars as scheduled, failed to follow the facility policy to administer medications within the 2 hour window, failed to enter BP orders into the computer correctly, and failed to document blood sugars and/or blood pressure readings, resulting in significant medication errors for Resident #2 and #3. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for 10/2016 revealed: a. on 21 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for 9/2016 revealed: a. on 22 occasions blood glucose monitoring was completed from 1 1/2 - 7 hours past the scheduled window b. on 12 occasions insulin was administered 1 1/2 - 7 hours past the scheduled window c. on 7 occasions [MEDICATION NAME] (antibiotic) was administered 2 - 8 1/2 hours past the scheduled window. Medical record review of the MAR for 10/2016 revealed: a. on 33 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window. b. on 2 occasions insulin was administered 1/2 - 1 1/2 hours past the scheduled window c. on 4 occasions [MEDICATION NAME] (antidepressant) was administered 2 - 3 hours past the scheduled window d. on 4 occasions [MEDICATION NAME] (antidepressant) was administered 1/2 - 3 hours past the scheduled window e. on 9 occasions [MEDICATION NAME] (anti-anxiety) was administered 1 1/2 - 4 hours past the scheduled window. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for 10/2016 revealed: a. on 7 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window c. on 6 occasions [MEDICATION NAME] was administered 1 1/2 - 3 hours past the scheduled window Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for 10/2016 revealed: a. on 18 occasions blood glucose monitoring was completed 1 1/2 - 3 hours past the scheduled window b. on 16 occasions insulin was administered 2 1/2 - 8 hours past the scheduled window c.on 5 occasions [MEDICATION NAME] (cardiac) was administered 3 1/2 - 6 hours past the scheduled window d. on 9 occasions [MEDICATION NAME] (blood pressure) was administered 1 1/2 - 3 hours past the scheduled window e. on 5 occasions [MEDICATION NAME] (blood pressure) was administered 1 1/2 - 3 hours past the scheduled window window f. on 3 occasions [MEDICATION NAME] (antianxiety) was administered 1 1/2 - 2 1/2 hours past the scheduled window Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for 9/2016 revealed: a. on 54 occasions blood glucose monitoring was completed 1 1/2 - 8 1/2 hours past the scheduled window b. on 18 occasions [MEDICATION NAME] (blood pressure) was administered 1 1/2 - 5 hours past the scheduled window c. on 13 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 5 1/2 hours past the scheduled window d. on 14 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 4 1/2 hours past the scheduled window e. on 3 occasions [MEDICATION NAME] (cardiac) was administered 1 1/2 - 2 1/2 hours past the scheduled window f. on 1 occasion [MEDICATION NAME] ([MEDICAL CONDITION]) and [MEDICATION NAME] (antacid) were administered 10 1/2 hours past the scheduled windowe Medical record review of the MAR for 10/2016 revealed: a. on 31 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window b. on 4 occasions insulin was administered 2 - 5 hours past the scheduled window c. on 20 occasions [MEDICATION NAME] was administered 1 1/2 - 7 /12 hours past the scheduled window d. on 11 occasions [MEDICATION NAME] was administered 2 - 3 hours past the scheduled window e. on 13 occasions [MEDICATION NAME] was administered 1 1/2 - 5 hours past the scheduled window. Medical record review revealed Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for 9/2016 revealed: a. on 30 occasions blood glucose monitoring was completed 1 1/2 - 7 hours past the scheduled window b. on 20 occasions insulin was administered 1 1/2 - 7 hours past the scheduled window c. on 43 occasions [MEDICATION NAME] (antianxiety) was administered 1 1/2 - 5 hours past the scheduled window. d. on 16 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 5 hours past the scheduled window e. on 16 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 5 hours past the scheduled window. Medical record review of the MAR for 10/2016 revealed: a. on 13 occasions blood glucose monitoring was completed 1 1/2 - 4 hours past the scheduled window c. on 19 occasions [MEDICATION NAME] was administered 1 1/2 - 2 1/2 hours past the scheduled window d. on 8 occasions [MEDICATION NAME] was administered 1 1/2 - 3 1/2 hours past the scheduled window e. on 8 occasions [MEDICATION NAME] was administered 1 1/2 hours - 3 1/2 hours past the scheduled window Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for 9/2016 revealed: a. on 47 occasions blood glucose monitoring was completed 1 1/2 - 7 hours past the scheduled window Medical record review of the MAR for 10/2016 revealed: a. on 34 occasions blood glucose monitoring was completed 1 1/2 - 7 1/2 hours past the scheduled window. Interview with Nurse Practitioner (NP) #2 on 10/24/16 at 12:20 PM in the Conference Room confirmed she was aware medications were being administered several hours late and it had been going on at least 6 months. Continued interview revealed residents would tell her they had not received their morning medications when she rounded in the afternoon. Refer to F157 K, F224 L SQC, F281 L, F282 L, F332 L SQC.",2019-10-01
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
1494,LAUGHLIN HEALTH CARE CENTER,445264,801 E MCKEE ST,GREENEVILLE,TN,37743,2018-07-21,656,E,1,0,X9GP11,"**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 residents at risk for elopement were care planned for elopement risk including appropriate interventions for 5 residents (#2, #3, #4, #7, and #10) of 16 residents reviewed with exit seeking behaviors. The findings included: Review of the facility policy Completing MDS (Minimum Data Set) Assessment and Comprehensive Care Plan, dated 9/2017, revealed .Purpose: To address problems or potential problems of residents .the care plan will be reviewed and revised as needed by the team of qualified persons at least quarterly, annually, and prn (as needed) for any significant changes. Wing managers will update care plan with any changes between care plan reviews . Review of the facility policy Care Communication Sheet (Resident), revised date 6/2005, revealed .The care communication sheet is a method of quickly identifying a resident's ability to perform activities of daily living and to inform all staff of a resident's needs .the care communication sheet will be used along with the care plan and medical record during the interdisciplinary care plan meeting . Review of the facility policy Elopement of Resident, revised date 1/2007, revealed .An elopement assessment will be done on every resident upon admission or when behaviors occur, to determine if the resident has a potential for wandering. If the assessment indicated a high risk potential, the charge nurse should initiate placement of a secure care bracelet (wander guard), placement of the bracelet is a nursing judgment and does not require a physician's order . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's admission Elopement Risk assessment dated [DATE] revealed the resident was identified at risk for elopement and a wander guard alarm bracelet was placed on the resident. Medical record review of the admission MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 (moderate cognitive impairment). Continued review revealed the resident required supervision for ambulation. Medical record review of Resident #2's comprehensive care plan dated 6/6/18 revealed the risk for wandering/elopement was not included in the care plan. Observation of Resident #2 on 7/11/18 at 1:45 PM, in her room, revealed the wander guard alarm bracelet was present on her right ankle. Interview with Unit Clerk #1 on 7/11/18 at 11:00 AM, in the conference room, revealed .we have a half a dozen or so (residents) on the east wing that wear wander guards .no one is actively exit seeking .most are just confused and might accidently go out the door .(Resident #2) goes to the door often and looks out .I try to keep a close eye on her . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #3's admission Elopement Risk assessment dated [DATE] revealed the resident was identified as at risk for elopement and a wander guard alarm was placed on the resident. Medical record review of Resident #3's comprehensive care plan dated 6/6/18 revealed the risk for wandering/elopement was not included in the care plan. Medical record review of the admission MDS dated [DATE] revealed a BIMS score of 9 (moderate cognitive impairment). Continued review revealed Resident #3 required limited assistance for ambulation with 1 person to assist. Observation of Resident #3 on 7/11/18 at 1:00 PM, in his room, revealed a wander guard alarm was present on his right ankle. Interview with Licensed Practical Nurse (LPN) #1 on 7/11/18 at 1:25 PM, at the West Wing Nurses' Station, revealed .the first night he (Resident #3) was here he tried to get out a couple of times .we just know who has wander guards .because we work with the same people . 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 a BIMS score of 9 (moderate cognitive impairment). Continued review revealed the resident required supervision for ambulation. Medical record review of Resident #4's care plan last revised 5/25/18 revealed .can become anxious/agitated .pace and wander in her wheelchair . Continued review revealed the placement/use of a wander guard alarm was not listed as an intervention. Medical record review of Resident #4's annual Elopement Risk assessment dated [DATE] revealed the resident was identified at risk for elopement and the use of a wander guard was still appropriate. Observation and interview with Resident #4 on 7/11/18 at 12:15 PM, in the dining room, revealed a wander guard alarm attached to her wheelchair. Interview with Registered Nurse (RN) #2 on 7/17/18 at 10:15 AM, in the conference room, confirmed Resident #4 .is at risk for elopement .someone would need to hold the door for her, but she would go out . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #7's comprehensive care plan, last revised 12/12/17 revealed the risk for wandering/elopement was not identified in the care plan. Medical record review of the quarterly MDS dated [DATE] revealed the resident had short and long term memory loss, was severely impaired for daily decision making, and required limited assist for locomotion off the unit in a wheelchair with 1 person to assist. Medical record review of Resident #7's quarterly Elopement Risk assessment dated [DATE] revealed the resident was identified at risk for elopement and the use of a wander guard alarm was still appropriate. Observation of Resident #7 on 7/17/18 at 8:15 AM, in his room, revealed a wander guard alarm was attached to his wheelchair. Interview with RN #2 on 7/17/18 at 10:25 AM, in the conference room, revealed .he could get out if someone opened the door for him . Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Significant Change in Status MDS for Resident #10 dated 7/5/18 revealed a BIMS score of 4 (severe cognitive impairment). Continued review revealed the resident was independent with locomotion with a wheelchair with 1 person supervision. Medical record review of the Significant Change in Status Elopement Risk assessment dated [DATE] revealed the resident was at risk for elopement and the use of a wander guard alarm was indicated. Medical record review of the comprehensive care plan dated 7/10/18 revealed the elopement risk and use of a wander guard alarm were not identified. Observation of Resident #10 on 7/20/18 at 10:50 AM, in his room, revealed a wander guard bracelet was on his right ankle. Interview with the Director of Nursing (DON) on 7/17/18 at 1:15 PM, in the conference room, revealed .would expect all assessments were completed, and if the residents are at risk for elopement it should have been included in the resident's care plan . Interview with the DON on 7/21/18 at 1:30 PM, in the conference room, confirmed if a resident's condition changes and a wander guard alarm were put in place, she would expect the staff to document the resident's behavior, complete an elopement assessment, and add the information to the care plan immediately.",2020-09-01
1117,LIFE CARE CENTER OF GREENEVILLE,445228,725 CRUM STREET,GREENEVILLE,TN,37743,2020-02-12,689,D,1,1,DKEJ11,"**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 an intervention to prevent falls for 2 residents (Residents #3 and #35) of 4 residents reviewed for falls of 27 sampled residents. The findings include: Review of the facility policy titled, Fall Management, reviewed 4/15/2019, showed .The facility must ensure that the resident's environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents.Implement interventions, including adequate supervision and assistive devices, consistent with a resident's.care plan. Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a Physician's order dated 2/11/2020 showed a one way slide to wheelchair (non-skid pad for wheelchair seat to prevent resident from sliding forward in the wheelchair) for Resident #3. Review of Resident #3's care plan dated [DATE]20 intervention .one way slide to wheelchair. Observation on Cedar hall by the nurse's station on 2/11/2020 at 1:08 PM, showed Resident #3 seated in her wheelchair without a one way slide in the wheelchair. Interview on 2/11/2020 at 1:13 PM, with Licensed Practical Nurse (LPN) #3 on the Cedar hall nurse's station, confirmed the one way slide was a current care plan intervention and was not in use in the resident's wheelchair seat. Interview on 2/11/2020 at 2:15 PM, with the Assistant Director of Nursing confirmed the one way slide should have been in the resident's wheelchair and was a current safety intervention on the resident's care plan. Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan dated 10/2/2018 showed the resident was at risk for falls due to gait/balance problems and unaware of safety needs with interventions including one way slide to wheelchair and assist of 2 staff for transfers. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE], showed the resident had modified independence for decision making and unclear speech. The resident required extensive assistance of 2 staff members for transfers and the resident had one fall with minor injury during the assessment period. Review of the Order Summary Report Active Orders As Of: 2/11/2020 showed a Physician's order dated 4/22/2018 for a one way slide to the wheelchair and a Physician's order dated 1/30/2020 for assist of 2 staff with transfers. Observation of Resident #35 on 2/11/2020 at 1:06 PM, showed Resident #35's call light was on, Resident #35 was seated in a wheelchair in the room at the bedside, Certified Nursing Assistant (CNA) #2 entered the room and assisted Resident #35 to the toilet from the wheelchair. During an interview and observation of Resident #35's wheelchair on 2/11/2020 at 1:23 PM, CNA #2 confirmed a one way slide was not in the resident's wheel chair. Observation of Resident #35 on 2/11/2020 at 1:30 PM, showed CNA #3 entered the resident's room and assisted the resident from the toilet back to his wheelchair. During an interview and observation of Resident #35's Kardex on 2/11/2020 at 2:04 PM, CNA #2 confirmed she had assisted the resident to the bathroom (assist of 1 staff) and the Kardex stated 2 assist with transfers and the resident was to have a one way slide in the wheelchair. During an interview on 2/12/2020 at 9:05 AM, the Administrator confirmed it is her expectation for the staff to follow care plans to prevent resident falls in the facility.",2020-09-01
1529,GREEN HILLS CENTER FOR REHABILITATION AND HEALING,445267,3939 HILLSBORO CIRCLE,NASHVILLE,TN,37215,2017-10-31,225,K,1,0,EO0911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observation, and interview, the facility failed to investigate allegations of abuse for 2 residents (#2, #16) of 4 residents reviewed and failed to report these allegations to the State Agency. This failure resulted in Harm for Residents #2 and #16. The findings included: Review of facility policy, Abuse and Neglect Prohibition revised ,[DATE] Section Prevention revealed .Residents, families, and staff will be able to report incidents and concerns without fear of retribution .Facility supervisors will immediately investigate and correct reported or identified situations in which abuse, neglect, injuries of unknown origin .The facility will protect residents from harm during the investigation .The facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment including injuries of unknown origin, and misappropriation of property to the administrator, State Survey Agency, and law enforcement officials and adult protective services, in accordance with Federal and State law through established procedures . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation and interview of Resident #2 on [DATE] at 9:00 AM revealed I almost died last night, the man behind the wooden part tried to kill me, he hit me here, and grabbed my arm, I think he is from another town. Resident #2 had visible bruising on her left forearm on lateral side. Resident #2 touched the left side of her face and stated, he hit me here. Resident #2 showed surveyor the inside of her mouth and stated It hurts in here. Medical record review of a Nurses Note for Resident #2 dated [DATE] at 11:17 AM revealed .Resident stay(ed) in the dining room patient stated that I still have anxiety r/t (related to) release of fire extinguisher, patient has bruises on arm . Medical record review of a Nurses Note dated [DATE] at 9:10 AM revealed, .Patient reported that she was hit on her left upper arm and left forearm, and side of face. Bruising noted to left arm and slight swelling to left side of face. Patient denies any pain at this time. She also stated the man that hit her was from another state. She also stated the patient was in the wooden part of the floor. (Nurse Practioner) notified today . Interview with Registered Nurse (RN) #2 at 10:50 AM on the telephone revealed she was informed of Resident #22 grabbing the arm of Resident #2. RN #2 stated One more time he had those behaviors, he tried to hit Resident #21 in the hallway. Further interview revealed Resident #22 picked up the plastic planter and attempted to hit other residents. RN #2 was asked if she reported the assault to the administrator stated No, I did not. Medical record review of a facility investigation dated [DATE] at 1:00 AM written by LPN #3 revealed .Patient was yelling, this nurse went to her room (Resident #2) and a male patient (#22) was in her room. She states that he was trying to kill her, she states that he grabbed her left arm, and she has a bruise on her left arm . Interview with RN #5 on [DATE] at 3:00 PM in the conference room revealed Resident #2 was grabbed and hit by Resident #22 around 1:15 AM in room [ROOM NUMBER]. RN #5 reported LPN #3 informed her of the incident. Further interview revealed Resident #22 was transferred to the third floor due to elopement behavior. RN #5 stated He has tried to hit her before; he is only up here because of his exiting behavior. RN #5 stated (LPN #3) has called the family and completed the incident report. RN #5 stated Yes, I was made aware of the incident at 7:50 AM on [DATE], no I have not reported it. Further interview with RN #5 revealed These patients are a little different up here with dementia. When asked to name the 7 types of abuse RN #5 stated No, I can't name them, I have it up in my office. Interview with the Director of Nursing (DON) on [DATE] at 9:30 AM in the conference room confirmed that she was made aware of an incident. The DON stated I was here around 2:00 AM, and helped evacuate all the residents on the secured unit while we cleaned the hall and rooms; all beds had to be changed from the powder in the fire extinguishers. I was told a resident pulled the pin and sprayed all the powder in the hallway. When asked who the resident was the DON stated I am not sure I think it was a fairly new resident. I think he might have [MEDICAL CONDITIONS]. Continued interview with the DON revealed she did not know about the incident with Resident #2 and Resident #22. Later interview with DON on [DATE] at 6:30 PM confirmed she was made aware of Resident #2 and Resident #22 altercations in Resident #2's room when she arrived on the unit at 2:00 AM. Further interview with the DON revealed when she was asked if she reported resident to resident abuse, she stated No. I have been told not to report it. When asked if she could name the 7 types of abuse the DON stated No I can not, I will have to look at the policy, I really am trying. When asked if this incident was reported to the State Agency the DON stated, No, it has not been reported. Interview with the DON on [DATE] at 5:50 PM in the conference room confirmed the facility failed to report the abuse to the State Agency and to protect Resident #2 during the investigation. Medical record review, observations, and interviews revealed the facility failed to thoroughly investigate the physical abuse incident between Resident #2 and Resident #22 involving physicial abuse. Medical record review revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] and [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired, exhibited behaviors of wandering ,[DATE] days of the previous 7 days, and used a wheelchair for mobility. Medical record review of a SBAR Summary dated [DATE] at 8:07 PM revealed, .Resident has a habit (holding others {wheelchair} or clothes) (patient) grasp fistful of (Resident #20's wheelchair) so (Resident #20) upset and smacking her face . Medical record review of a Nurses Note dated [DATE] at 8:53 PM revealed, .Resident up in (wheelchair) and wandering .observed face, skin redness almost disappeared . Interview with the DON on [DATE] at 9:20 AM in the conference room confirmed she was not aware of a resident to resident altercation on [DATE] between Resident #16 and Resident #20. Continued interview confirmed the facility failed to report allegations of abuse to the State Agency. Telephone interview with RN #2 on [DATE] at 10:20 AM confirmed she was caring for Resident #16 on [DATE] on the 3:00 PM-11:00 PM shift and was at the nurse's station on the 3rd floor when someone told her Resident #20 had hit Resident #16. Continued interview revealed the RN was unable to remember who reported the incident to her. Continued interview confirmed the nurse separated the 2 residents and noted Resident #16 had a red line on the left side of her face below the eye which was present for at least 2 days and confirmed she wrote the SBAR Summary. Continued interview with RN #2 when asked if she had been trained in abuse prevention stated, Oh sure. I've had several in-services, the last one was less than a month. Continued interview revealed when asked if the nurse thought it was abuse, the RN stated, No. I didn't see it as abuse. It's a secure unit with combative patients. This wasn't the first time (Resident #20) was combative. I've seen this many times. The Nurse Practitioner gave orders for meds (medicines) or sent them to the hospital so it's behaviors. Continued interview with RN #2 when asked if she reported the resident to resident altercation to the Abuse Coordinator stated, We report to the Unit Manager and she reports to the DON. I document on the SBAR so they know. No. I did not notify the Administrator. Interview with RN #5 on [DATE] at 3:03 PM in the conference room confirmed she was the Unit Manager on the 3rd floor and was aware of a resident to resident altercation that occurred on [DATE]. Continued interview revealed the RN stated, I reported it verbally to the Administrator the next day in the clinical stand up meeting. Further interview revealed the RN was not instructed to initiate an investigation by the Administrator. Interview with the DON on [DATE] at 6:40 PM in the conference room confirmed the facility failed to investigate allegations of abuse to Resident #16 and failed to report abuse to the State Agency. The facility's failure resulted in Harm to Residents #2 and #16.",2020-09-01
4460,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2016-09-06,322,D,1,0,T33N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observation, and interview, the facility failed to label the tube feeding formulary bag, and failed to document the amount of formula and flush administered for 1 Resident (#1) of 9 residents reviewed. The findings included: Review of facility policy Tube Feeding-Hydration, undated revealed .Purpose: To provide proper hydration, via a feeding tube .Standard: Physician orders [REDACTED].Process: Record the cc's (cubic centimeters) .The amount of water given at each ordered flush, along with the total amount given each day is documented . Review of facility policy Intake and Output Measurement of Fluids, undated revealed .Purpose: To provide an accurate record of the resident's intake and output .Process: Fluids from .tube feedings is calculated and recorded by the licensed nurse . Medical record review revealed Resident #1 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician order [REDACTED].#4, at the nursing station on 8/22/16 at 12:23 PM, revealed the tube feeding formula was [MEDICATION NAME] 1.5 calorie concentrate at 70 cc for 22 hours, Water Flush Auto per pump at 52 cc per hour for 22 hours, and water 30 ml before and after each medication pass. Observation on 8/22/16 at 12:18 PM, revealed Resident #1 in bed in his room, with 600 ml's of tube feeding formula in a bag hanging on a pole. Further review revealed the formula bag label did not indicate the time of starting the feeding, the formula ordered, the rate it should be set to be administered or the initials of the nurse. Further observation revealed no water flush bag was on the pole. Tube feeding formula at 70 cc for 22 hours would provide 1540 cc per day and the water flush at 52 cc for 22 hours would provide 1144 cc per day. The medication flush would vary depending on the number of medications administered. Interview with LPN #4 on 8/22/16 at 12:22 PM, at the 1 West nursing station revealed when asked if water flushes had been provided LPN #4 stated .I have provided water with medications . When asked if the LPN had done any other water flushes the LPN checked the physician orders [REDACTED]. we don't have auto flush bags for awhile now . When asked what awhile meant the LPN stated .months at least . Further interview with LPN #4 at 12:58 PM at the 1 West nursing station when asked if any water flushes were administered LPN #4 stated .No, we don't have auto flush . When asked how he was calculating or accounting for what the resident needed for the flush LPN #4 stated .I have a problem . Medical record review of the 8/2016 Diet Flow Sheet form from the readmission on 8/16/16 revealed no documentation on 8/16/16, 8/17/16, and 8/19/16; and on 8/18/16, 8/20/16 and 8/21/16 one formulary and one flush was documented. Interview with the Director of Nursing (DON) on 8/22/16 at 3:15 PM, in the Business Office Manager (BOM) office, revealed when asked what the DON expected nursing staff to write on the tube feeding formulary bag when it was hung and administered stated I expect label to have the name of the resident, date and time it was started and the rate to be administered . Interview with LPN #5 on 8/22/16 at 5:12 PM, at the 1 West nursing station, after reviewing the 8/2016 Diet Flow Sheet form confirmed the facility failed to fill out the form completely. Observation on 8/23/16 at 8:15 AM, revealed Resident #1 in bed and the tube feeding formula bag with the label including the resident's name, date, start time, and initials. Further review revealed no rate of administration was documented on the label. Interview with the DON on 8/23/16 at 10:00 AM, in the BOM office confirmed the DON had checked the tube feeding formulary bag and the label did have some information .but was missing the rate . Interview with the DON on 8/24/16 at 11:00 AM, in the BOM office confirmed the facility failed to document on the diet flow sheet for tube feeding and fluids. Interview with the DON on 8/24/16 at 8:25 AM, in the BOM office confirmed the facility failed to follow the facility policy to document the intake of the fluids every shift.",2019-09-01
1418,SUMMIT VIEW OF ROCKY TOP,445259,204 INDUSTRIAL PARK RD,ROCKY TOP,TN,37769,2017-06-28,328,D,1,1,YWM011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observation, and interview, the facility failed to maintain equipment used in the provision of services for a [MEDICAL CONDITION] in a clean and sanitary condition and failed to administer [MEDICAL CONDITION] care for 1 resident (#79) of 1 resident observed with a [MEDICAL CONDITION] of 35 residents reviewed. The findings included: Review of a facility policy, [MEDICAL CONDITION] Care, dated (MONTH) 2005 revealed .remove old dressings and ties .change dressings when soiled or wet .change ties when soiled or wet .[MEDICAL CONDITION] should be changed as indicated, and at least monthly .provide [MEDICAL CONDITION] care as often as needed, at least twice daily for old, established tracheostomies .a replacement [MEDICAL CONDITION] must be available at the bedside at all times . Medical record review revealed Resident #79 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Physician Recapitulation Orders for the months of (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), revealed .trach care Day Eve Night .change O2 (oxygen) tubing, humidifier bottle and clean filter Night Shift every 14 days at Shift 3 .[MEDICAL CONDITION] every 3 months and prn (as needed) .trach care as needed .suction as needed . Medical record review of medication records [REDACTED]. Medical record review of electronic care notes by Unit Manager #1 dated 12/28/16, revealed .suctioning performed prior [MEDICAL CONDITION] with thick yellow tinged secretion noted. Inner Cannula changed with #6 Shiley (type [MEDICAL CONDITIONS]. Medical record review of electronic care notes by Wound Care Nurse (WCN) #1 dated 3/15/17, revealed, .Inner cannula changed, size #6 Shiley,[MEDICAL CONDITION] performed . Observation on 6/26/17 at 8:43 AM, in the resident's room, revealed Resident #79 lying in bed with eyes closed. Continued observation revealed Resident #79 had [MEDICAL CONDITION] humidified oxygen by concentrator and Easy Air Flow machine and a suction machine at the bedside with approximately 200-250 milliliters (ml) of fluid in the canister. Further observation revealed the Easy Air Flow machine and filters were dusty and the oxygen concentrator was dusty. Continued observation revealed the resident's mouth had dried saliva around the lips, and [MEDICAL CONDITION] and string ties were soiled. Observation and interview with Licensed Practical Nurse (LPN) #15 on 6/26/17 at 8:50 AM, confirmed [MEDICAL CONDITION] was dirty and soiled, dried saliva was around the resident's mouth, the humidifier water bottle and oxygen tubing were not dated, the Easy Air Flow machine and the oxygen concentrator were dusty. Continued interview confirmed the filters were cleaned weekly by 3rd shift, the Easy Air Flow machine is for moisture only, the suction canister is .usually emptied when it's half full . and .trach care is given once a day depending on his secretions, but usually night shift does it . Observation on 6/26/17, at 3:24 PM, in the resident's room, revealed [MEDICAL CONDITION] dressing was still soiled, dried saliva was still around the mouth. Interview with LPN #15 on 6/26/17, at 3:25 PM, at the nursing station, confirmed the Certified Nurse Aides (CNA) do mouth care sometimes and the nurses do mouth care sometimes. I don't know if he had mouth care today or not . Observation on 6/27/17, at 8:40 AM, in the resident's room, revealed the resident was awake with eyes open, non-verbal, did not respond to verbal stimuli, and [MEDICAL CONDITION] were still soiled. Interview with UM #1 on 6/27/17 at 8:55 AM, at the front desk, [MEDICAL CONDITION] .was probably done last night and they probably didn't change everything . on Resident #79. Interview with the Nurse Practitioner (NP) #1 on 6/28/17, at 12:00 PM, in the conference room, confirmed the resident .has terrible secretions .I would [MEDICAL CONDITION] to be changed [MEDICAL CONDITION] .",2020-09-01
1658,GRACE HEALTHCARE OF WHITES CREEK,445281,3425 KNIGHT DRIVE,WHITES CREEK,TN,37189,2018-03-02,697,J,1,1,GWBQ11,"**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 manage or prevent pain to help residents attain or maintain the highest practicable level of well being for 3 residents (#24, #61, #32) of 29 residents reviewed for pain. This failure to manage pain effectively placed Resident #24, Resident #61, and Resident #32 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was informed of the Immediate Jeopardy on 2/28/28 at 4:05 PM in the Administrator's office. F-697 is Substandard Quality of Care. An Acceptable Allegation of Compliance which removed the immediacy of the jeopardy was received and corrective actions were validated through review of documents, observations, and staff interviews conducted onsite on 3/2/18. The Immediate Jeopardy was effective from 11/21/17 through 2/23/18. The findings included: Review of facility policy, Pain Management, undated revealed .Pain is defined as an individual's unpleasant sensory or emotional experience. Acute pain is pain of abrupt onset or escalation. Chronic pain is pain that is persistent or recurrent. Pain is a highly subjective, personal experience for which there are no consistent objective biological markers .In the long-term care setting the comfort and well-being of the individual resident should always be paramount .Adequate pain management should be sought in each case .The same pain control measures that are used for residents who are able to communicate should be used for residents unable to communicate their pain due to dementia, [MEDICAL CONDITION] or other causes . Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #24 scored 9 on the Brief Interview for Mental Status (BIMS) indicating she was moderately cognitively impaired. Continued review of the MDS revealed Resident #24 required extensive assistance of 2 people for transfers and dressing; extensive assist of 1 person for grooming and bathing; and was always incontinent of bowel and bladder. Further review revealed Resident #24 was non-ambulatory; was placed in a wheelchair; and was unable to propel the wheelchair. Medical record review of Wound Care Notes dated 11/21/17 revealed Resident #24 was admitted to the facility with a Stage IV pressure ulcer (full thickness tissue loss with extensive destruction) to the right heel, measuring 1.2 centimeters (cm) x (by) 1.5 cm x 1.3 cm with undermining (deep tissue damage) of 2 cm at 11:00 (using the 11:00 o'clock position on a clock). Continued review of Nurses' Notes revealed Resident #24 went off-site to the Wound Clinic weekly for treatment of [REDACTED]. Medical record review of Wound Clinic notes dated 11/21/17 revealed Resident #24 had a Stage III ulcer (full thickness loss to tissue) on the right heel longer than 9 months and the facility had been using [MEDICATION NAME] (wound care mixture) with minimal improvement. Further review revealed the pressure ulcer measures 0.9 centimeters (cm) x (by) 0.6 cm x 1.8 cm with red granulation in the wound bed. Medical record review of the Medication Administration Record (MAR) for 11/2017 revealed Resident #24 was ordered [MEDICATION NAME] (Tylenol) 325 milligrams (mg), give 2 tablets every 4 hours as needed. Medical record review of Nurses Notes dated 11/20/17 at 9:22 AM revealed Resident #24 complained of heel pain and was medicated with Tylenol 650 mg by LPN #3. Medical record review of the MAR for 11/2017 revealed no documentation of the Tylenol administration. Review of facility investigation dated 11/21/17 revealed Resident #24 went to the Wound Clinic. Continued review revealed when CNA #1 and CNA #17 were getting Resident #24 ready for her appointment, when she complained of leg pain. Further review revealed CNA #1 reported the resident's pain to LPN #9 who assessed the leg but took no action. Continued review revealed upon return the resident's knee appeared swollen with the knee cap leaned over. Certified Nurse Aide (CNA) #3 reported her observations to the nurse. Further review revealed Licensed Practical Nurse (LPN) #3 assessed the resident who complained of heel pain when questioned. Continued review revealed CNA #1 later transferred the resident who complained of leg pain; LPN #3 was notified a second time and assessed the resident, but did not observe excessive swelling to the leg. Medical record review of the MAR for 11/2017 revealed no documentation Tylenol was administered for the resident's complaint of pain. Review of facility investigation dated 11/27/17 revealed CNA #3 was showering the resident and noted the resident's right knee was swollen and the knee was not sitting straight up the way it was on 11/21/17. Continued review revealed CNA #5 informed LPN #5 of the swollen knee who agreed the knee was swollen and said she would have Physical Therapy look at it. Further review revealed LPN #5 observed the knee to be swollen, painful to move, and warm to touch, and notified the Charge Nurse (LPN #4). Continued review revealed LPN #4 assessed the right knee of Resident #24 and agreed it was swollen, warm, and painful and notified the physician who ordered transfer to the Emergency Department (ED). Further review of the facility investigation revealed the ED nurse called the facility to find out if the resident had fallen because she had a femur fracture. Review of the Emergency Department (ED) record dated 11/25/17 at 12:02 AM, revealed Resident #24 had a history of [REDACTED]. Continued review revealed a statement there was no trauma and the resident is non-ambulatory. Continued review revealed the resident suffered a .comminuted interarticulated displaced angulated distal femoral fracture extending into the knee joint .(fracture of femur into many parts and extending into the knee separating the surface of the bone into many parts) Review of the ED information sheet revealed .Elderly people typically have poor bone quality and a fall from a standing position can cause such a fracture. Symptoms of this type of fracture include pain with weightbearing; swelling and bruising; tenderness to touch; knee may look out of place and the leg may appear shorter and crooked . Medical record review of the Comprehensive Care Plan revealed an update on 11/24/17 with a problem of swelling of the right knee and painful to touch. Continued review revealed approaches included cool compresses as needed; administer pain medications; inform provider; and X-ray if ordered and inform provider of results. Telephone interview with LPN #9 on 1/31/18 at 10:35 AM revealed she had no idea Resident #24 had a [MEDICAL CONDITION] because no one had told her about it. Continued interview revealed Resident #24 had pressure ulcers on both heels and usually complained of heel pain. Further interview revealed when the resident complained of pain she assumed it was from the heel. Continued interview revealed the facility was unable to determine the cause for the fracture. Interview with CNA #3 on 1/31/18 at 2:30 PM on the 100 hall revealed when Resident #24 came back from the Wound Clinic her knee was swollen. Continued interview revealed she told the LPN #3 about the knee. Further interview revealed CNA #3 took Resident #24 to her room and put her into bed. Medical record review of the 11/2017 MAR revealed no documentation Tylenol was administered. Interview with CNA # 5 on 2/1/18 at 6:20 AM in the conference room revealed when Resident #24 came back from the Wound Clinic on 11/21/17, her legs looked different. Continued interview revealed she asked LPN #4 look at the resident's legs and the knee was turned inward and she complained of pain. Continued interview revealed LPN #5 said the resident's knee was not right and she would notify the Charge Nurse (LPN #4). Further interview revealed the LPN #5 asked Physical Therapy if they could help with positioning and the therapist stated not to bother doing anything because the leg didn't look right. Interview with CNA #1 on 2/1/18 at 6:35 AM in the conference room revealed Resident #24 had an appointment at the Wound Clinic on 11/21/17 at 7:45 AM and she asked a co-worker to help get the resident dressed and into a wheelchair for pickup. Continued interview revealed about 2:00 PM Resident #24 complained of leg pain and the LPN assessed the leg but found no concerns. Medical record review of the 11/2017 MAR revealed no documentation of Tylenol administration in spite of the resident complaining of pain. Interview with the Director of Nursing (DON) on 2/1/18 at 4:03 PM in her office revealed Resident #24 had a heel pressure ulcer which was treated at the off-site Wound Clinic. Continued interview revealed she complained of foot pain regularly. Further interview revealed the CNA notified the nurse of the knee swelling who thought a physical therapy consult was needed. Continued interview revealed when swelling was reported a second time the resident was transferred to the hopsital Emergency Department (ED) and the femur fracture was diagnosed . Continued interview revealed there was no conclusion as to the cause of the fracture. Further interview revealed the DON called the Wound Clinic to find out how the resident was transferred and interviewed CNA #2 who accompanied the resident to the appointment, finding out Resident #24 was transferred using a stand-pivot method. Continued interview with the DON confirmed Resident #24 did not receive appropriate pain management. Telephone interview with CNA #2 on 2/1/18 at 5:35 PM revealed there was no problem observed with the van ride or getting Resident #24 in and out of the clinic. Continued interview revealed once inside the (wound clinic) staff stood the resident up and eased her to the treatment bed; eased her legs onto the bed; and propped her right leg on a pillow. Interview with CNA #3 saw the knee upon return from the Wound Clinic and knew something was wrong and told both LPN #3 and LPN #4. Further interview revealed LPN #3 saw Resident #24 and decided there was nothing wrong. Continued interview revealed from 11/21/17 - 11/23/17 there was little documentation of observation of the resident's knee. In summary, Resident #24 was admitted to the facility on [DATE] with a right heel Stage IV pressure ulcer. The resident had comorbidities of Diabetes Mellitus and [MEDICAL CONDITION]. On 11/21/17 upon return from the Wound Clinic, CNA #3 noted the resident's right knee was swollen. The resident was complaining of pain in her legs; LPN #3 stated in interview she administered Tylenol; but she failed to document the administration. The CNAs stated they told the nurses about Resident #24's swollen knee and pain however, the nurses failed to document any assessment of the resident's knee and failed to document administration of pain medication. On 11/24/17 Nurses' Notes revealed the first documentation of the resident's knee being swollen, painful, and warm to touch. There is no documentation pain medication was administered for the knee when the resident complained of pain. The Physician was notified on 11/24/17 and Resident #24 was sent to the ED where a comminuted interarticulated displaced angulated distal femoral fracture extending into the knee joint was identified. The failure to administer pain medication when the CNAs notified the Nurses' the resident was complaining of pain constituted inadequate pain management for Resident #24. Medical record review revealed Resident #61 was admitted to the facility on [DATE] and readmitted on [DATE] and 12/12/17 with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged to the hospital on the evening of 12/9/17. An additional [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #61 had a Brief Interview of Mental Status (BIMS) score of 1 indicating the resident was severely cognitively impaired. Further review revealed Resident #61 required extensive assistance with bed mobility and was total dependent for transfer, dressing, toilet use, personal hygiene and bathing. Continued review revealed resident had a range of motion limitation in the upper and lower extremities on both sides. Further review revealed the resident received PRN (as needed) pain medication. Medical record review of a Care Plan dated 12/29/16 revealed Resident #61 was at risk for poor nutritional status related to [DIAGNOSES REDACTED]. Medical record review of a Care Plan dated 1/4/17 revealed Resident #61 was at risk for alteration in comfort related to a history of right leg pain, decreased mobility, and multiple chronic disease processes. Medical record review of the Medication Administration Record, (MAR) for (MONTH) (YEAR) revealed Resident #61 had an order dated 12/4/17 for [MEDICATION NAME]/[MEDICATION NAME] (pain medication) 5/325 milligrams, one tablet by mouth three times daily prn. Continued review revealed no [MEDICATION NAME] pain medication was administered 12/4/17 through 12/9/17. Continued review revealed there was no order for Tylenol. Review of a witness statement signed by CNA #10 dated Saturday, 9, (YEAR) revealed .(Resident #61) was in the bed .This morning, 12-9-2017 she complain(ed) her knee was hurting .As I was changing her she complain(ed) of pain in her knee . Continued review of the witness statement revealed an addendum dated 12/9/17 at 8:21 PM and signed by the DON who documented .CNA reported that nurse on 11:00 PM-7:00 AM was made aware around 5:00 AM of residents complaint of pain to right knee . Review of a witness statement signed by LPN (Licensed Practical Nurse) #9 dated 12/9/17 included in the facility investigation revealed, .When I went in resident's room to give pain med (medication) for rt (right) leg that (CNA #10) told me she was hurting she mentioned that man dropped me .This occurred between 5:30 AM and 6:00 AM on 12/9/17 . Review of a witness statement signed by LPN #7 dated 12/9/17 revealed .When passing AM (morning) meds (medications) resident was complaining her knee was hurting while they transferred her to her chair. After being in chair resident was calm. I ask her why she was yelling. She said that man drop(ped) her while putting her in bed. Resident then told (RN #2) the same thing about being drop(ped). Resident calm and quiet while in chair, sleeping at intervals in chair. After lunch resident was put to bed and calm the rest of the shift waiting to be x-rayed . Medical record review of the Nurse Notes for 12/9/17 revealed no documentation by LPN #9 regarding voiced pain, that a man had dropped her, or that any pain medication was administered. Medical record review of a Physician's Telephone Order dated 12/9/17 at 12:30 PM revealed Stat (immediately) right knee x-ray due to swelling and pain . and signed by LPN #7. Medical record review of a Nurses' Note dated 12/9/17 at 12:43 PM by LPN #7 revealed .resident complain of R (right) knee pain stated she was drop(ped) by a man last night right knee noted to be swollen painful to touch or move MD (medical doctor) made aware order to have x-ray done and call him .will continue to monitor waiting on mobil x-ray to come to facility for x-ray . Medical record review of the hospital History and Physical to which Resident #61 was transferred to dated 12/9/17 revealed .The patient is a [AGE] year old lady who was sent to ED (Emergency Department) this evening from her nursing facility for a suspicion of right femoral fracture . Continued review revealed Resident #61 had been admitted to this hospital in (MONTH) (YEAR) for generalized weakness and again in (MONTH) (YEAR) for an episode of coffee-ground emesis. Further review revealed .She is status [REDACTED].She is immobile and is blind in the left eye and is significantly deaf .She seems reasonably comfortable, resting in bed, but does hurt when her left leg is manipulated .She has been apparently bed bound at the nursing home for at least the last year and it is not clear how she broke her right leg at this point . Interview with LPN #7 on 1/31/18 at 7:55 AM on the 200 hall revealed she was passing medications the morning of 12/9/17 and she heard Resident #61 hollering out. Continued interview revealed the resident hollered out a lot but this was a different tone. Further interview revealed LPN #7 went to Resident #61's room to check on her and staff were getting the resident up in her geri-chair. Continued interview revealed Resident #61 said her leg hurt and that a man had dropped her. Surveyor asked What did her leg look like? and LPN stated the resident's knee was swollen but no bruising, she had pain with movement. Continued interview revealed Once she was in her chair she was ok referring to her pain level. LPN stated she called the doctor and received an order for [REDACTED]. Continued interview revealed the mobile x-ray service came at the change of shift around 2:30 - 3:00 PM on 12/9/17. Telephone interview with LPN #9 on 1/31/18 at 10:18 AM by telephone revealed she worked the 11:00 PM to 7:00 AM shift which began on 12/8/17 and completed on the morning of 12/9/17. Surveyor asked LPN #9 what she remembered about Resident #61 the morning of 12/9/17 and LPN #9 stated the resident complained of foot and leg pain a lot and then stated I gave her Tylenol that morning. Medical record review of Physician order [REDACTED]. Telephone interview with CNA #10 on 1/31/18 at 11:08 AM by telephone revealed Resident #61 complained of leg pain in the early morning hours on 12/9/17 and he told LPN #9 and she went in to check on her. Interview with LPN #2 on 1/31/18 at 3:35 PM in the Restorative Nursing office revealed on 12/9/17 she went and assessed Resident #61. Continued interview revealed the resident told her that her leg was hurting. Surveyor asked What medication did (LPN #9) give to this resident? and LPN #2 stated there was nothing charted, we went back and did narcotic counts and nothing was given. Interview with the Director of Nursing (DON) on 2/1/18 at 3:50 PM in the Assistant Director of Nursing's (ADON) office, after discussion of Resident #61's complaint of being dropped and of knee pain, confirmed the facility did not follow their policy on administering pain medication when a resident reported to be in pain. Interview with the Administrator on 2/1/18 at 5:08 PM in the ADON's office, after reviewing Resident #61's care regarding the reporting of pain and no pain medication given, stated You're not telling us anything we didn't know, that's why we fired them. (LPN #9. CNA #10) Medical record review revealed Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #32 had a BIMS of 14 indicating he was cognitively intact. Medical record review of the MAR dated 1/2018 revealed for dates 1/23/18 thru 1/26/18 .[MEDICATION NAME] (opioid) 12 MCG (Micrograms)/HR (Hour) Patch apply on epatch (one patch) every 3 days for apin (pain). Rotate site . Was not documented as administered. Observation of Resident #32 on 1/31/18 at 12:20 PM in his room with the DON present revealed she performed as skin assessment. Continued observation revealed no [MEDICATION NAME] Patch could be located on the resident. Resident #32 stated .I was wondering why my hip was hurting . Interview with LPN #1 on 1/31/18 at 12:25 PM in Resident #32's room, was interviewed on how staff was notified when to check placement of [MEDICATION NAME] Patch. LPN #1 responded .The computer has a reminder that pops each shift . Interview with LPN #1 on 2/1/18 at 2:33 PM in the Medication room at the back nurses' station revealed Resident #32 needed another hard script to be faxed to pharmacy. I don't believe he got a [MEDICATION NAME] Patch on that day. Interview with LPN #2 on 2/1/18 at 3:15 PM revealed the pharmacy was called on 1/31/18. The original order was faxed on 1/23/18. But MG (Milligrams) was placed on the order instead of MCG (Micrograms). Continued interview revealed Resident #32 did not have a [MEDICATION NAME] Patch on and the order was refaxed on 1/31/18. Interview with the DON on 2/1/18 at 3:30 PM at the back nurses station confirmed the facility failed to ensure Resident #32 received his [MEDICATION NAME] Patch (pain patch), which resulted in Resident #32 not receiving the [MEDICATION NAME] for 10 days and the resident complaining of pain. The surveyor verified the Allegation of Compliance by: 1. On 12/4/18 - 12/5/18 pain assessments were completed on all residents with no further residents being affected and reviewed on 3/1/18. 2. On 2/2/18 licensed staff were educated on Incomplete Data on MAR and TAR, and [MEDICATION NAME] Patch and Verification. 3. On 2/28/18 review of daily audits of resident observations for change in pain, change or decline in condition, assessment as indicated with physician and/or Nurse Practitioner notification, and follow-up revealed audits were completed with Charge Nurse and CNA assigned to each resident. 4. On 3/2/18 observation of all residents with [MEDICATION NAME]es revealed patches were in place; dated with the date of placement; and dosage. 5. On 3/1/18 review of audits comparing pain medication ordered and its presence in the medication cart. 6. On 3/2/18 review of pain assessments revealed they were current on all residents. 7. On 3/1/18 - 3/2/18 interview with licensed staff members regarding [MEDICATION NAME]es, placement, verification of dosage, ordering patches, and how to handle Pharmacy issues revealed they were aware of the correct procedures. Noncompliance continued at a scope and severity of D for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance Committee. The facility is required to submit a plan of correction. Refer to F-580 Refer to F-600 Substandard Qualtiy of Care Refer F-641",2020-09-01
4424,CREEKSIDE CENTER FOR REHABILITATION AND HEALING,445516,306 W DUE WEST AVENUE,MADISON,TN,37115,2016-10-24,281,L,1,0,CT4U11,"**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 meet professional standards to administer medications properly and in a timely fashion; to communicate a significant change in the resident's condition to the appropriate professional; and to implement a physician's, advanced nurse practitioner's, or physician's assistant's order in a timely fashion (Lippincott Manual of Nursing Practice, 10th Edition, published 2014) by failing to complete blood glucose testing as ordered by the physician for 9 residents (#2, #3, #4, #5, #6, #7, #8, #9, #10) of 9 diabetic residents reviewed; failed to administer insulin per physician's order for 7 residents (#2, #3, #5, #6, #7, #8, #9) of 7 residents receiving insulin; failed to administer cardiac and blood pressure medications as ordered by the physician for 3 residents (#3, #6, #7) of 3 residents reviewed for cardiac and blood pressure medications; failed to administer antidepressant and antianxiety medications as ordered by the physician for 3 residents (#8, #9, #10) of 3 residents receiving antidepressants; and failed to follow guidelines for care of a resident with a wound vac for 1 resident (#18) of 7 residents reviewed with wound care. These failures placed all residents in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator (NHA) was informed of the Immediate Jeopardy on 10/24/16 at 3:25 PM in the Conference Room. The findings included: Review of facility policy, Medication Administration, revised 3/16/15 revealed, .Administer medications within 60 minutes of the scheduled time . Review of facility policy, Diabetes, Nursing Care of the Adult Diabetes Mellitus Resident, undated, revealed, .The purpose of this guideline is .Prevent recurrence of [MEDICAL CONDITION]/[DIAGNOSES REDACTED] (high and low blood sugars). Recognize, assist and document the treatment of [REDACTED].obtain pre-meal fingerstick blood glucose within 60 minutes (maximum) of anticipated meal .The physician should be notified when the blood sugar falls above his/her specified blood sugar range and/or above 400 mg/dL (milligrams per deciliter) . Review of facility policy, Negative Pressure Wound Therapy (NPWT), undated, revealed, .Review health care provider's orders for frequency of dressing change, type of foam to use, amount of negative pressure and cycle (intermittent or continuous) .Routinely check that the vacuum level is set as prescribed and the dressing is properly sealed .Inspect condition of wound on ongoing basis; note drainage and odor .verify airtight dressing seal and correct negative pressure setting. Measure wound drainage output in canister .Chart in the nurses's notes the appearance of wound, color, characteristics of any drainage .NPWT pressure setting, dressing change, and resident response to dressing change . The Medical Director of the facility is the physician of record for all the 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 the resident had a Brief Interview for Mental Status (BIMS) of 4 indicating the resident was severely cognitively impaired. She had continuous behaviors of inattention that did not change, and had rejected care 1-3 days of the previous 7 days. Continued review revealed the resident received 51% or more of her calories, 500 cc (cubic centimeters) or more of fluid through a feeding tube, and received 7 injections of insulin during the previous 7 days. The resident was impaired to her bilateral lower extremities, and impaired on her left upper extremity. She used a wheelchair for ambulation. Observation on 10/11/16 at 1:15 PM, in Resident #2's room revealed Licensed Practical Nurse (LPN) #1 was preparing to administer a bolus tube feeding to the resident. Continued observation revealed the LPN administered 300 cc of Glucerna 1.5 and 240 cc of water through the PEG tube without first checking placement or checking for residual. Interview with LPN #1 on 10/11/16 at 1:25 PM at the medication cart outside room [ROOM NUMBER]B confirmed she did not check placement or residual prior to administering 300 cc of Glucerna 1.5 tube feeding or 240 cc of water. The LPN confirmed she did not follow the care plan as directed for Resident #2. Medical record review of Physician's Orders for Resident #2 dated 9/22/16 revealed an order for [REDACTED]. The scheduled administration time was 9:00 PM. Medical record review of the 9/2016 and 10/2016 Medication Administration Record [REDACTED]. Interview with Registered Nurse (RN) #2 by phone on 10/12/16 at 3:20 PM confirmed 21 Units of [MEDICATION NAME] was not administered to Resident #2 on 9/22/16 at 9:00 PM as ordered. Medical record review of a Physician's Order dated 6/4/16 revealed, .ACCUCHECKS (finger stick for blood sugar) BEFORE BOLUS FEEDINGS AND SSI (sliding scale insulin) AS FOLLOWS: 0-59 = CALL MD 60-150=0, 151-200=2u (units), 201-250=4u, 251-300=6u, 301-350=8u, 351-400 = 10u .NOTIFY MD AND RECHECK IN 15 MINUTES . The scheduled time was 6 AM, 12 PM, 6 PM, and 12 AM daily. Medical record review of the 6/2016 Medication Administration Record [REDACTED]. Continued review revealed blood sugars were checked 1-4 hours late 2 times for the month of 6/2016. Interview with Licensed Practical Nurse (LPN) #3 on 10/18/16 at 2:20 PM, in the conference room revealed he called Nurse Practitioner (NP) #2 on 6/4/16 regarding Resident #2's blood sugar of 211 and was told to hold the SSI dose of 4 units. Continued interview with the LPN confirmed he did not write an order to hold the 4 units of insulin and he did not administer the dose per the sliding scale protocol. Medical record review of the 6/2016 Medication Administration Record [REDACTED] 591 on 6/4 at 7:30 AM 432 on 6/6 at 6:00 AM 401 on 6/7 at 12:00 AM High on 6/9 at 12:00 PM 456 on 6/12 at 6:00 AM 429 on 6/18 at 6:00 AM Medical record review revealed no notification of the MD or Nurse Practitioner (NP) regarding Resident #2's elevated blood sugars. Medical record review of the 7/2016 MAR indicated [REDACTED]. The time frame excludes the 60 minute window of time (60 minutes before and 60 minutes after the scheduled time) which is allowable to administer medication before or after the scheduled time. Medical record review of the 7/2016 MAR indicated [REDACTED] 564 on 7/1 at 6:00 AM 441 on 7/1 at 12:00 PM 503 on 7/6 at 12:00 AM 489 on 7/9 at 12:00 PM 518 on 7/10 at 12:00 AM 511 on 7/10 at 12:00 PM 405 on 7/12 at 12:00 AM 466 on 7/25 at 6:00 AM 459 on 7/27 at 12:00 AM 436 on 7/31 at 6:00 PM Medical record review revealed no notification of the MD or NP regarding Resident #2's elevated blood sugars. Medical record review of the 8/2016 MAR indicated [REDACTED] 475 on 8/1 at 12:00 AM 492 on 8/7 at 6:00 PM 456 on 8/20 at 6:00 PM 432 on 8/21 at 6:00 PM 493 on 8/25 at 6:00 PM Medical record review revealed no notification of the MD or NP regarding the elevated blood sugars. Medical record review of the 9/2016 MAR indicated [REDACTED]. Continued medical record review of the 9/2016 MAR indicated [REDACTED]. There was no documentation the blood sugar was re-checked in 15 minutes after administration of the 10 units of SSI. The blood sugar was not checked at 6:00 PM per order. The blood sugar was 327 at 12:00 AM on 9/23 and no SSI was administered; the blood sugar was 560 at 6:00 AM and no SSI was administered, the blood sugar was not re-checked in 15 minutes, and the physician was not notified. Continued review revealed no physician orders to hold accuchecks, or SSI in Resident #2's medical record. Telephone interview with LPN #5 on 10/18/16 at 4:00 PM revealed, (RN #2) gave me report to hold the insulin for lab work in the morning. I should have looked to see the order myself, and I did not call the Doctor when the sugar was 560. I was just going on what I was told. Interview with LPN #6 on 10/19/16 at 7:15 AM, in the conference room confirmed Resident #2's blood sugar was 47 on 9/7/16 and she failed to notify the physician. Medical record review of Resident #2's 10/2016 MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 10/19/16 at 4:05 PM in the conference room confirmed the facility policy was to notify the physician if a blood sugar was less than 60 or greater than 400. Continued interview revealed the DON was unaware accuchecks were up to 5 hours late. Further interview with the DON stated, I knew they were a little late but I had no idea they were 2 1/2-3 hours late. Continued interview with the DON confirmed the facility failed to check blood sugars as ordered, failed to follow the facility policy, and failed to notify the physician of the elevated blood sugars for Resident #2. Interview with the DON on 10/19/16 at 4:05 PM, in the conference room confirmed not administering [MEDICATION NAME] as ordered on [DATE] and administering the insulin at 11:25 PM instead of 9:00 PM were medication errors. Continued interview with the DON confirmed the facility failed to follow physician orders for Resident #2. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission MDS dated [DATE] revealed the resident was severely cognitively impaired, had impairments to all extremities, received insulin 1 time over the previous 7 days and received 51% or greater of his calories and 501 cc per day of fluid through a feeding tube. Medical record review of a physician's telephone order dated 9/22/16 revealed, .Accuchecks before meals and at bedtime . The scheduled time of administration was 7:30 AM, 12:00 PM, 5:00 PM, and 9:00 PM. The order did not include sliding scale insulin (SSI) orders. Medical record review of the 9/2016 MAR indicated [REDACTED]. Medical record review revealed no physician's telephone orders regarding accuchecks, SSI, or administration time changes. Medical record review of Resident #3's Physician's Recapitulation Orders for 9/2016 revealed an order dated 9/23/16 for accuchecks with SSI. The scheduled times were 10:00 AM, 2:00 PM, 6:00 PM and 10:00 PM. Medical record review of the 9/2016 and 10/2016 MAR indicated [REDACTED] 9/24 scheduled at 10:00 AM checked at 3:05 PM 9/24 scheduled at 2:00 PM checked at 4:20 PM 9/25 scheduled at 10:00 AM checked at 3:38 PM 9/25 scheduled at 2:00 PM checked at 5:33 PM 9/25 scheduled at 10:00 PM checked at 11:23 PM 9/26 scheduled at 10:00 AM checked at 12:39 PM 9/26 scheduled at 2:00 PM checked at 3:28 PM 9/26 scheduled at 10:00 PM checked at 5:20 AM on 9/27 9/28 scheduled at 10:00 AM checked at 11:19 AM 9/28 scheduled at 2:00 PM checked at 4:04 PM 9/28 scheduled at 10:00 PM checked at 11:36 PM 9/29 scheduled at 10:00 AM checked at 3:19 PM 9/29 scheduled at 2:00 PM checked at 3:20 PM 10/4 scheduled at 2:00 PM checked at 6:08 PM Medical record review of a physician's telephone order dated 9/12/16 revealed, .[MEDICATION NAME] HCL (used to treat low blood pressure) 5 mg tab (tablet) give one tab PT (per tube) before meals; BP (blood pressure) to be checked prior to administration, Hold for BP (systolic greater than 120 or diastolic greater than 80) . The order was written by LPN #4 and signed by NP #1. Medical record review of the Electronic Physician's Order dated 9/12/16 for [MEDICATION NAME] 5 mg revealed it was entered into the computer by LPN #4 at 7:00 PM. The electronic order contained a special requirement to check the blood pressure prior to administration and to hold if the systolic blood pressure was less than 120. Medical record review of Resident #3's 9/2016 MAR indicated [REDACTED].[MEDICATION NAME] HCL 5 MG TABLET give one tablet per tube before meals. CHECK BP (blood pressure) . There were no blood pressure parameters transcribed onto the MAR. Medical record review of the 9/2016 MAR indicated [REDACTED]. 9/12 at 10:00 PM. BP 149/90 9/13 at 10:00 AM. BP 152/82 9/13 at 2:00 PM. BP 125/64 9/13 at 6:00 PM BP 122/80 9/13 at 10:00 PM. BP 124/53 9/14 at 10:00 AM. BP 134/70 9/14 at 2:00 PM. BP 130/70 9/14 at 6:00 PM. BP 134/70 9/14 at 10:00 PM. BP 129/82 9/15 at 10:00 AM. BP 126/75 9/15 at 2:00 PM. BP 128/75 9/16 at 10:00 AM. BP 120/100 9/16 at 2:00 PM. BP 118/88 Continued review of an Electronic Physician's Order dated 9/16/16 revealed LPN #3 removed the parameter to hold the [MEDICATION NAME] 5mg if the systolic blood pressure was less than 120 on 9/16/16 at 5:01 PM. The original parameters from the 9/12/16 order to hold the medication if the systolic BP was greater than 120 or the diastolic BP was greater than 80 was not entered into the computer or transcribed onto the MAR. Medical record review of the MAR indicated [REDACTED]. Interview with the Regional Nurse on 10/24/16 at 2:00 PM, in the conference room confirmed the facility failed to follow physician orders for Resident's #2 and #3. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders dated 7/26/16 revealed .Please give 8 ounces [MEDICATION NAME] 1.5 per tube as needed if meal intake is less than 50% . Continued review of physician orders dated 9/20/16 revealed .[MEDICATION NAME] 1.5 cal liquid, Give 8 ounces per tube BID (twice daily) between meals with 120 ml (milliliters) H2O flush before and after each bolus . Medical record review of the MAR for (MONTH) (YEAR) revealed the 8 ounces of [MEDICATION NAME] were administered at 10:00 AM and 10:00 PM. Continued review revealed the 8 ounces to be given with food intake less than 50% was scheduled for 9:00 AM, 1:00 PM, and 7:00 PM. Further review of the MAR indicated [REDACTED]. Medical record review of nursing notes for 10/2016 revealed no documentation the [MEDICATION NAME] was given between meals as ordered. Interview with LPN #7 on 10/17/16 at 3:05 PM, in the conference room revealed she documented the amount the resident ate and put a check mark to indicate she was aware of the amount the resident ate. Continued interview revealed if the resident ate less than 50% of the meal the nurse would administer [MEDICATION NAME] to the resident. Interview with LPN #3 on 10/17/16 at 3:11 PM, in the conference room revealed nurses place a check mark on the MAR indicated [REDACTED]. Continued interview revealed if the resident ate less than 50% the staff would give [MEDICATION NAME] because that was the order. Further interview revealed LPN #3 was not aware of any place to document the [MEDICATION NAME] when it was given. Continued interview revealed .If the amount the resident eats is less than 50% we assume the nurse administered the [MEDICATION NAME] . Medical record review of the MAR for (MONTH) (YEAR) revealed on 21 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for (MONTH) revealed: a. on 7 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window b. on 4 occasions insulin was administered 1 1/2 - 2 hours past the scheduled window c. on 6 occasions [MEDICATION NAME] was administered 1 1/2 - 3 hours past the scheduled window. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED] a. on 22 occasions blood glucose monitoring was completed from 1 1/2 - 7 hours past the scheduled window b. on 12 occasions insulin was administered 1 1/2 - 7 hours past the scheduled window c. on 7 occasions [MEDICATION NAME] (antibiotic) was administered 2 - 8 1/2 hours past the scheduled window. Medical record review of the MAR for (MONTH) (YEAR) revealed: a. on 33 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window b. on 2 occasions insulin was administered 1/2 - 1 1/2 hours past the scheduled window c. on 4 occasions [MEDICATION NAME] (antidepressant) was administered 2 - 3 hours past the scheduled window d. on 4 occasions [MEDICATION NAME] (antidepressant) was administered 1/2 - 3 hours past the scheduled window e. on 9 occasions [MEDICATION NAME] (anti-anxiety) was administered 1 1/2 - 4 hours past the scheduled window Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for (MONTH) (YEAR) revealed: a. on 18 occasions blood glucose monitoring was completed 1 1/2 - 3 hours past the scheduled window b. on 16 occasions insulin was administered 2 1/2 - 8 hours past the scheduled window c. on 5 occasions [MEDICATION NAME] (cardiac) was administered 3 1/2 - 6 hours past the scheduled window d. on 9 occasions [MEDICATION NAME] (blood pressure) was administered 1 1/2 - 3 hours past the scheduled window e. on 5 occasions [MEDICATION NAME] (blood pressure) was administered 1 1/2 - 3 hours past the scheduled window f. on 3 occasions [MEDICATION NAME] (antianxiety) was administered 1 1/2 - 2 1/2 hours past the scheduled window Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for (MONTH) revealed: a. on 54 occasions blood glucose monitoring was completed 1 1/2 - 8 1/2 hours past the scheduled window b. on 18 occasions [MEDICATION NAME] (blood pressure) was administered 1 1/2 - 5 hours past the scheduled window c. on 13 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 5 1/2 hours past the scheduled window d. on 14 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 4 1/2 hours past the scheduled window e. on 3 occasions [MEDICATION NAME] (cardiac) was administered 1 1/2 - 2 1/2 hours past the scheduled window f. on 1 occasion [MEDICATION NAME] ([MEDICAL CONDITION]) and [MEDICATION NAME] (antacid) were administered 10 1/2 hours past the scheduled window Medical record review of the MAR for (MONTH) (YEAR) revealed: a. on 31 occasions blood glucose monitoring was completed 1 1/2 - 5 1/2 hours past the scheduled window b. on 4 occasions insulin was administered 2 - 5 hours past the scheduled window c. on 20 occasions [MEDICATION NAME] was administered 1 1/2 - 7 /12 hours past the scheduled window d. on 11 occasions [MEDICATION NAME] was administered 2 - 3 hours past the scheduled window e. on 13 occasions [MEDICATION NAME] was administered 1 1/2 - 5 hours past the scheduled window. Medical record review revealed Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for (MONTH) (YEAR) revealed: a. on 30 occasions blood glucose monitoring was completed 1 1/2 - 7 hours past the scheduled window b. on 20 occasions insulin was administered 1 1/2 - 7 hours past the scheduled window. c. on 43 occasions [MEDICATION NAME] (antianxiety) was administered 1 1/2 - 5 hours past the scheduled window d. on 16 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 5 hours past the scheduled window e. on 16 occasions [MEDICATION NAME] (antidepressant) was administered 1 1/2 - 5 hours past the scheduled window. Medical record review of the MAR for (MONTH) (YEAR) revealed: a. on 13 occasions blood glucose monitoring was completed 1 1/2 - 4 hours past the scheduled window b. on 6 occasions insulin was administered 1 1/2 - 3 1/2 hours past the scheduled window c. on 19 occasions [MEDICATION NAME] was administered 1 1/2 - 2 1/2 hours past the scheduled window d. on 8 occasions [MEDICATION NAME] was administered 1 1/2 - 3 1/2 hours past the scheduled window e. on 8 occasions [MEDICATION NAME] was administered 1 1/2 hours - 3 1/2 hours past the scheduled window Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MAR for (MONTH) (YEAR) revealed: a. on 47 occasions blood glucose monitoring was completed 1 1/2 - 7 hours past the scheduled window Medical record review of the MAR for (MONTH) (YEAR) revealed: a. on 34 occasions blood glucose monitoring was completed 1 1/2 - 7 1/2 hours past the scheduled window. Interview with the Director of Nursing (DON) on 10/20/16 at 4:40 PM in the Conference Room, confirmed medications were administered outside the window of 60 minutes before and 60 minutes after the scheduled time. Continued interview confirmed blood glucose monitoring and insulin administration occurred outside the window. Medical record review revealed Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] revealed the resident was severely cognitively impaired, always incontinent of bowel and bladder and had a Stage IV pressure ulcer to the sacrum. Medical record review of a telephone physician's order dated 10/10/16 prescribed by NP #3 revealed, .Coccyx pressure area - NPWT to pack/fill woundbed & drape to seal .Continue AG Collagen to cover coccyx wound bed each Vac (change) . Medical record review of the Treatment Administration Record (TAR) for 10/16 revealed the order was not followed on 10/11 or 10/12. Observation of Resident #18 on 10/18/16 at 10:20 AM in the resident's room revealed the resident was in bed, eyes closed. A wound vac was present to the side rail with serous drainage noted. Interview with the Wound Nurse on 10/19/16 at 11:30 AM in Hermitage Hall when asked when the resident's wound vac was placed stated, Friday. (10/14). Continued interview revealed when asked what the treatment order dated 10/10 meant the Wound Nurse stated, that the wound vac was there. Continued interview revealed the Wound Nurse confirmed she documented care of the resident and the wound vac on 10/13, 10/14, 10/17, 10/18, and 10/19. Further review revealed there was no additional documentation of when the wound vac was placed, the negative pressure setting, how often it was to be changed, amount and color of drainage or how the resident was tolerating it. The Wound Nurse stated, I should have documented all of that. Interview with the DON on 10/19/16 at 4:05 PM in the conference room confirmed the Wound Nurse should have clarified the 10/10/16 treatment order for the wound vac to Resident #18 on 10/10/16, and most certainly when the wound vac was placed. Continued interview with the DON confirmed there should have been documentation of the amount, color and odor of drainage, how the resident was tolerating the wound vac, the amount of negative pressure the wound vac was set on, and the type of wound vac machine and there was not. Interview with LPN #8 on 10/20/16 at 1:00 PM in the conference room confirmed she had cared for the resident on 10/15/16 and had documented on the TAR she had followed the treatment order dated 10/10/16. When asked what the protocol was for care of a resident with a wound vac she stated, It is changed every Monday, Wednesday, and Friday and it is done by the Treatment (Wound) Nurse. When asked what her documentation of the order meant, she stated, I've never changed a wound vac before. I checked that it was there. The LPN confirmed she did not provide any care, or documentation of the wound, or wound vac for Resident #18. Telephone interview with LPN #11 on 10/20/16 at 4:50 PM confirmed she had cared for the resident on 10/16/16. When asked what care she provided to the resident she stated, He had a wound vac to his sacrum. I changed the tape. The wound was exposed and I secured the dressing with tape. The LPN confirmed she did not change the dressing, or document the status of the wound, wound vac settings, drainage type and amount, or how the resident was tolerating the care. Refer to F157 K, F224 L SQC",2019-10-01
3272,"THE WATERS OF SMYRNA, LLC",445502,202 ENON SPRINGS ROAD EAST,SMYRNA,TN,37167,2018-01-16,600,K,1,0,POU411,"**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 abuse by 3 residents (#13, #15, #31) who were perpetrators; failed to provide a safe environment for 9 residents (#14, #16, #21, #26, #27, #28, #29, #30, #31) who were victims; and failed to ensure the safety of an unknown number of other potential victims whom the facility could not identify of 16 residents reviewed for abuse. The facility's failure resulted 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 1/16/18 at 2:10 PM in the conference room. The Immediate Jeopardy was effective on 8/15/17 and is ongoing. The findings included: Review of facility policy, Abuse Prevention Program dated 1/19/17, revealed .It is the policy of this facility to prevent resident abuse, neglect, mistreatment, and misappropriation of resident property .All alleged violations MUST be reported to the Administrator and Director of Nursing (DON) .After notification of alleged abuse or neglect the Administrator or person in charge of the facility shall immediately commence an investigation of the incident reported . Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #15 scored 1 on the Brief Interview for Mental Status (BIMS) indicating he was severely cognitively impaired. Continued review of the MDS revealed Resident #15 required extensive assistance with transfers, dressing, grooming, and bathing. Further review of the MDS revealed Resident #15 displayed no behaviors, either physical or verbal, toward others; had no wandering; and had no resistance to care. Medical record review of the Comprehensive Care Plan dated 6/13/17 revealed Resident #15 was at risk for increasing confusion secondary to [MEDICAL CONDITION] and Agitation. Continued review of the Care Plan revealed interventions included: explain all procedures; use simple commands; pleasant calm interaction with resident; provide prompting and cueing as needed; observe for signs of frustration and anxiety; involve in small groups; reality orientation as needed. Continued review of the Care Plan dated 6/13/17 revealed Resident #15 had [MEDICAL CONDITION] medication use to help manage and alleviate [MEDICAL CONDITION], history of aggression, and depression related to a [DIAGNOSES REDACTED]. Resident has episodes of wandering into others' rooms at times. Further review revealed interventions included: carry out medication management regime as prescribed; observe for side effects and complication; offer behavioral counseling and intervention to help resident cope with mood and/or behavioral distress and dysfunction. Medical record review of Resident #15's Progress Notes included the following information: Medical record review of Progress Notes dated 8/5/17 revealed there were multiple aggressive behaviors noted today. Witnessed going into another patient's room and hit her . Medical record review of Progress Notes revealed a late entry on 9/3/17 for 9/2/17 which stated, .Reported to this nurse that resident hit at a family member and a resident . Medical record review of Progress Notes dated 9/3/17, revealed the .Resident hit resident in (room number) twice this AM . Medical record review of Progress Notes dated 9/24/17 revealed multiple entries including: 9/24/17 Resident has hit another resident, chased a family member, attempting to hit her, and hit two staff members, and groped breasts of another incapacitated resident. 9/24 .He was witnessed by another resident groping the breasts of an incapacitated resident who is unable to speak or remove herself from the situation .C Wing Nurse reported to this nurse that he kicked another resident. 9/24/17 11:30 AM .Resident was exhibiting repeated intrusive behaviors, wandering in and other of other resident's rooms .attempting to touch other residents . Medical record review of Progress Notes dated 9/24/17 revealed .at 11:09 AM resident hit another resident, chased a family member attempting to hit her, hit 2 staff members; and groped breasts of an incapacitated resident . Continued review of Progress Notes at 11:12 AM revealed .he was witnessed by another resident groping the breasts of an another incapacitated resident who is unable to speak or remove herself from the situation .C wing nurse reported to this nurse that he kicked another resident . Further review of Progress Notes at 11:30 AM revealed Resident #15 was .exhibiting repeated intrusive behaviors, wandering in and out of other residents' rooms .attempting to touch other residents . Medical record review revealed Resident #15 was sent to the hospital on [DATE] and returned to the facility on [DATE] with no changes in medications or new orders. Medical record review of Progress Notes dated 12/18/17 revealed Resident #15 went up to Resident #16 in the hallway and punched her in the left cheek. Continued review revealed Resident #15 was sent to the hospital on [DATE] through 1/8/18. Interview with the DON on 1/8/18 at 4:10 PM in the conference room revealed Resident #15 had a history of [REDACTED].#15 returned to the facility after being gone a month and .he was doped up, really lethargic beyond his normal . Further interview revealed the resident underwent [REDACTED]. Continued interview revealed Resident #15 went about 2 weeks without any behaviors then just .out and hit another resident . Further interview revealed the facility sent the resident to the hospital on [DATE] but they sent him back stating he did not need treatment. Continued interview revealed upon the resident's return to the facility the DON sent him out to another hospital and this psychiatric hospital was now trying to transfer him back to the facility. Continued interview revealed she did not think it was safe for the resident to return to the facility and she would have to provide 1:1 supervision for the next 72 hours if he came back .to see if we can keep him here while keeping others safe . Further interview on 1/9/18 revealed Resident #15 returned to the facility the previous evening and was placed on 1:1 supervision. Observation of Resident #15 on 1/10/18 at 12:55 PM revealed the resident asleep in his bed. Certified Nurse Aide (CNA) #4 was present in the room and stated he was providing 1:1 supervision of the resident who had just been readmitted from the hospital the previous evening. CNA #4 also stated Resident #15 had displayed 1-2 behaviors of aggression and punched the CNA while he was being showered on the same day. Interview with CNA #2 on 1/11/18 at 11:28 AM in the break room revealed Resident #15 .punched people randomly. He would be sitting there minding his own business and would just hit out . Continued interview revealed the staff tried to keep Resident #15 away from certain people and would just remove him from the area. Further interview revealed there were no specific interventions in place except to remove him from the area. Interview with CNA #3 on 1/11/18 at 11:52 AM in the break room revealed .I've seen him hitting others. He rolls up to somebody and stares into their face. He actually kicked a family. The only thing to prevent it is to keep an eye on him. If you see him rolling up to somebody, redirect him . Interview with Corporate Consultant #1 on 1/10/18 at 9:20 AM at the C-wing nurses' station, revealed there were no investigations for the incidents on 8/5/17, 9/2/17, 9/3/17, and 9/24/17. Continued interview confirmed for each allegation of resident-to-resident abuse a full investigation should be conducted to determine if the allegation was substantiated in order to plan interventions to protect residents; put these interventions in place immediately; and prevent further abuse. Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS revealed Resident #31 had periodic confusion related to Dementia. Continued review revealed the resident had no behaviors during the assessment period. Medical record review of Progress Notes dated 6/3/17 revealed Resident #31 was involved in an incident of .physical aggression towards another resident . No specifics of this incident, which resulted in Resident #31 being hospitalized for [REDACTED]. Medical record review of Progress Notes dated 9/16/17 revealed Resident #31 was observed in the dining room with .her hand held back at another resident and the second resident stated Resident #31 hit her. When this nurse asked the resident if she hit her she held her hand up and said in the nose, in the nose, just once, just once. Will send resident to ER (emergency room ) for psych (psychiatric) evaluation . Medical record review of Progress Notes dated 9/21/17 revealed Resident #31 was reported to .have slapped a male patient who had been invading the space of other individuals all afternoon. Patient was in dining room eating supper. Both patients were separated several times. Resident (#31) sent to ER for evaluation . Medical record review of Progress Notes dated 12/22/17 revealed Resident #31 slapped another resident in the face. When Resident #31 was asked what happened stated .I didn't hit her; she hit me . A witness stated Resident #31 slapped the other resident. Resident #31 was transferred to the hospital until 1/3/18. Interview with the DON on 1/15/18 at 3:10 PM in the conference room revealed she was unable to find an investigation for the incidents. Continued interview revealed they just sent Resident #31 out to the hospital each time. Telephone interview with Registered Nurse (RN) #2 on 1/16/18 at 12:05 PM revealed RN #2 did not report this incident as abuse because .I considered it a behavior problem. Not an abuse problem. Abuse needs to be purposeful. If you have psychiatric problems the residents can't be held to the same behaviors as someone who doesn't. Abuse is intentional, trying to hurt someone . Continued interview revealed RN #2 stated We need additional eyes to redirect these residents. More staff would always be helpful. It would be useful to prevent future resident to resident altercations. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #13 scored 2 on the BIMS indicating he was severely cognitively impaired. Continued review of the MDS revealed the resident required extensive assistance with transfers, dressing, grooming, and bathing. Review of the facility investigation revealed a Witness Explanation of Incident dated 8/15/17 revealed a witness statement .a male resident alerted me there was an emergency in the dining room, that he is playing with her (female genitalia). I went to the dining room and (Resident #13) had his right hand up the pants of a female resident (Resident #14). She was motioning him to keep coming and was patting her private area. This nurse removed (Resident #13) from the area . Review of a facility investigation dated 11/5/17 revealed Resident #13 was seen fondling a female resident's breast (Resident #21) while she was sleeping in her wheelchair. Continued review revealed Resident #13 was removed from the area and sent to the hospital on [DATE]. Further review revealed on return from the hospital Resident #13 was started on [MEDICATION NAME] Acetate (a female hormone used to reduce sexual behaviors) to be given daily for inappropriate sexual behavior. Medical record review of Medication Administration Records for (MONTH) (YEAR) and (MONTH) (YEAR) revealed Resident #13 refused his medication on 5 different days. Interview with the DON on 1/8/18 at 2:25 PM in the conference room revealed Resident #13 had a long history of liking the ladies. Continued interview revealed he was sent to the hospital after his incidents of sexual contact with female residents and finally he went to a psychiatric hospital where they started him on medication to decrease his sexual urges. Further interview confirmed Resident #13 had several episodes of unwanted sexual contact with female residents. Interview with Licensed Practical Nurse (LPN) #3 on 1/9/18 at 11:20 AM on the 200 hall revealed (Resident #14) used to live on the same hall as Resident #13 however she had been moved to another hall. Continued interview revealed Resident #14 had been moved back to the unit where Resident #13 resided and LPN #1 felt It was a terrible idea since (Resident #14) had been moved to decrease repeated sexual contact with (Resident #13). Observation on 1/9/18 at 11:28 AM revealed Resident #14 was residing 4 rooms away from Resident #13. Additional interview with the DON on 1/9/18 at 12:20 PM at the 100 hall nurses' station revealed she was not aware Resident #13 was spending time up and around the facility in his wheelchair. F-600 resulted in Substandard Quality of Care.",2020-09-01
1888,HILLCREST HEALTHCARE CENTER,445316,111 E PEMBERTON STREET,ASHLAND CITY,TN,37015,2017-08-10,224,K,1,1,D1L611,"**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 neglect by failing to provide the services necessary to avoid physical harm for residents utilizing electrical power strips for 1 resident (#87); failed to prevent neglect by failing to ensure the facility utilized approved electrical power strips for 14 residents (#87, #70, #22, #29, #91, #88, #65, #49, #16, #1, #12, #15, #24, #47) of 70 residents in the facility; and failed to prevent neglect by failing to prevent exploitation of 5 residents (#22, #26, #30, #49, #91) of 14 residents reviewed for abuse. The facility's system 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 #87. The Administrator was notified of the Immediate Jeopardy on 8/10/17 at 1:00 PM in the Administrator's office. The facility's failure at F-224 represents Substandard Quality of Care. The findings included: Review of facility policy, Abuse, Neglect, and Exploitation/Dementia Management, revised 6/14/17 revealed .'Neglect' means failure of the facility .to provide goods and services to a resident that are necessary to avoid physical harm .The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including but not limited to the following possible indicators: Evidence of photographs or videos of a resident regardless of whether the resident provided consent and regardless of the resident's cognitive status . Medical record review revealed Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired, required extensive assistance of 2 or more people for bed mobility, dressing, toileting, and personal hygiene, was dependent with assistance of 2 or more people for transfers and bathing and required supervision and set up help for eating. Continued review revealed the resident did not ambulate and was receiving Hospice services. Observation on 8/7/17 at 9:10 AM in the resident's room revealed Resident #87 was laying on the right side of the bed with the head of bed elevated. Continued observation revealed to the left side of the resident was a white electrical power strip with a cell phone charger attached to a cell phone plugged into a electrical power strip lying in the bed. Further observation revealed the electrical power strip was plugged into the wall and was in the 'on' position. Continued observation revealed a cup with approximately 2 ounces of red fluid in it on the overbed table to the right side of the bed next to the resident, and a urinal with approximately 200 milliliters of urine in it hanging on the trash can to the right side of the bed next to the resident. Interview with Licensed Practical Nurse (LPN) #6, assigned to Resident #87, on 8/7/17 at 9:15 AM in the C hall denied knowledge of the electrical power strip in bed with the resident and stated she had not assessed the resident yet. Observation on 8/7/17 at 9:18 AM in the resident's room revealed LPN #6 attempted to remove the electrical power strip from the resident's bed and he became very agitated. Continued observation revealed the Social Worker (SW) came to the resident's room, and she asked him if she could place the electrical power strip on the floor. The resident agreed and the SW removed the electrical power strip from the bed and placed it on the floor to the left side of the bed. Interview with CNA #2 on 8/7/17 at 9:30 AM in C hall revealed she regularly cared for the resident. Further interview with the CNA revealed she had observed him at 7:45 AM and at 8:15 AM, and the electrical power strip was not in the bed. Further interview revealed the CNA stated the resident could roll independently and reach the electrical power strip from the floor with his right hand, and roll back independently, and stated, that was probably how the electrical power strip got into the bed. Interview with CNA #3 on 8/7/17 at 9:35 AM in C hall revealed she also cared for the resident and last saw him at 8:00 AM, but could not recall if the electrical power strip was in the bed with the resident. The CNA stated the resident was not able to roll independently, needed assistance with bed mobility, and could use his right arm independently. Observation on 8/7/17 at 12:36 PM in the resident's room revealed the resident was in the same position in bed when observed at 9:10 AM. Further observation revealed the same glass of red fluid and the urine in the urinal were in the same place as they were at 9:10 AM. The electrical power strip was laying on top of the green lid of a clear tote stored on the floor to the left side of the bed with the resident's phone charger plugged into it. Continued observation revealed CNA #2 placed a lunch tray on the overbed table and positioned the overbed table over the resident. Continued observation revealed the CNA lowered the head of the bed, pulled the resident up in bed unassisted, raised the head of the bed, repositioned the over bed table in front of the resident and prepared the lunch tray for the resident. Further observation revealed two 8 ounce glasses of fluid on the tray were relocated to the left upper portion of the over bed table. Observation revealed the resident's lower extremities did not move voluntarily during the repositioning. Continued observation revealed the resident was able to use his right arm and hand to feed himself. The resident's left arm and hand had no voluntary movement. Interview with the Director of Nursing (DON) on 8/8/17 at 8:15 AM in the DON's office confirmed Resident #87 could not stand and needed assistance with all activities of daily living (ADL's). The DON stated he was bed bound, became very angry with repositioning, and preferred to stay on the right side of the bed on his back. The DON did not know how the electrical power strip got into the resident's bed. Interview with the Social Worker (SW) on 8/8/17 at 8:30 AM in the SW's office revealed she had a fairly good rapport with Resident #87. Continued interview with the SW revealed, He is very territorial. He hides things in his bed behind his back, under the blue pad, and under the covers. The SW stated the resident was admitted with the phone and phone charger but she was not sure where the electrical power strip came from. Interview and observation with the Maintenance Director on 8/8/17 at 8:45 AM in Resident #87's room confirmed the electrical power strip belonged to the facility and it was 'on' and charging the phone. The Maintenance Director stated the electrical power strip was not supposed to be on the floor, that's why it's on the tote. The resident was asked to pull the phone charger, stored on the green lid of a clear tote stored on the floor, toward him. Using his right hand, the resident pulled on the phone and the phone cord to lift the electrical power strip. Further observation revealed the resident could not pull the electrical power strip onto the bed because the electrical power strip got hung on the underside of the mattress. The resident was not able to move his left arm or hand. A telephone call to the Life Safety Supervisor (LSS) at the State Agency on 8/8/17 at 9:15 AM revealed there was 1 type of electrical power strip approved for resident use with personal items at the facility. The LSS stated it had to be a UL (Underwriter's Laboratory) 1363 type of electrical power strip. Observation on 8/8/17 at 9:20 AM in Resident #87's room with another surveyor present revealed the electrical power strip used by the resident was a SS-2B-F (Temporary Power Tap) UL. Listed 99K8 E897, not an approved electrical power strip per the Life Safety Code regulation. Further observation revealed the electrical power strip had Caution Use only in dry location engraved on the electrical power strip. Interview with the Maintenance Director on 8/8/17 at 11:47 AM in the D hall was asked to provide the manufacturer's recommendations for the electrical power strip used in Resident #87's room. Continued interview at 12:02 PM in the classroom revealed the Maintenance Director provided this surveyor with a manufacturer's printed sheet and an opened box of a GE black electrical power strip. It was not the same model used by Resident #87. Further interview at 12:50 PM in the D hall, the Maintenance Director was informed by the surveyor the information he provided was not the same model used by the resident, and he stated, well they're all the same, it's general information. The Maintenance Director was not able to provide any manufacturer's recommendations for the SS-2B-F UL electrical power strip used by Resident #87 and provided by the facility. Observation on 8/8/17 at 1:40 PM in the resident's room with the SW and Registered Nurse (RN) #2 present revealed the SW asked Resident #87 to pick up his phone charger that was plugged into the electrical power strip and see if he could put it in his bed. The resident was observed moving his right lower leg and turning a little toward his left side while using his right hand to pull the electrical power strip up and over the mattress while it was attached to the phone charger. The SW and RN #2 confirmed the resident could place the electrical power strip in bed unassisted. Observations on 8/8/17 between 3:30 PM and 4:30 PM revealed the following resident rooms contained electrical power strips not in compliance with the Life Safety Code (LSC) regulation with devices plugged into the electrical power strip: B-200 Hall 208A/Resident #70; C-300 Hall 306/Resident #22, 307A/Resident #29; E-500 Hall 501A/Resident #91; F-600 Hall 601A/Resident #88, 602B/Resident #65, 603A/Resident #49, 605A/Resident #16 606A/Resident #1, 608B/Resident #12, 609B/Resident #15, 610A/Resident #24 and 610B/Resident #47. Interview with the Maintenance Director on 8/10/17 at 9:30 AM in D hall confirmed none of the electrical power strips previously used in the facility were model 1363, and stated he was confused with all the updates and changes recently. In summary, the facility failed to prevent neglect by failing to provide the services necessary to avoid physical harm for residents utilizing electrical power strips based on the observation of Resident #87 with an electrical power strip in his bed which he was physically able to pull onto his bed. Further observation revealed fluids were accessible to Resident #87 while the electrical power strip was in the bed and while stored on the clear tote box stored on the floor. Further observation revealed a total of 14 residents were utilizing unapproved electrical power strips. The facility Administration and Maintenance Director were unaware of which electrical power strips were approved to be used in the facility. Refer to F-323. The Immediate Jeopardy was effective from 8/7/17 through 8/10/17. An acceptable Allegation of Compliance on 8/10/17, which removed the immediacy of the jeopardy, was received and corrective actions were validated through direct observation of the removal of all electrical power strips in the facility; direct care staff interviews regarding education; review of maintenance audits of rooms with electrical power strips and their removal; interview with the Maintenance Director to validate comprehension of the approved type of electrical power strips acceptable for use in the facility; and review of in-service training records dated 8/8/17-8/9/17. The Allegation of Compliance was verified by: 1. Observation validated the electrical power strip was removed from Resident #87's bed by the Social Worker on 8/7/17 at 9:30 AM, and the Maintenance Director had removed the electrical power strip from the resident's room, 305A, on 8/8/17 at 2:30 PM. 2. Review of the electrical power strip audit conducted on 8/8/17 and observation of resident rooms validated all the electrical power strips were removed from resident rooms on 8/9/17. Validation: by review of the letter sent to the resident's family regarding electrical power strip use; by interview with the Administrator on 8/9/17 at 12:22 PM in the classroom confirming the letter dated 8/9/17 was mailed to the families on electrical power strip use; by review of the list of family names the letter was mailed to; and by observation of the signage placed on bathroom doors in resident rooms that all electrical power strips must be approved by maintenance prior to use. Review of the email from the facility to the Life Safety Director at the State Agency validated the .Power strips providing power to non-patient-care-related equipment must be relocatable Power taps (RPT) listed as UL 1363 . Review of the admission packet verified the electrical power strips use had to be approved by the Maintenance Director prior to use. Interview with the Administrator on 8/9/17 at 12:22 PM in the classroom verified the Resident and Family Councils, scheduled for (MONTH) (YEAR), included the approved power strip use information. 3. Interviews on 8/10/17 with 4 Housekeeping and Laundry staff, 3 Nurse Aides, 7 CNA's, 3 LPN's and 3 RN's between 8:55 AM and 9:30 AM validated they had been inserviced on no electrical power strips in the building unless approved by Maintenance and electrical power strips were to be mounted, not on the floor, and not in bed with residents. Review of the facility audit of staff in-servicing validated staff not on duty had been contacted to educate them on the electrical power strip use. Interview with the Maintenance Director on 8/10/17 at 9:30 AM on the D hall verified he had been educated by the Administrator on 8/9/17, on the approved type of electrical power strips acceptable in the facility. The Maintenance Director stated, Model 1363 was for personal equipment, and 1363A was for medical equipment. 4. Interview with the Administrator on 8/10/17 at 1:20 PM in her office validated she or her designee would monitor for continued compliance through weekly quality improvement audits. The findings will be reported immediately to the Administrator and in the subsequent morning QA (Quality Assurance) meeting. Audit findings will be discussed in facility QAPI (Quality Assurance and Performance Improvement) meetings. Noncompliance continues at a scope and severity of [NAME] for monitoring the effectiveness of corrective actions and evaluation of monitoring by the QA Committee. The facility is required to submit a plan of correction. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Significant Change Minimum Data Set ((MDS) dated [DATE] revealed Resident #22 scored 2 on the Brief Interview for Mental Status (BIMS) indicating she was severely cognitively impaired. Continued review of the MDS revealed Resident #22 required extensive assistance of 2 people for transfers, dressing, and grooming; was totally dependent on 2 people for bathing; was frequently incontinent of bladder and always incontinent of bowel. Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #26 scored 13 on the BIMS indicating she was cognitively intact. Continued review of the MDS revealed Resident #26 required supervision with transfers and ambulation; limited assistance of 1 person with dressing; supervision with toileting and grooming; limited assistance of 1 person for bathing; and was always continent of bowel and bladder. Medical record review revealed Resident #30 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual MDS dated [DATE] revealed Resident #30 scored 12 on the BIMS indicating moderate cognitive impairment. Continued review of the MDS revealed Resident #30 required extensive assistance of 1 person for transfers, dressing, and grooming; was totally dependent on 1 person for bathing; was occasionally incontinent of bladder and always incontinent of bowel. Medical record review revealed Resident #49 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Significant Change MDS dated [DATE] revealed Resident #49 scored 11 on the BIMS indicating she had moderate cognitive impairment. Continued review of the MDS revealed Resident #49 required supervision with transfers,eating, toileting; required limited assistance with dressing and grooming; required physical help of 1 person with bathing; and was always continent of bowel and bladder. Medical record review revealed Resident #91 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual MDS dated [DATE] revealed Resident #91 scored 6 on the BIMS indicating she was severely impaired cognitively. Continued review of the MDS revealed Resident #91 required supervision with transfers and grooming; limited assistance with dressing and toileting; physical assistance of 1 person for bathing; and was frequently incontinent of bowel and bladder. During 1/2017 the facility had a birthday party for Resident #26 and pictures were taken of the occasion. Included in the pictures were Residents #49, #30, #91, #22, and #26. These pictures were later posted on social media. Interview with the Director of Nursing on 8/10/17 at 10:10 AM in the nurse's station revealed she was unaware of any instance of a Certified Nurse Aide (CNA) taking pictures of residents and posting them on social media. Interview with the Administrator on 8/10/17 at 10:20 AM in her office, revealed she was unaware of any CNA taking pictures of residents and posting them on social media. She spoke with Social Services and the Activity Director and neither of them was aware of such a posting. Telephone interview with CNA #1 on 8/10/17 at 3:54 PM revealed she did not take any pictures of the birthday party. Further interview revealed Social Services took the pictures at the birthday party. Then CNA #1 stated the activities assistant took the pictures on her phone; sent them to CNA #1 who posted them on her social media page for the daughter of Resident #26. Interview with the Director of Activities, on 8/10/17 at 4:10 PM in the classroom, revealed she did not send any pictures to CNA #1. The Admissions Coordinator put the pictures on the facility's social media page. Interview with the Admissions Coordinator, on 8/10/17 at 4:20 PM in the classroom, revealed the Admissions Coordinator and the Administrator had access to the social media page which was on the facility's web site. Further interview with the Admissions Coordinator revealed she did not send any pictures to staff, but staff can take pictures from the social media page and send them where they want. Interview with the Administrator on 8/10/17 at 4:45 PM in the Administrator's office, confirmed staff were not permitted to take pictures of residents and post them on social media, and confirmed this was exploitation of residents. Refer to F-323 K.",2020-09-01
4097,ELK RIVER HEALTH AND REHABILITATION OF WINCHESTER,445319,32 MEMORIAL DRIVE,WINCHESTER,TN,37398,2016-11-01,431,D,1,0,O8V411,"**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 liquid Ativan (Benzodiazepine medication used to treat anxiety) in the medication refrigerator according to manufacturer's recommendations and as labled by the pharmacy for 1 resident (#1) of 3 residents reviewed. The findings included: Review of facility policy, Storage of Medications, revised ,[DATE] revealed, .The facility shall store all drugs .in a safe, secure, manner .Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station .Narcotics (controlled substances) requiring refrigeration should be secured to the inside of the refrigerator in a locked box . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident was placed on hospice on [DATE] and expired on [DATE]. Medical record review of a Physicians order dated [DATE] revealed Lorazepam (also known as Ativan-Benzodiazepine used to treat anxiety) Intensol (solution) 2 mg/ml (milligrams per milliliter) give 0.25 ml sublingual every 6 hours as needed for anxiety. The bottle contained 30 ml of the medication. Observation of the medication room refrigerator on [DATE] at 9:30 AM, with the Director of Nursing (DON) revealed a locked refrigerator requiring a key to open and a clear plastic locked narcotic (controlled substance) box inside the refrigerator requiring a separate key. No narcotics were present at this time inside the narcotic box. Observation and interview with the Pharmacy Consultant and the DON on [DATE] at 9:00 AM, in the medication room revealed the disposal container for wasted medications was opened. Continued observation revealed a 30 ml bottle of Ativan inside the box for Resident #1. The box had a label added by the pharmacy that read Refrigerate in light blue letters located at the bottom of the box. Continued observation revealed instructions to store at ,[DATE] degrees Fahrenheit were included on the outside of the box of Ativan. The Pharmacy Consultant and DON confirmed the Ativan was to be stored in the medication refrigerator when it was received at the facility. Telephone interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 9:35 AM confirmed the Ativan for Resident #1 had been stored in the medication cart. Interview with LPN #2 on [DATE] at 11:00 AM, in the conference room revealed, After a dose of Ativan was given, it had been kept on the cart, not in the refrigerator. Telephone interview with LPN #3 revealed, The box (of Ativan) had a label on it to refrigerate. When asked why it was stored in the medication cart, the LPN stated, I'm not sure. They told us in an in-service to refrigerate it when it comes from the pharmacy. Telephone interview with LPN #4 on [DATE] at 1:30 PM revealed, I opened it (Ativan) on Sunday (,[DATE]), gave it, and put it back in the cart. When asked if the Ativan was labeled to refrigerate the LPN stated, I honestly didn't look. Interview with the DON on [DATE] at 3:00 PM, in the conference room confirmed the facility failed to store Ativan in the medication refrigerator as labeled for Resident #1.",2019-11-01
4428,CREEKSIDE CENTER FOR REHABILITATION AND HEALING,445516,306 W DUE WEST AVENUE,MADISON,TN,37115,2016-10-24,353,L,1,0,CT4U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observation, and interview, the facility failed to provide adequate nursing services to meet the needs of 2 (Resident #2, #3) residents of 2 residents reviewed as evidenced by checking blood sugars and administering medications consistently late, resulting in significant medication errors, failure to follow facility policies, care plans, physician orders, and failure to document pertinent findings in resident's medical record. These failures placed all residents in Immediate Jeopardy (a situation in which one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident.) The Administrator (NHA) was informed of the Immediate Jeopardy on 10/24/16 at 3:25 PM in the Conference Room. The findings included: Review of facility policy, Medication Administration, revised 3/16/15 revealed, .Administer medications within 60 minutes of the scheduled time . Review of facility policy, Guidelines for Medications, undated revealed .All blood sugars that are less than 60 or greater than 400 must be rechecked in 15 minutes and documented . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a comprehensive care plan dated 6/7/16 revealed a problem of medical management for Diabetes Mellitus Type II. Interventions included, .Administer my scheduled insulin as ordered; Obtain my finger stick blood sugars as ordered . Observation and interview with Licensed Practical Nurse (LPN) #1 on 10/11/16 at 1:15 PM, in Resident #2's room revealed the LPN checked the resident's blood sugar and was administering a bolus tube feeding scheduled at 12:00 PM. The LPN confirmed the tube feeding was administered a little late. Continued interview with LPN #1 in the hallway outside of the resident's room when asked if there was enough staff available to meet the needs of the resident's stated, I've been a nurse for [AGE] years, we're always short staffed. When asked if medications were administered consistently late the LPN stated, I can not lie, when (Resident #3's) tube feedings were every 2 hours and (Resident #2's) are every 6 hours, it was impossible. I've had 30 patients some days. Medical record review of a physician's orders [REDACTED].ACCUCHECKS (finger stick for blood sugar) BEFORE BOLUS FEEDINGS AND SSI (sliding scale insulin) AS FOLLOWS: 0-59 = CALL MD 60-150=0, 151-200=2u (units), 201-250=4u, 251-300=6u, 301-350=8u, 351-400 = 10u .NOTIFY MD AND RECHECK IN 15 MINUTES . The scheduled time was 6 AM, 12 PM, 6 PM, and 12 AM daily. Medical record review of the 6/2016 Medication Administration Record [REDACTED]. Continued review revealed blood sugars were checked 1-4 hours late 2 times for the month of 6/16. Medical record review of the 7/2016 MAR indicated [REDACTED]. The time frame excludes the 60 minute window of time which is allowable to administer medication before or after the scheduled time. Medical record review of Resident #2's 9/2016 MAR indicated [REDACTED]. Medical record review of the 10/2016 MAR for Resident #2 revealed blood sugars were checked 17 minutes-4 hours and 35 minutes late 8 times from 10/1-10/20/16 and checked 1 hour and 26 minutes early on 10/8/16. Telephone interview with RN #2 on 10/12/16 at 3:20 PM confirmed he did not write a telephone order to hold 1 dose of insulin and did not put an order in the computer on 9/22/16 for Resident #2. The RN stated, I'm new to learning the system, it was only my second time working on the floor. I didn't know how to make it a physician's orders [REDACTED]. Telephone interview with LPN #5 on 10/18/16 at 4:00 PM revealed, (RN #2) gave me report to hold the insulin for lab work in the morning. I should have looked to see the order myself, and I did not call the Doctor when (Resident #2's) sugar was 560. I was just going on what I was told. Continued interview revealed, We were so short staffed and he (RN #2) left at 11:30 PM. I had all the patients on Capitol(NAME)and half of the middle section. I had 25 patients from 7-11 (PM) and 37 patients from 11-7 (11 PM-7AM). We were very busy, and we didn't have enough help. Half the time the 3rd nurse leaves at 11 PM and with only 2 nurses on the(NAME) its really difficult to get things done. The first med pass takes 4-5 hours alone. Any nurse will verify how short we are. Medical record review of the 9/2016 MAR indicated [REDACTED]. Interview with LPN #6 on 10/19/16 at 7:15 AM, in the conference room revealed the LPN was tearful. The LPN stated, I had a bad night last night. I had 19 residents and I was the only nurse on [NAME]meade (skilled unit). The evening supervisor stayed until 3 AM and she usually leaves at 11 PM because I had an admission at 6:30 PM and I was downing in paperwork. Continued interview revealed when asked about Resident #2's blood sugar of 47 the LPN confirmed she did not document the blood glucose after following the [DIAGNOSES REDACTED] protocol and rechecking it 15 minutes later and should have. LPN #6 stated, I was orienting and that was the 1st time I was by myself. I followed (LPN #8) the day before, but because they were short staffed I had patients and was by myself that day. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan dated 7/19/16 revealed a problem of insulin dependent diabetes. Interventions included, .Administer my insulin according to my physician's orders [REDACTED]. Medical record review of a telephone physician's orders [REDACTED].Accuchecks before meals and at bedtime . The scheduled time of administration was 7:30 AM, 12:00 PM, 5:00 PM, and 9:00 PM. The order did not include sliding scale insulin (SSI) orders. Medical record review of the 9/2016 MAR indicated [REDACTED]. Medical record review revealed no telephone physician orders [REDACTED]. Medical record review of the Physician's recapitulation orders for 9/2016 revealed an order dated 9/23/16 for accuchecks with SSI. The scheduled times were 10:00 AM, 2:00 PM, 6:00 PM and 10:00 PM. Medical record review of the 9/2016 and 10/2016 MAR indicated [REDACTED] 9/24 scheduled at 10:00 AM checked at 3:05 PM 9/24 scheduled at 2:00 PM checked at 4:20 PM 9/25 scheduled at 10:00 AM checked at 3:38 PM 9/25 scheduled at 2:00 PM checked at 5:33 PM 9/25 scheduled at 10:00 PM checked at 11:23 PM 9/26 scheduled at 10:00 AM checked at 12:39 PM 9/26 scheduled at 2:00 PM checked at 3: 28 PM 9/26 scheduled at 10:00 PM checked at 5:20 AM on 9/27 9/28 scheduled at 10:00 AM checked at 11:19 AM 9/28 scheduled at 2:00 PM checked at 4:04 PM 9/28 scheduled at 10:00 PM checked at 11:36 PM 9/29 scheduled at 10:00 AM checked at 3:19 PM 9/29 scheduled at 2:00 PM checked at 3:20 PM 10/4 scheduled at 2:00 PM checked at 6:08 PM Medical record review of the comprehensive care plan dated 7/19/16 revealed a problem of signs of [MEDICAL CONDITION]. Interventions included, .Administer my cardiac .meds (medications) as ordered . Medical record review of a physician's telephone order dated 9/12/16 revealed, .[MEDICATION NAME] HCL (used to treat low blood pressure) 5 mg tab (tablet) give one tab PT (per tube) before meals; BP (blood pressure) to be checked prior to administration, Hold for BP (systolic greater than 120 or diastolic greater than 80) . The order was written by LPN #4 and signed by NP #1. Medical record review of the 9/2016 MAR for Resident #3 revealed [MEDICATION NAME] 5 mg was administered to the resident with the following BP documented. 9/12 at 10:00 PM. BP 149/90 9/13 at 10:00 AM. BP 152/82 9/13 at 2:00 PM. BP 125/64 9/13 at 6:00 PM BP 122/80 9/13 at 10:00 PM. BP 124/53 9/14 at 10:00 AM. BP 134/70 9/14 at 2:00 PM. BP 130/70 9/14 at 6:00 PM. BP 134/70 9/14 at 10:00 PM. BP 129/82 9/15 at 10:00 AM. BP 126/75 9/15 at 2:00 PM. BP 128/75 9/16 at 10:00 AM. BP 120/100 9/16 at 2:00 PM. BP 118/88 Interview with the ADON on 10/18/16 at 4:45 PM, in the conference room revealed, I've observed 4 staff members that need to go back to orientation due to lack of basic nursing skills. I've looked at charts and seen lack of documentation. I've stayed until 10:00 PM helping to get admissions admitted because the nurses can't do the med cart, chart, care for the residents, work on new orders, assessments or NP orders all at the same time. Interview with NP #1 on 10/19/16 at 2:45 PM, in the conference room when asked if she was aware accuchecks and medications were being administered up to 5 hours late, stated, No. I can see how busy the nurses are trying to pass meds, care for the residents, deal with the families, and chart, so I can see how they are late. It's a lot. I've always felt like they were short staffed. The acuity is so high, especially on IBW (skilled) unit. The shortage of staff is my big concern. Interview with the DON on 10/19/16 at 4:05 PM, in the conference room acknowledged staffing was an issue and stated a nurse told her she was so stressed because they are now expected to do things they hadn't done for the last 1 1/2 years. The DON stated, I told her it was basic nursing that should have been happening all along. Interview with NP #2 on 10/24/16 at 2:20 PM, in the conference room when asked if she was aware accuchecks and medications were being administered up to 5 hours late shook her head and stated, Yes, it's been ongoing for about 6 months. I hear it from the patients consistently that they are still waiting to receive their meds. Nurses go past the time frame for meds due to the amount of patients they have. They say they are too busy and can't get it all done. They have to do orders, patient care, meds, charting and new admissions. Refer to F157 K, F224 L SQC, F 281 L, F 332 L SQC, F333 L SQC.",2019-10-01
1538,GREEN HILLS CENTER FOR REHABILITATION AND HEALING,445267,3939 HILLSBORO CIRCLE,NASHVILLE,TN,37215,2017-10-31,323,K,1,0,EO0911,"**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 supervision and interventions to prevent accidents resulting in falls for 5 residents (#1, #16, #17, #19, #28) of 7 residents reviewed; Resident #1 sustained 2 hip fractures. The resulting failure constituted an 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 District Director of Operations was notified of the Immediate Jeopardy on 10/30/17 at 3:00 PM in the Administrator's Office. F323 is Substandard Quality of Care (SQC) The findings included: Review of facility policy, Fall Management, revised 7/2017 revealed, .The facility assists each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs .to minimize the risk for falls .The Interdisciplinary Team (IDT) evaluates each resident's fall risks. A Care Plan is developed and implemented, based on this evaluation, with ongoing review .When a resident is found on the floor, the facility is obligated to investigate to determine how the resident got there and put into place an intervention to minimize it from recurring .The nurse will discuss recommended interventions to reduce the potential for additional falls with the resident and/or resident's representative and document in the Care Plan and Progress Notes .The IDT reviews all resident falls within 24-72 hours at the IDT meeting to evaluate circumstances and probable cause for the fall .The Care Plan will be reviewed and/or revised as indicated .The At Risk Review committee members will review residents with falls for documentation, compliance, and interventions on a weekly basis . Medical record review revealed Resident #1 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located in the secure unit on the 3rd floor of the facility. Medical record review of a Discharge Return Anticipated Minimum Data Set ((MDS) dated [DATE] revealed the resident was moderately cognitively impaired, ambulatory, occasionally incontinent of urine, and always continent of bowel, and had 1 fall without injury since the prior assessment. Medical record review of Fall Risk Assessments dated 1/9/17, 4/18/17, and 6/26/17, revealed Resident #1 was assessed to be at High Risk for falls. Medical record review of a Comprehensive Care Plan dated 1/18/17 and revised 4/18/17 revealed a focus of at risk for falls with interventions to anticipate and meet the resident's needs, and be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Medical record review of Nursing Monthly Summaries dated 2/8/17, 3/8/17 and 5/8/17 revealed the resident was oriented to person only, and was ambulatory most of the day. Medical record review of a SBAR (Situation, Background, Assessment, Recommendation) Summary dated 6/20/17 at 12:49 PM revealed, .Resident had a fall in (the) hallway, housekeeping services alerted this writer .Resident has a skin tear on right arm and is complaining of right leg pain .Resident is being sent to (emergency room ) for evaluation and treatment . Medical record review of a Nurses Note dated 6/20/17 revealed no documentation regarding the circumstances of the fall, witness names, assessment of right lower extremity, pain level, or transferring and positioning information. Medical record review of a hospital History and Physical dated 6/20/17 revealed the resident had a medical history significant for Dementia, had a fall and .reported significant pain with the right lower extremity/right hip .awake, alert, but not oriented .she can follow simple commands, but not consistently .Image(s) (X-Ray) Hip 06/20/2017 (3:53) PM IMPRESSION: RIGHT femoral neck fracture . Continued review revealed the resident underwent [REDACTED]. Medical record review of a Medical Progress Note dated 6/28/17 revealed the visit type was readmission/post hospital discharge review. Continued review revealed, .readmitted .following acute hospitalization for fall with subsequent right femur fracture .She is no longer ambulatory at this time .She is self-propelling (wheelchair) around hall, but is very slow and weak .General Appearance .Disheveled, Thin/frail . Medical record review of a Medical Progress Note dated 7/6/17 revealed, Pt (patient) requires frequent re-orientation to environment and monitoring for falls .Since readmission from hospital, (patient) has been much more lethargic, weak .She is now non-ambulatory and is unable to self-propel (wheelchair) due to fractured hip and cognitive impairment .General Appearance .Disheveled, Thin/frail .Continue close fall precautions and report any acute injuries . Review of an Incident/Accident Report form dated 8/2/17 at 2:00 PM revealed Resident #1 was found on the floor in the dining room and, .Resident was sitting in dining room after lunch. Got out of wheelchair and tried to walk . Medical record review of a Nurse's Note dated 8/2/17 revealed no documentation regarding the circumstances of the fall, witness names, assessment of the left lower extremity, transferring, positioning, or activity level of the resident after the fall. Medical record review of a Radiology Report for Resident #1 dated 8/2/17 at 5:57 PM eastern time (4:47 PM central time) revealed, .Acute fracture, left femoral neck . Medical record review of a Medical Progress Note dated 8/3/17 revealed, .(Patient) seen at staff request regarding fall .last evening resulting in pain to left hip. X-ray of hip ordered and has returned .with (positive) left femoral neck fracture .General Appearance .Disheveled .(positive) pain with slight abduction (moving the leg away from the middle of the body) of (Left Lower Extremity) .Radiography .Testing Reviewed: Date 8/03/17 Test Results: Left femoral neck fracture .Administration to (evaluate) and investigate falls for any possible cause of recurrent falls and for future fall precautions interventions . Medical record review of a Hospital History and Physical dated 8/3/17 at 11:11 AM, Resident #1 complained of left hip pain status [REDACTED].She underwent an x-ray which revealed a fracture of the left femoral neck .she will not answer questions or really follow commands .Her urinalysis was felt to be consistent with a urinary tract infection .she is being admitted for further evaluation and treatment .Assessment/Plan [DIAGNOSES REDACTED].Acute UTI (urinary tract infection) . Telephone interview with Registered Nurse (RN) #3 on 10/24/17 at 3:50 PM revealed the Nurse was an Agency Nurse and was caring for Resident #1 when she had falls on 6/20/17 and 8/2/17. Continued interview revealed on 6/20/17 at approximately 12:15 PM the resident was found on the floor in another resident's room by Housekeeper (HK) #1 who alerted the RN. Continued interview revealed RN #3 stated, We went down there and she was moaning and groaning. I got vital signs but didn't move her and alerted the Nurse Practitioner. Me and 2 techs assisted her back to bed. The Nurse Practitioner was already on the 3rd floor and she told us to call 911 and send her to the hospital. Further interview with the Nurse regarding the resident's fall on 8/2/17 revealed, It was in the dining room after dinner (lunch). She had oxygen on and was in the wheelchair. I think she tried to get up and walk and fell . I called the Nurse Practitioner and she said she'd be right there because there were so many falls on the 3rd floor. Continued interview revealed when asked how the resident was transferred, RN #3 stated, I don't know who did it or how she was transferred, but I had an inkling she had a fracture. Further interview with RN #1 revealed, They are staffed mostly with agency. They are short on techs a lot. I've worked with 3 techs on day shift when we needed 4 or 5. They need more on the dementia (secure) unit because they walk all the time. It's poorly staffed. Interview with the Director of Nursing (DON) on 10/24/17 at 6:50 PM in the conference room when asked what the facility could have done to prevent the second fall for Resident #1 on 8/2/17 the DON stated, If we had our own staff it would have been easier for consistency and to notice any subtle changes with her. Interview with the Administrator with the DON present on 10/24/17 at 6:55 PM in the conference room stated when she began working at the facility in (MONTH) there were at least 20 agency staff employees working in the facility on a daily basis. Continued interview confirmed the facility currently used 6 different agencies to staff the facility with Nurses and Certified Nurse Aides (CNA's). Further interview with the Administrator confirmed the facility had problems with staffing. Interview with HK #1 on 10/25/17 at 7:55 AM in the 3rd floor dayroom confirmed she found Resident #1 in the doorway of a resident's room on 6/20/17. Continued interview with HK #1, revealed she called for RN #3 and she came out of another resident's room, got a wheelchair, and I picked the resident up by myself under her arms. She was able to stand on her own some, cause the nurse checked her first. Then I sat her down in the wheelchair and the nurse wheeled her back to her room. Continued interview with HK #1 confirmed no other staff members were present or assisted HK #1 or RN #3. Interview with MDS Coordinator #2 on 10/30/17 at 3:30 PM in the conference room confirmed Resident #1 was not capable of using her call light and her Comprehensive Care Plan did not accurately reflect interventions to prevent falls. Interview with the DON on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed the facility had no fall prevention program or fall risk protocol in place for residents assessed to be at high risk for falls. Continued interview confirmed the facility failed to investigate the cause of the falls for the resident and failed to provide fall interventions to prevent accidents resulting in a fracture to the right hip and a fracture to the left hip of Resident #1. Medical record review revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] and 8/1/17 with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located on the 3rd floor of the facility. Medical record review of a Quarterly MDS dated [DATE] revealed Resident #16 was severely cognitively impaired, had no behaviors and required extensive assistance of 2 or more people for bed mobility and transfers, and ambulated in her room only once or twice with assistance of 1 person; was unsteady and only able to stabilize with staff assistance and used a wheelchair for mobility. Continued review revealed the resident was always incontinent of bladder and frequently incontinent of bowel. Continued review revealed the resident had no previous falls. Further review of a Quarterly MDS dated [DATE] revealed Resident #16 had behaviors of wandering 1-3 days of the previous 7 days, required extensive assistance of 1 person for bed mobility, ambulation in her room, and locomotion on and off the unit and used a wheelchair for mobility. Further review revealed the resident had 1 fall with no injury and 2 falls with injury since the previous assessment. Medical record review of Fall Risk Assessments dated 7/11/17 and 10/10/17 revealed the resident was assessed to be at High Risk for falls. Medical record review of a SBAR Summary dated 7/31/17 at 4:02 PM revealed, .found on floor in door(way) hematoma and bleeding noted on forehead . Medical record review revealed no further documentation regarding the resident's fall or care she received. Medical record review of a hospital record dated 7/31/17 at 5:43 PM revealed .soft tissue swelling of the frontal scalp .Acute subcapital right femoral neck fracture . Continued review of a History and Physical revealed, .She had a laceration to her forehead .The (emergency room ) Physician noticed her right leg was shorter than her left, and a hip xray showed a hip fracture .laceration to forehead with steri strips (porous surgical tape strips which can be used to close small wounds) in place .right leg short and externally rotated . Medical record review of a Medical Progress Note dated 8/2/17 revealed, .Re-admission assessment .seen .following acute hospitalization of fall with head laceration and suspected right hip fracture .no surgical intervention was performed .non-ambulatory and sitting up in (wheelchair) .continues to pick at forehead laceration and has caused increased bleeding .Appearance .Disheveled .large open shallow abrasion to forehead with active bleeding .monitor for falls .Administrative staff to assure appropriate fall prevention interventions are in place and that (patient) is in a safe environment . Continued review revealed the Administrative staff failed to have fall prevention interventions and a safe environment. Medical record review of a SBAR Summary dated 8/24/17 at 7:17 PM revealed, .Resident found on floor in right lateral position (patient) has skin tear on right eyebrow area .Resident usually has wandering on hallway with (wheelchair) sometimes (patient) fall on floor with injury or without injury (patient) need special (wheelchair) for safety .skin tear site dressing done with steri strips . Medical record review of a SBAR Summary dated 9/6/17 at 11:57 AM revealed, .alert with some confusion was called to hallway noticed the resident was sitting on the floor on buttocks noticed blood from forehead clean with (normal saline) and apply bandage . Medical record review of a Medical Progress Note dated 9/11/17 revealed, .seen for (evaluation) and treatment of [REDACTED].indicating (positive) infection .labs obtained following recurrent fall with reopening of forehead abrasion .increased restlessness and anxiousness .Bruising and skin tears to upper extremities .Remains at a high risk of falls. Will hopefully improve with treatment of [REDACTED].Encourage po (by mouth) fluids to prevent further UTI's . Medical record review of an SBAR Sumary dated 9/27/17 at 3:01 PM revealed, .fall no injury . Continued review revealed no further documentation regarding the fall. Medical record review of a Comprehensive Care Plan dated 4/14/16 revealed a focus of .Has had an actual fall with no injury (related to) Unsteady gait, Psychoactive drug use, Poor Balance, Poor communication/comprehension . Continued review revealed the following interventions: (1) 4/14/16 Place frequently used items and call light in reach; Offer/Assist to toilet frequently and as accepted; For no apparent acute injury, determine and address causative factors of the fall; Encourage resident to ask for assistance; Continue interventions on the at-risk plan. (2) 7/25/16 Add anti-roll back to wheelchair. (3) 8/4/17 Bedroom door to be ajar while patient in room alone. Landing strips (fall mats) to both side of bed. (4) Documented on 8/30/17 for 8/24/17. Seating was adjusted with new cushion for wheelchair in place. Observation of Resident #16 on 10/25/17 at 8:30 AM in the 3rd floor dining room revealed she was seated in a wheelchair with a cushion on it at a table waiting for breakfast with 3 other residents. Continued observation revealed she was alert, calm and nonverbal. Continued observation revealed no anti-roll back device to her wheelchair. Interview with the DON on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed the facility failed to investigate the cause of multiple falls to the resident and place specific, individualized, interventions on the Care Plan to prevent future falls. Continued interview revealed when asked what the 'interventions on the at risk plan' were the DON stated, I have no idea. Further interview confirmed the resident did not have an anti- roll back device to her wheelchair, and the facility had no fall prevention program or fall risk protocol in place for residents assessed to be at high risk for falls. Continued interview with the DON when asked what the facility could have done to prevent multiple falls for Resident #16, the DON stated, If we had our own staff it would have been easier for consistency and to notice any subtle changes. Further interview with the DON confirmed the facility failed to provide appropriate fall interventions to prevent accidents resulting in a forehead hematoma, a right femoral neck fracture, a right eyebrow laceration and multiple bruises to Resident #16. Medical record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located in the secured unit on the 3rd floor of the facility. Medical record review of a Fall Risk assessment dated [DATE] revealed the resident was assessed to be at High Risk for falls. Medical record review of the Initial Care Plan dated 9/1/17 did not include safety or fall risk as a focus or potential problem and no interventions to prevent a fall. Medical record review of a Discharge Return/Anticipated Return MDS dated [DATE] revealed the resident was moderately cognitively impaired and had behaviors not directed to others for 1-3 days of the look back period. The resident required supervision for ambulation in his room and had only ambulated in the hallway 1 or 2 times during the look back period. Medical record review of a SBAR Summary dated 9/7/17 at 10:35 AM revealed, .Resident fell down on his head, was unresponsive for a few minutes .increased confusion, decreased consciousness .unresponsiveness .labored breathing . Continued review revealed the resident was transported to the hospital. Medical record review of a hospital History and Physical dated 9/7/17 at 3:18 PM revealed, .He was found on the floor on the side of his bed this morning with evidence of trauma to the front of his head .more confused from baseline .admitted in (MONTH) with heart failure exacerbation .started on .midodrine for syncope . Further review of the physical exam revealed, .Large nodule on front of forehead .2 (plus) pitting edema to flanks . Continued review revealed, .he is chronically hypotensive related to cirrhosis . Medical record review of a Care Plan note dated 9/20/17 revealed, .(Interdisciplinary Team) review of falls .sent out post fall and readmitted .has history of cardiac issues .patient to be out (in) day area as (frequently) as possible . Medical record review of the Comprehensive Care Plan dated 10/17/17 with a focus of Risk for falls related to confusion, gait/balance problems, incontinence, psychoactive drug use, unaware of safety needs with interventions as follows: (1) Anticipate and meet the resident's needs; (2) Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; (3) Ensure that the resident is wearing appropriate nonskid footwear when ambulating, transferring, or mobilizing in (wheelchair). Continued review revealed no further interventions to place in the day area frequently to prevent future falls was present. Observation of Resident #17 on 10/25/17 at 8:35 AM in the 3rd floor dining room revealed the resident was seated at a table in a wheelchair with 3 other resident's waiting for breakfast to be served. Continued observation revealed the resident was alert and quiet. Interview with MDS Coordinator #2 on 10/30/17 at 3:30 PM in the conference room confirmed Resident #17 was a high fall risk and had no intervention on Care Plan of increased risk for falls with interventions on the Initial Care Plan dated 9/1/17. Continued interview confirmed the facility failed to identify the resident was at risk for actual falls, and failed to provide an intervention after an actual fall. Interview with the DON on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed the facility had no fall prevention program or fall risk protocol in place for residents assessed to be at high risk for falls. Continued interview confirmed the facility failed to investigate the cause of the fall and failed to prevent accidents resulting in a fall with a forehead hematoma and hospitalization for Resident #17. Medical record review revealed Resident #19 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission MDS dated [DATE] revealed the resident was cognitively intact, required extensive assistance of 1 person for bed mobility, transfers, and ambulation in her room. Continued review revealed she was not steady on her feet and was only able to stabilize with staff assistance. Medical record review of a Fall Risk assessment dated [DATE] revealed the resident was assessed to be High Risk for falls. Medical record review of an initial Comprehensive Care Plan dated 9/26/17 revealed a focus of Safety/Fall Risk related to History of Falls and decreased safety awareness with interventions to observe for placement and function of devices per facility protocols; and Initiate Safety checks as indicated. Medical record review of a Care Conference Note date 9/28/17 revealed, .Resident is a high fall risk . Medical record review of a SBAR Summary dated 10/8/17 at 5:19 AM revealed Resident had a fall and, .resident was getting up from bed to go walk to restroom when she slipped . Medical record review revealed no further documentation regarding the fall was present. Medical record review of a Nurses Note dated 10/15/17 at 9:00 PM revealed, .notified .while assisting patient to the commode, the patient sat down quickly on her own, and bumped her back against the rail next to the commode. At the time the patient stated she hit her head, but (CNA) denies witnessing patient hit her head .will notify the MD (Medical Doctor) if any acute (symptoms) observed or patient expresses pain . Medical record review of a SBAR Summary dated 10/16/17 at 12:13 AM revealed, .fell (complain of) (left) hip pain .resident was transferring self with walker to restroom, staff heard loud noise, enter room observe resident lying on floor on back in front of toilet, stated she hit her head, staff assisted resident up and to bed. (Complain of) pain to (left) hip while walking, notified MD on call orders received to send to hospital for (evaluation) . Medical record review of a Comprehensive Care Plan dated 10/26/17 revealed a focus of at risk for falls related to confusion at times, gait/balance problems, incontinence, and pain with interventions dated 10/26/17 for .(1) 10-8-17 send sock home with family, provide nonskid socks in room; (2) Anticipate and meet the resident's needs. (3) Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; (4) Ensure the resident is wearing appropriate nonskid footwear when ambulating, transferring or mobilizing in wheel chair; (5) 10/9/17 landing pads to bedside. Interview with MDS Coordinator #2 on 10/30/17 at 3:30 PM in the conference room confirmed the initial Comprehensive Care Plan for Resident #19 had no interventions to prevent falls and there was no protocol for safety checks. Continued interview confirmed the facility failed to complete the Comprehensive Care Plan with interventions to prevent a fall until after the resident was discharged . Interview with the DON on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed Resident #19 was still in the hospital due to the fall on 10/16/17 with a left hip fracture. Continued interview confirmed the facility had no fall prevention program or fall risk protocol in place for residents assessed to be at high risk for falls. Further interview with the DON confirmed the facility failed to provide fall interventions to prevent accidents resulting in a fracture for Resident #19. Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a SBAR Summary dated 10/6/17 revealed, .10/5/17 Resident was found on the floor. Resident was sent to (hospital) as requested by family . Further review revealed the resident was seen in the Emergency Department and sent back to the facility with discharge instructions for a closed head injury and hypertension. Medical record review of an Interdisciplinary (IDT) Post Fall Review dated 10/20/17 revealed Resident #28 fell and was found in her room. Continued review revealed the fall was unwitnessed and no injuries were documented. Further review revealed no documentation of neuro checks. Medical record review of a Comprehensive Care Plan revealed interventions were not initiated until 10/25/17 after the resident sustained [REDACTED]. Interview with the Administrator with the DON present on 10/25/17 at 6:50 PM in the conference room confirmed the facility had problems with staffing and used 6 different agencies to staff the facility with nurses and Certified Nurse Aides (CNAs). Continued interview revealed the Administrator stated when she began working at the facility in (MONTH) there were at least 20 agency staff working in the facility on a daily basis. Interview with DON on 10/31/2017 at 6:10 PM in the conference room confirmed the facility failed to provide interventions to prevent a fall for Resident #28. Refer to F224 K SQC Refer to F309 K SQC",2020-09-01
5730,"NHC HEALTHCARE, OAK RIDGE",445128,300 LABORATORY RD,OAK RIDGE,TN,37831,2015-12-14,225,D,1,0,RT3L11,"**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 report an alleged allegation of abuse to the state agency and to all other agencies as required for 1 resident (#2) of 4 residents reviewed for Abuse. The findings included: Review of facility policy, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect and Misappropriation of Property, revised 8/1/11 revealed .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 (including to the State Survey and Certification Agency) . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Nurse Practitioner (NP) progress note dated 12/1/15 at 12:30 PM revealed .Nurses report increased anxiety .Did say she (Resident #2) was hit .bruise to L (left) lower lip; bruise/contusion raised L forehead; bruise R (right) axilla (underarm); bruise and scratch L ant (anterior) chest; skin tear R FA (forearm) . Observation of Resident #2 on 12/8/15 at 1:15 PM, sitting in a reclining chair in the hallway outside Wing 2 Nurses Station revealed old yellow bruising noted above the left eye. Interview with Licensed Practical Nurse (LPN) #3, charge nurse on the date of the incident, on 12/8/15 at 1:00 PM, at the Wing 2 Nurses Station revealed the incident occurred about 7:30 AM on 12/1/15 while the staff were attempting to get Resident #2 out of bed at which time the resident became combative with the staff. Skin assessment was completed and revealed the resident with a small raised area above the left eye, which later appeared bruised, and 2 skin tears on the arms which had dressings on prior to the incident that had reopened and were cleansed and covered. Interview with the Administrator on 12/10/15 at 10:30 AM, in the Administrator's office revealed the facility had completed the investigation on 12/1/15 following the 7:30 AM incident prior to the NP visit at 12:30 PM. Further interview revealed the NP was requested to see the resident related to the resident's increased anxiety. Continued interview revealed the facility did not communicate to the NP prior to visiting the resident any information regarding the earlier incident, at which time the resident became combative with the staff resulting in bruising and skin tears. Further interview revealed the NP documented the resident stated she was hit. Continued interview confirmed the facility failed to report to the state agency the allegation of abuse the resident communicated to the NP on 12/1/15.",2018-12-01
3202,THE MEADOWS,445496,8044 COLEY DAVIS ROAD,NASHVILLE,TN,37221,2018-08-01,609,D,1,1,6SVU11,"**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 report an injury of unknown origin for 1 resident (#20) of 3 residents reviewed for abuse. The findings include: Review of the facility policy Administrative Procedures Manual revised 12/11/17 revealed .The facility will 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 no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the state Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures . Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. Medical record review of the Facility Investigation dated 6/27/18 revealed an injury of unknown origin was found on the back of Resident #20's head. Further review revealed the physician, family and the corporate office was notified on 6/27/18. Interview with Director of Nursing (DON) on 7/31/18 at 3:18 PM in her office revealed the DON had notified the regional nurse and the administrator immediately. The DON stated We did not notify the state, but the Ombudsman was made aware, we would never not report something intentionally, we felt we were following the steps we were supposed to follow. Interview with the Administrator on 8/1/18 at 4:54 PM in the DON's office confirmed the facility failed to report an injury of unknown origin. The Administrator stated correct when questioned if the facility had failed to report an injury of unknown origin to the state agency.",2020-09-01
2649,MT JULIET HEALTH CARE CENTER,445439,2650 NORTH MT JULIET ROAD,MOUNT JULIET,TN,37122,2019-03-13,880,D,1,1,O5E111,"**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 use appropriate infection control prevention and standards of practice during medication administration for 2 of 9 residents, #49, and #59 during medication administration. The findings include: Review of the facility policy, Medication Administration, dated 11/2017 and revised 11/2018 revealed, .perform hand hygiene . Medical record review revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #59 was admitted to the facility 12/3/12 with [DIAGNOSES REDACTED]. Observation of the medication administration with the RN #1 on 3/11/19 on the 400 hall at 7:30 PM revealed RN #1 opened medication cart drawer, then opened 6 different medications packets and put them in his unwashed, ungloved hand and placed them into the medication cup. Observation of the medication administration with RN #3 on 3/12/19 on 100 hall at 08:59 AM, observed RN #3 obtaining medications for Resident # 59 and putting medications into her ungloved, unwashed hand. Continued observation revealed RN #3 then placed the 4 medications into the medicine cup for Resident # 59. Interview with the RN #1 on 3/11/19 on the 400 hall at 10:40 PM confirmed . I should have not touched the medication with my hands . Interview with RN #3 on 3/12/19 at the 100 hall medication cart at 9:05 AM revealed .I should not have touched the medications with my bare hand . Interview with the Director of Nursing on 3/13/19 in his office at 10:12 AM confirmed .I would not expect a nurse to place medication in their hands .",2020-09-01
845,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-09-13,226,E,1,0,DOIC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observation, and interview, the facility staff failed to report bruises, injury of unknown origin, to the administrative staff for 2 residents (#1, #2) of 3 residents reviewed with bruising. The findings included: Review of facility policy, Accidents and Incidents, revised (MONTH) 2011 revealed .All accidents or incidents involving residents .occurring on our premises shall be invested and reported to the Administration .The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall promptly initiate and document investigation of the accident or incident .The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Sets ((MDS) dated [DATE] and 8/17/17 revealed Resident #1 had moderate difficulty with hearing, clear speech, could make self understood and usually understood others; was moderately cognitively impaired, had no [MEDICAL CONDITION], mood, [MEDICAL CONDITION] or behaviors; required extensive 1 person assistance with bed mobility, transfers, walking in the room, dressing, toileting, personal hygiene; balance was not steady and required staff to stabilize and had no issue with range of motion in upper and lower extremities. Medical record review of the Physician order [REDACTED].#1 received Aspirin (anti-coagulant) 81 milligrams (mg) by mouth once a day. Medical record review of the care plan initiated 11/29/16, and updated on 2/17/17, 5/25/17, and 8/24/17, revealed .Problem .Requires staff assist with toileting needs for safety and hygiene purposes, communicates needs for toileting, is at risk for skin alteration r/t (related to) presence of frail/fragile skin .Interventions .Assess skin daily during routine care for redness, shearing, blisters, or open areas . Further review revealed the .Problem .Potential for abnormal bleeding/bruising, clotting r/t medication therapy. Receives ASA (Aspirin) .Interventions .Observe, document, and report to MD/NP (Medical Doctor/Nurse Practitioner) PRN (as needed) any .bruising .Protect from injury as able . Observation and interview with Resident #1 on 9/12/17 at 12:43 PM revealed Resident #1 in her room fully reclined with feet extended in a recliner with 2 reddish purple bruises to the top of the right hand. When the resident was asked how the bruises to the right hand occurred the resident pointed to the left side of the over bed table in front of her and stated I hit it right there. Further interview revealed the resident was not sure when the bruise occurred and that she .takes Aspirin every day and bruises real easy . Interview with Registered Nurse (RN) #2 on 9/12/17 at 12:50 PM at the 100 hall nursing station, confirmed she was assigned to Resident #1 and had been on duty 1 hour due to Licensed Practical Nurse (LPN) #8, assigned to Resident #1, leaving the facility ill. Further interview revealed the RN was not aware of the bruise to the right hand. Interview with LPN #6 on 9/12/17 at 12:54 PM in the conference room revealed the LPN was the Unit Manager for Resident #1 and was not aware of the bruise on the right hand. Interview with Certified Nurse Aide (CNA) #8 on 9/12/17 at 1:05 PM outside room [ROOM NUMBER] confirmed the CNA was assigned to Resident #1. Further interview revealed the CNA was aware of the bruise at 10:30 AM on 9/12/17 when she took the resident to the bathroom. Further interview revealed she went to inform the Charge Nurse, LPN #8, but could not find him and the CNA continued with her duties. Further interview confirmed the CNA failed to report the bruise to any person in administrative capacity. Interview with Resident #1's daughter on 9/13/17 beginning at 7:55 AM in the resident's room revealed the daughter was asked regarding the right hand bruise observed on 9/12/17 when the Resident stated .I hit it there . as she pointed to the left corner of the over bed table and the daughter stated That's what she told me too but my brother saw it happen and it was in the bathroom at the sink . Interview with the Director of Nursing (DON) and the Assistant DON (ADON) on 9/13/17 at 6:00 PM in the conference room confirmed the facility staff failed to report the right hand bruise to the administrative staff timely. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician order [REDACTED]. Medical record review of the Admission Minimum (MDS) data set [DATE] revealed Resident #2 was highly impaired with hearing; had clear speech, sometimes could make self understood, and sometimes could understand others; had short and long term memory impairment with moderately impaired cognitive skills for daily decision making; no [MEDICAL CONDITION]; was feeling down/depressed/hopeless and tired/little energy for 2-6 days; and was physically abusive 1-3 days during the review period. Further review revealed the resident required extensive 1 person assistance with bed mobility, dressing, eating, hygiene, and extensive 2 person assistance with transfers, and toilet use. Medical record review of the care plan dated 8/11/17 revealed .Problem .Potential for abnormal bleeding or clotting r/t (related to) medication therapy, anticoagulant .Interventions .Observe, document, and report to MD/NP (Medical Doctor/Nurse Practitioner) PRN (as needed) any .bruising .Protect from injury as able . Observation on 9/12/17 at 11:58 AM revealed Resident #2 in the Memory Unit dining room in a speciality chair with a tray attached and the resident's arms, torso, head and legs were in continuous motion. Further observation revealed the left hand had a dark purple bruise on the wrist bone and another bruise on the top of the hand. Further observation revealed the right hand had a bruise at the wrist and another at the thumb joint. Further observation at 5:38 PM, with the Administrator present, revealed Resident #2 in the specialty chair on the Memory Unit by the nursing station. Interview with the Administrator on 9/12/17 at 5:38 PM on the Memory Unit by the nursing station confirmed Resident #2 had 2 bruises on each hand. Interview with LPN #3 on 9/12/17 at 5:40 PM on the Memory Unit by the nursing station confirmed Resident #2's medical record, binder with Skin Reports, and Nurse's Notes did not have documentation addressing the 4 bruise sites observed on 9/12/17. Interview with the Director of Nursing on 9/13/17 at 6:15 PM in the conference room confirmed the facility staff failed to report the 4 bruises for Resident #2 timely to the administrative staff.",2020-09-01
414,SIGNATURE HEALTHCARE OF PUTNAM COUNTY,445136,278 DRY VALLEY RD,COOKEVILLE,TN,38506,2017-09-27,241,D,1,0,QHMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observation, and staff interview, the facility failed to provide dignity covers for catheter bags for 2 (Resident #3 and Resident #10) of 3 sampled residents. This had the potential to affect all 15 residents who had catheters. Failure to provide dignity covers for catheter drainage bags had the potential to demean patients. The findings included: Review of the facility's policy titled, Catherization Care, revised of 9/7/17, indicated, .13. Routinely check to ensure .Drainage bag is covered with a privacy cover unless resident requests otherwise. 1. Resident #3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/25/17 at 12:00 PM, Resident #3 was observed eating lunch in room [ROOM NUMBER]. The drainage bag for the catheter was attached to the bed. The catheter drainage bag which had approximately 300 cubic centimeters (cc) of urine was visible and did not have a dignity cover on it. 2. On 9/25/17 at 1:30 PM, Resident #10 was observed lying in his bed in room [ROOM NUMBER]. The drainage bag for the catheter which was observed hanging on the bed with approximately 200 cc's of urine was visible without a dignity cover. During an interview on 9/25/17 at 12:30 PM, on the 200 Hallway, Certified Nursing Assistant #1 confirmed the drainage bag for the catheter should have a cover over it. During an interview on 9/25/17 at 2:40 PM, in the conference room, the Director of Nursing (DON) stated all catheter drainage bags should have a dignity cover on them. The DON further stated the facility has ordered new dignity bags for the catheter drainage bags and the facility is currently using pillowcases to cover the catheter drainage bags until the new dignity bags arrive.",2020-09-01
4458,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2016-09-06,282,D,1,0,T33N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observation, interview, and pharmacy data review, the facility failed to follow the care plan to administer the tube feeding and flushes as ordered for 1 Resident (#1) of 9 residents reviewed. The findings included: Review of facility policy, Tube Feeding-Hydration, undated revealed .Purpose: To provide proper hydration, via a feeding tube .Standard: Physician orders [REDACTED].Process: Record the cc's (cubic centimeters) .The amount of water given at each ordered flush, along with the total amount given each day is documented . Review of the undated facility policy entitled Intake and Output Measurement of Fluids revealed .Purpose: To provide an accurate record of the resident's intake and output .Process: Fluids from .tube feedings is calculated and recorded by the licensed nurse . Medical record review revealed Resident #1 was admitted to the facility pn 3/4/16, and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the care plan with the original date of 3/12/16 and updated 6/14/16 .Resident is on tube feeding . revealed .and Flushes as ordered . Medical record review of the Physician order [REDACTED]. Observation on 8/22/16 at 12:18 PM revealed Resident #1 in bed in his room, a tube feeding formula, [MEDICATION NAME] 1.5 Calorie, was in a bag on a pole with 600 milliliters (ml) in the bag and the pump was set at 70 cc (cubic centimeters) per hour. Further observation revealed no water flush bag was hung on the pole. Interview with Licensed Practyical Nurse (LPN) #4 on 8/22/16 at 12:22 PM at the 1 West nursing station revealed when asked if the LPN had provided water flushes stated .I have provided water with medications . When asked if the LPN had done any other water flushes the LPN checked the physician orders [REDACTED]. we don't have auto flush bags for awhile now . When asked what awhile meant the LPN stated .months at least . Further interview with LPN #4 at 12:58 PM at the 1 West nursing station when asked if any water flushes were administered stated .No, we don't have auto flush . When asked how he was calculating or accounting for what the resident needed for the flush stated .I have a problem . Medical record review of the 8/2016 Diet Flow Sheet form beginning from the readmission on 8/16/16 revealed no documentation on 8/16/16, 8/17/16, and 8/19/16; and on 8/18/16, 8/20/16 and 8/21/16 one formulary and one flush was documented. Interview with LPN #5, on 8/22/16 at 5:12 PM at the 1 West nursing station after reviewing the 8/2016 Diet Flow Sheet form confirmed the facility failed to fill out the form completely. Interview with the Director of Nursing (DON), on 8/24/16 at 8:25 AM, in the Business Office Manager (BOM) office, confirmed the facility failed to follow the facility policy to document the intake of the fluids every shift and failed to follow the physician order [REDACTED].",2019-09-01
4459,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2016-09-06,309,D,1,0,T33N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observation, interview, and pharmacy data review, the facility failed to follow the physician order [REDACTED].#1); and failed to follow physician orders [REDACTED].#2) of 9 residents reviewed. The findings included: Review of facility policy, Tube Feeding-Hydration, undated revealed .Purpose: To provide proper hydration, via a feeding tube .Standard: Physician orders [REDACTED].Process: Record the cc's (cubic centimeters) .The amount of water given at each ordered flush, along with the total amount given each day is documented . Review of facility policy, Intake and Output Measurement of Fluids, undated revealed .Purpose: To provide an accurate record of the resident's intake and output .Process: Fluids from .tube feedings is calculated and recorded by the licensed nurse . Medical record review revealed Resident #1 was admitted on [DATE], facility discharge on 8/2/16 with readmission to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician order [REDACTED]. Observation on 8/22/16 at 12:18 PM revealed Resident #1 in bed in his room, a tube feeding formula, [MEDICATION NAME] 1.5 Calorie, was in a bag on a pole with 600 milliliters (ml) in the bag and the pump was set at 70 cc (cubic centimeters) per hour. Further observation revealed no water flush bag was hung on the pole. Interview with Licensed Practical Nurse (LPN) #4 on 8/22/16 at 12:22 PM at the 1 West nursing station revealed when asked if the LPN had provided water flushes stated .I have provided water with medications . When asked if the LPN had done any other water flushes the LPN checked the physician orders [REDACTED]. we don't have auto flush bags for awhile now . When asked what awhile meant the LPN stated .months at least . Further interview with LPN #4 at 12:58 PM at the 1 West nursing station when asked if any water flushes were administered stated .No, we don't have auto flush . When asked how he was calculating or accounting for what the resident needed for the flush LPN #4 stated .I have a problem . LPN #4 confirmed they had not administered 52 ml per hour flush as ordered. Medical record review of the 8/2016 Diet Flow Sheet form, where they document tube feeding and flush ml every shift, beginning from the readmission on 8/16/16 revealed no documentation on 8/16/16, 8/17/16, and 8/19/16; and on 8/18/16, 8/20/16 and 8/21/16 one formulary and one flush was documented. Interview with LPN #5, on 8/22/16 at 5:12 PM at the 1 West nursing station, after reviewing the 8/2016 Diet Flow Sheet form confirmed the facility failed to fill out the form completely. Interview with the Director of Nursing (DON) on 8/24/16 at 8:25 AM, in the Business Office Manager (BOM) office confirmed the facility failed to follow the facility policy to document the intake of the fluids every shift and failed to follow the physician order [REDACTED]. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 8/22/16 at 9:05 AM revealed Resident #2 in her room with a patch visible on her chest and 8/22 written on the patch. Medical record review of the Physician's telephone order dated 7/30/16 revealed .Nitro patch (patch with [MEDICATION NAME] for cardiac condition) 0.2 mg (milligrams)/hr (per hour) 1 daily on in AM . Medical record review of the 8/2016 Medication Administration Record [REDACTED]. Further review revealed the patch was initially administered on 8/4/16. Review of the pharmacy data revealed on 8/2/16 the pharmacy received the telephone order dated 7/30/16 and sent the order to the back-up pharmacy. Further review revealed the back-up pharmacy delivery ticket for the [MEDICATION NAME] was delivered to and received by the facility on 8/2/16. Interview with LPN #3 on 8/24/16 beginning at 8:55 AM, in the BOM office revealed she wrote the telephone order dated 7/30/16. Further interview revealed the nurse misdated the phone order and it was really written on 8/2/16. Further interview confirmed the facility failed to follow the physician order [REDACTED].",2019-09-01
480,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-09-13,600,E,1,0,9GQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, observation, review of the facility's investigation, and interviews the facility failed to protect residents from abuse for 4 residents (#3, #6, #7, and #8) of 14 residents reviewed for abuse. The findings include: Review of the undated facility policy, Abuse, Neglect and Misappropriation or Property, revealed .It is (facility's) policy to prevent the occurrence of abuse .Abuse includes physical abuse, mental abuse, verbal abuse .willful means non-accidental .Verbal abuse is use of any oral, written or gestured language that includes any threat, or any frightening, disparaging or derogatory language, to residents .regardless of .ability to comprehend . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident had short and long term memory deficits and moderately impaired cognitive skills for daily decision making . Observation and interview with Resident #3 on 9/10/18 at 1:40 PM, in Resident #3's room, revealed the resident was awake, alert, and lying in bed. Continued observation revealed the resident did not appear fearful or anxious at this time. Interview with Resident #3 revealed no recollection of the incident. Interview with the Speech Pathologist (SLP) on 9/12/18 at 9:25 AM, in the conference room, revealed they were bringing in the meal trays. (Identified resident) was walking around. (Resident #3) had just been served, and (Identified resident) came up behind her and reached around and picked up her milk. (Resident #3) had a verbal outburst .HEY and flailed her arm up; that action and her verbal outburst appeared to be what provoked (Identified resident) to hit her on her left upper arm. (Identified resident) did intentionally hit her; it wasn't an accident. She intended to strike her. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status score of 6, indicating severe cognitive impairment. Continued review revealed Resident #6 required extensive assistance with bed mobility, transfers, mobility, personal hygiene, and toilet use. Review of a facility investigation dated 8/19/18, revealed an identified resident directed harsh, foul language at Resident #6during a random encounter. Continued review revealed the identified resident had a history of [REDACTED]. Observation and interview on 9/10/18 at 2:20 PM with Resident #6 in her room revealed the resident seated in a wheelchair, well-groomed, and without fearfulness or anxiety. Interview at this time revealed Resident #6 could not recall anything happening, but stated I think one of them talked bad to me. Interview with Certified Nursing Assistant (CNA) #2 on 9/11/18 at 5:55 PM, in the conference room revealed, (Resident #6) was coming out of her room in her Wheel chair (w/c) she stood up, about that time the identified resident came out of his room. I was coming out of a Room on B hall, and the CNA (Certified Nurse Aide) from A hall said (Resident #6) is standing up, so I took off towards her. Her roommate was yelling, and she had come to the hall to get help. (Identified resident} was yelling at her you stupid [***] sit down in that f---ing (used entire word) chair. I've told you not to be standing and to not come out of your room. I (referring to CNA #2) am going towards them, telling him I've got this, but he keeps on coming towards us and cursing her. I sat her down in her chair, and am trying to calm her, and he keeps cursing. I took her out of the room, and rolled her up the hall to the nurse. He followed us and said I own these people, and own the halls. He was speaking in a threatening tone, and it frightened (Resident #6). He was directly speaking to (Resident #6). Medical record review revealed Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. Continued review revealed physical behavioral symptoms directed towards others occurring 1 to 3 days during the assessment period. Review of a Care Plan dated 3/14/16, for Resident #7 revealed .8/16/18 Res (resident) to Res altercation .Separate Residents .15 minute checks . Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly MDS dated [DATE], revealed a BIMS score of 8 indicating moderate cognitive impairment. Review of a Care Plan dated 6/21/18 for Resident #8 revealed 8/16/18 Res to Res altercation .Staff education .8/21/18 DC 15 minute checks . Review of the facility's investigation dated 8/24/18, revealed (Resident #7) .stated both residents entered the dining room doorway at the same time. (Resident #8) .called .(Resident #7) a [***] , and (Resident #7) .slapped .( Resident #8) across the face. (Resident #8) . reported she then slapped .(Resident #7) across the face. When (Resident #8) .was interviewed she stated she was going out to smoke .someone got in front of her, she told them to stop pushing, the other resident had slapped her in the face and she returned the slap. Continued review revealed the facility has two separate smoking times for both residents to eliminate the possibility of these two residents interacting. Observation/interview with Resident #7 on 9/10/18 at 1:50 PM, in the smoke shack, revealed the resident seated in a chair. Continued observation revealed no aggressive behavior observed. Interview with Resident #7 at this time revealed the resident stated, I just hit her; I don't know why. Observation/interview with Resident #8 on 9/10/18 at 2:00 PM, in the smoke shack revealed the resident was unable to recall the incident, and stated she hadn't had any problems with anybody. Interview with the Environmental Services Staff member on 9/10/18 at 3:00 PM, in the conference room, revealed she had witnessed at least part of the altercation between Resident #7 and Resident #8. I was coming out of laundry, and overheard (Resident #8) calling (Resident #7) a [***] . I took off running up there to see what was going on. I saw (Resident #8) had her hand on (Resident #7)'s side and (Resident #7) had her hand on (Resident #8)'s face. I don't know who hit who first, I saw them hitting at the same time. They were both willfully swinging at each other with open hands. Interview with the Administrator on 9/13/18 at 4:40 PM, in the conference room, confirmed the facility had failed to follow their abuse policy, and had failed to protect residents (#3, #6, #7, and #8) from abuse.",2020-09-01
1606,CUMBERLAND VILLAGE CARE,445276,136 DAVIS LANE,LAFOLLETTE,TN,37766,2018-08-30,677,D,1,0,O28W11,"**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 provide nail care for 2 residents (#3, #4) of 5 residents reviewed. The findings include: Review of the facility policy, Activities of Daily Living (ADLS), revised 11/28/16, revealed .A patient who is unable to carry out ADL's receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. Further review revealed he required extensive assistance with personal hygiene. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly MDS dated [DATE], revealed Resident #4 had short and long term memory problems. Continued review revealed the resident required extensive assistance with personal hygiene. Observation of Resident #3 on 8/28/18 at 3:25 PM, in the activities room, revealed the resident seated in a wheel chair, gazing out the window. Further observation revealed the resident had dark, thick debris under all of his fingernails. Observation/interview with Licensed Practical Nurse (LPN) #5 on 8/28/18 at 3:37 PM, in the activities room, revealed nail care was to be done on shower days, and on an as needed (PRN) basis. Continued interview confirmed Resident #3 had dark thick debris under all of his fingernails. Resident #3 needed PRN nail care, and it appeared he had not received nail care with his shower earlier in the day. Observation of Resident #4 on 8/30/18 at 7:40 AM, in the dining room, revealed the resident seated in a wheel chair, being fed by a Certified Nurse Assistant (CNA). Further observation revealed the resident had dark debris around the sides, bottom, and underneath her fingernails. Interview with CNA #5 on 8/30/18 at 7:45 AM, in the dining room, confirmed she had not washed the resident's hands prior to the meal, and the resident did have thick dark debris on the sides, bottom and underneath her fingernails. Interview with LPN #7 on 8/30/18 at 7:50 AM, in the dining room confirmed the resident's fingernails had dark thick debris underneath her nails, on the sides, and bottom of the nails. Interview with CNA #7 on 8/30/18 at 7:55 AM, in the conference room, confirmed she had given Resident #7 a shower prior to breakfast, and she had not performed nail care. Interview with the Director of Nursing (DON) on 8/30/18 at 10:20 AM, in the conference room confirmed it was the expectation of the facility personal hygiene including nail care would be done on an as needed basis. Residents nails should be maintained and clean at all times. Continued interview confirmed the facility had failed to provide nail care for Resident #3 and #4.",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
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
1724,HUNTSVILLE HEALTH AND REHABILITATION,445288,287 BAKER STREET,HUNTSVILLE,TN,37756,2020-01-30,600,D,1,0,BDDL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, physical altercation form review and facility investigation review and interview the facility failed to prevent abuse for 2 residents (#4, #5) of 5 residents reviewed for abuse. The findings included: Review of the facility policy, Abuse, Neglect and Misappropriation of Resident Funds Policy, undated, showed .The Resident has the right to be free from verbal.abuse.Verbal abuse is any use of oral.language that is made to Residents directly.derogatory remarks.Resident to Resident abuse includes verbal.or physical abuse. Medical record review showed Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #4's Quarterly Minimum Data Set ((MDS) dated [DATE] showed a brief interview mental status score of 15 indicating the resident was cognitively intact. Medical record review of Resident #4's care plan dated 11/24/2019 showed the resident had potential to be verbally aggressive related to poor impulse control. Medical record review showed Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #5's Annual MDS dated [DATE] showed a brief interview for mental status score of 15 indicating the resident was cognitively intact. Interview with the Administrator and Risk Manager on 1/14/2020 at 9:00 AM stated the Administrator and MDS nurse was making rounds on 1/5/2020 and discovered a fish bowl in a bathroom which he shared with 4 other residents. The residents stated the fish bowl did not belong to any of the four residents assigned to the room. The fish bowl had a green substance at the bottom of it and the Administrator requested that CNA #1 throw the fish bowl away. The Risk Manager stated the resident (Resident#4) had used some foul language and called the CNA foul names on 1/7/2019 because she had thrown the fish bowl away. The Risk Manager stated the CNA had called the resident a bunch of cripples in response to the foul language on 1/7/2019. Continued interview confirmed on 1/7/2020 the Risk Manager was notified that Resident #4 and Resident #5 had an alleged altercation and had to be separated by the staff. Review of a facility physical altercation form dated 1/7/2020 showed .a few days ago. (CNA #1) took his fishbowl full of aftershave and threw it away.he cussed at her for rating him and his roommate out.He then said as she walked off he heard her say something offensive about him and his roommate. DON had called and suspended CNA (CNA #1) on 1-07-2020, but at this time she gave her resignation. Review of the facility investigation dated 1/7/2020 showed .(Resident #5) said he went into (Resident #4) room to tell him to apologize to.staff for being so disrespectful.(Resident #5 ) said (Resident #4) started cursing and threatening him.(Resident #5) said he (Resident #4) then took off his (Resident #4) arm of wheelchair and said he (Resident #4) was going to hit him (Resident #5). then grabbed his (Resident #4) t-shirt and pull him downward on defense.He said neither myself (Resident #5) or (Resident #4).hit each other. Interview with Resident #5 on 1/13/2020, at 12:15 PM, the resident stated he was content and happy at the facility. The resident also stated that the staff were .good people. and he was not abused by staff at the facility. Interview with Resident #4 on 1/13/2020, at 12:30 PM, stated a CNA had called him a cripple. Telephone interview with CNA #1 on 1/14/2020, at 10:40 AM, stated she had been assigned to care for Resident #4 on the of the incident on 1/7/2020. CNA #1 stated Resident #4 had called her ugly names all shift. CNA #1 stated she was overwhelmed on 1/7/2020 and had called the residents bunch of cripple. In summary, Resident #4 cursed staff members at the facility related to a discarded fish bowl and CNA #1 responded with a derogatory statement. Resident #5 attempted to have Resident #4 apologize to facility staff and Resident #4 refused. Resident #5 then grabbed Resident #4's shirt after Resident #4 cursed and threatened Resident #5 for attempting to get Resident #4 to apologize to staff. In conclusion the facility failed to prevent resident to resident abuse for Resident #4 and Resident #5 and the facility failed to prevent verbal abuse to Resident #4.",2020-09-01
1537,GREEN HILLS CENTER FOR REHABILITATION AND HEALING,445267,3939 HILLSBORO CIRCLE,NASHVILLE,TN,37215,2017-10-31,312,D,1,0,EO0911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of Shower List-3rd floor, observation, and interview, the facility failed to carry out and maintain grooming, bathing and personal hygiene for 2 residents (#6, #7) of 28 residents reviewed. The findings included: Review of facility policy, Standards of Care for C.N.[NAME] (Certified Nurse Aides) Practice revised 2/2017 revealed, .CNA required skills include .assisting the resident bathing, grooming, dressing . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission Minimum Data Set ((MDS) dated [DATE] revealed moderate cognitive impairment and was totally dependent for bathing and dressing with assistance of 1 staff person. Review of the Shower List for the 3rd floor revealed Resident #6 was scheduled for a shower on Monday, Wednesday, and Friday for the 7:00 AM to 3:00 PM shift. Observation of Resident #6 on 10/23/17 at 7:50 AM in the resident's room revealed he was not clean and unshaven with body odor present. Interview with Resident #6 on 10/23/17 at 8:00 AM in the resident's room when asked if he had received a shower revealed, .I don't know .do you think I need one .are you going to help me . Interview with Registered Nurse (RN) #5 on 10/30/17 at 4:00 PM in the conference room confirmed the only documented shower the resident had was on 10/24/17 and no further documentation pertaining to showers was provided. Medical record review revealed Resident #7 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Quarterly MDS on 7/25/17 and 10/24/17 revealed the resident was severely cognitively impaired and required extensive assistance of 1 staff person for dressing, personal hygiene, and bathing. Observations of Resident #7 on 10/23/17 at 10:15 AM, 10/24/17 at 11:15 AM and 10/25/17 at 12:05 PM in the 3rd floor dining room revealed the resident was dressed in a gray T-shirt with a white long sleeved shirt under it and a gray pair of sweat pants. Additional observation on 10/25/17 at 8:50 AM in the 3rd floor secured unit, revealed Resident #7 had oatmeal on the right side of her mouth and dried tan-light brown staining down the front of her shirt. Review of the Shower List for the 3rd floor revealed Resident #7 was scheduled for a shower on Monday, Wednesday, and Friday on the 7:00 AM to 3:00 PM shift. Interview with CNA #9 on 10/25/17 at 12:05 PM in the 3rd floor dining room confirmed the resident had been in the same clothes since 10/23/17. Continued interview with the CNA confirmed the resident had been wiped off but had not received a shower for several days due to not having enough staff scheduled. Continued interview confirmed the facility failed to carry out and maintain grooming, bathing and personal hygiene for Resident #7.",2020-09-01
1407,SUMMIT VIEW OF ROCKY TOP,445259,204 INDUSTRIAL PARK RD,ROCKY TOP,TN,37769,2020-01-17,842,D,1,0,XWNL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of a facility document, and interview, the facility failed to complete an inventory of personal belongings timely for 1 resident (Resident #7) of 7 residents reviewed for complete medical records. The findings include: Review of facility policy, Personal Property, dated 9/2012 showed .The resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility Stop Loss document (report of missing items) dated [DATE] at 5:30 PM, showed Resident #7's wife reported that Resident #7's wedding band was missing. The facility checked for a personal belongings inventory list for the resident and the resident .did not have one. During interview with the Director of Nursing (DON) on 1/17/2020 at 5:32 PM, the DON confirmed a personal inventory form was not completed on admission for Resident #7. The DON stated .we did one later.([DATE]).",2020-09-01
5833,CUMBERLAND VILLAGE GENESIS HEALTHCARE,445276,136 DAVIS LANE,LAFOLLETTE,TN,37766,2015-11-17,514,D,1,0,6YVL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of a facility fall investigation and interview, the facility failed to ensure an accurate medical record related to a fall for one resident (#3) of 3 residents reviewed for falls. The findings included: Review of the facility policy for falls management revealed, .Utilize the Fall Response Protocol .for both witnessed and unwitnessed falls .Document accident/incident .As a new event in the Risk Management System .On a Change of Condition Note . Review of the facility's Fall Response Protocol revealed, .Documents & (and) Investigate Circumstances .Change of Condition Note . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nurse's note dated 6/9/15 at 4:00 AM, by Licensed Practical Nurse (LPN) #2 revealed, .Resident noted to be lying in floor of dining room on right side. Assessment completed. [MEDICAL CONDITION] noted to right wrist and hand area. Able to move fingers. No discoloration noted. PEERLA (acronym used to describe the look and function of the eyes-pupil equal, round, reactive to light and accommodation). Moves all other extremities without noted pain or difficulty. No s/sx (signs or symptoms) of pain or discomfort noted at present. Assisted up and set back in chair per staff. MD (Medical Doctor) notified. Son .notified . Review of the facility's investigation of the fall dated 6/9/15 revealed, At approximately 12:30 (not 4:00 AM as reported by LPN #2) resident was noted to be lying in floor of dining room on right side. Assessment completed with no injuries or s/sx pain. Assisted in chair by staff. Later in shift @ (at) approx. (approximately) 4:00 (AM), CNA (Certified Nursing Assistant) noted [MEDICAL CONDITION] to right wrist and hand area. Able to move fingers, however appears to have some discomfort. No discoloration noted. PEERLA .When staff attempted to stand, resident exhibited signs of pain to Rt. (right) leg. Assisted into w/c (wheelchair) per 2 staff members. Moves all other extremities without noted pain or difficulty. On call MD (Medical Doctor) .notified and new order obtained to send resident to (hospital) .Son .notified of incident .to be seen in ER (emergency room ) .Neuro (Neurological) checks initiated and within normal limits for resident . Review of a written statement by CNA #1 dated 6/9/15 revealed, .AT 12:45 approx. I walked out of the bathroom. (LPN #2) yelled for me from the day room .walked in there and (resident) was laying in the floor. Me & (and) (LPN #2) picked her up and looked over her .didn't see any redness or anything. (LPN #2) said ()this didn't (did not) happen .I'm not going to chart this .probably sat down there and fell asleep () .done my round and then went up front about 3 am to start the next round and when I returned .(CNA #2) called me into the dayroom .showed me (resident's) wrist .went and got (LPN #2) and told her I thought that she had actually fallen earlier and showed her (resident's) wrist .then said to get vital (signs) and she would be charting that it happened at 4 am .Me & (CNA #2) couldn't get her to walk to her room so we could change her but she couldn't even stand so we got her in a wheelchair and pushed her to her room where we changed her and she seemed to cringe like she was in pain .(LPN #2) told the on call dr (doctor) and (son) that she fell at 4 am but she fell at 12:45 am . Continue review of the facility's investigation revealed no written statement was provided by LPN #2 related to the fall. Interview with the Assistant Director of Nursing (ADON) I 11/2/15, at 3:15 PM in the front conference room confirmed the resident was observed lying on the floor (in the day room of the secured unit) around midnight by LPN #2 and Certified Nursing Assistant (CNA) #1. Continued interview confirmed LPN #2 failed to document the fall in the medical record. Continued interview confirmed LPN #2 falsified the medical record by documenting the fall occurred at 4:00 AM instead of midnight. Continued interview confirmed LPN #2 failed to complete a change of condition note for four hours after the fall. Continued interview confirmed LPN #2 was terminated on 6/10/15, in part, for falsification of the medical record related to the fall. Attempts to interview LPN #2 were unsuccessful. Current contact information was not available. Telephone interview with CNA #1 on 11/4/15 at 11:25 AM confirmed her written statement dated 6/9/15, as read to her via telephone. Continued interview confirmed the fall occurred at 12:30 AM instead of 4:00 AM as documented by LPN #2.",2018-11-01
5832,CUMBERLAND VILLAGE GENESIS HEALTHCARE,445276,136 DAVIS LANE,LAFOLLETTE,TN,37766,2015-11-17,323,D,1,0,6YVL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of a facility fall investigation, and interview, the facility failed to ensure a full assessment was completed after a fall for 1 resident (#3) of 3 residents reviewed for falls. The findings included: Review of facility policy, Falls Management, revised 5/15/14 revealed, .Utilize the Fall Response Protocol .for both witnessed and unwitnessed falls .Perform Neurological Assessment for all unwitnessed falls and witnessed falls with head injury . Review of the Fall Response Protocol revised 5/2013 revealed .Immediate intervention: Did patient sustain injury? Look for lacerations, abrasions, and obvious deformities .Perform neurological assessment for all unwitnessed falls and witnessed falls with head injury . Medical record review revealed Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Nurse's Notes dated 5/29/15-6/8/15 revealed Resident #1 frequently wandered on the secured unit, going in and out of other resident's rooms, rummaged through other residents' belongings, transferred and ambulated as desired without assistance, and required verbal cueing and redirection from staff. Medical record review of the annual Minimum Data Set ((MDS) dated [DATE] revealed the resident required no physical help from staff with ambulation in the room or the corridor. Medical record review of a falls risk assessment dated [DATE] revealed the resident was at high risk for falls. Medical record review of a nurse's note dated 6/9/15 at 4:00 AM by Licensed Practical Nurse (LPN) #2 revealed, .Resident noted to be lying in floor of dining room on right side. Assessment completed. Edema noted to right wrist and hand area. Able to move fingers. No discoloration noted. PEERLA (acronym used to describe the look and function of the eyes-pupil equal, round, reactive to light and accommodation). Moves all other extremities without noted pain or difficulty. No s/sx (signs or symptoms) of pain or discomfort noted at present. Assisted up and set back in chair per staff. MD (Medical Doctor) notified. Son .notified . Review of the facility's investigation of the fall dated 6/9/15 revealed, At approximately 12:30 (not 4:00 AM as documented by LPN #2) resident was noted to be lying in floor of dining room on right side. Assessment completed with no injuries or s/sx of pain. Assisted in chair by staff. Later in shift @ (at) approx. (approximately) 4:00 (AM), CNA (Certified Nursing Assistant) noted edema to right wrist and hand area. Able to move fingers, however appears to have some discomfort. No discoloration noted. PEERLA .When staff attempted to stand, resident exhibited signs of pain to Rt. (right) leg. Assisted into w/c (wheelchair) per 2 staff members. Moves all other extremities without noted pain or difficulty. On call MD (Medical Doctor) .notified and new order obtained to send resident to (hospital) .Son .notified of incident .to be seen in ER (emergency room ) .Neuro (Neurological) checks initiated and within normal limits for resident . Review of a written statement (part of the facility's investigation of the fall) by CNA #1 dated 6/9/15 revealed, .At 12:45 .(LPN #2) yelled for me from the day room .walked in there and (resident) was laying in the floor. Me & (and) (LPN #2) picked her up and looked over her .didn't see any redness or anything. (LPN #2) said 'this didn't (did not) happen .I'm not going to chart this .probably sat down there and fell asleep' .done my round and then went up front about 3 am to start the next round and when I returned .(CNA #2) called me into the dayroom .then showed me (resident's) wrist .went and got (LPN #2) and told her I thought that she had actually fallen earlier and showed her (resident's) wrist .then said to get vital (signs) and she would be charting that it happened at 4 am .Me & (CNA #2) couldn't get her to walk to her room so we could change her but she couldn't even stand so we got her in a wheelchair and pushed her to her room where we changed her and she seemed to cringe like she was in pain .(LPN #2) told the on call dr (doctor) and (son) that she fell at 4 am but she fell at 12:45 am . Continue review of the facility's investigation revealed no written statement was provided by LPN #2 related to the fall. Medical record review of a hospital Operative Report dated 6/10/15, revealed the resident had a Right Femoral Neck Fracture and Right Distal Radius and Ulna Fracture (wrist fracture). Continued review revealed the resident had surgical repair of the Hip Fracture and closed repair with casting of the Wrist Fracture. Interview with the Assistant Director of Nursing (ADON) on 11/2/15 at 3:15 PM, in the front conference room confirmed the resident was observed lying on the floor (in the day room of the secured unit) around midnight by LPN #2 and CNA #1. Continued interview revealed the resident didn't complain after the fall and was placed in a straight-backed chair in the day room by LPN #2 and CNA #1. Continued interview revealed the CNA (#1) reported to the Director of Nursing (DON) and the ADON during the investigation that LPN #2 assessed the resident and found no obvious injuries or complaints. Continued interview confirmed LPN #2 was terminated on 6/10/15, for failure to follow facility protocol related to the fall; failure to document the fall at the time it occurred; and falsification of the medical record related to the fall. Telephone interview with CNA #1 on 11/4/15, at 11:25 AM confirmed her written statement dated 6/9/15 as read to her via telephone. Continued interview revealed at the time of the fall, LPN #2 and CNA #2 looked over the resident; did not observe any bruising or swelling; and the resident did not appear in pain. Continued interview confirmed LPN #2 did not assess the resident's range of motion or neurological status until 4:00 AM. CNA #2 stated, We should have taken her to her bedroom. Walking would have caused obvious pain and we would have seen that. By the time we would have gotten her to her room, her wrist would have been obviously injured.",2018-11-01
3711,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2017-03-03,223,D,1,0,UP9L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of a facility investigaiton, and interview, the facility failed to prevent abuse for 2 residents (#1, #4) of 14 residents reviewed for abuse. The findings included: Review of facility policy, Abuse Prevention Program, updated 1/19/17 revealed .The facility will not tolerate resident abuse or treatment by anyone including staff members, other residents, consultants, volunteers, staff of other agencies, family members, legal guardians, friends, or other individuals .All personnel must promptly report any incident or suspected incident of resident abuse, mistreatment, or neglect including injuries of unknown origin .Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being .Physical abuse is hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment . Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #4 scored 2 on the Brief Interview for Mental Status, indicating she was severely impaired cognitively. Continued review revealed Resident #4 required supervision with transfers, ambulation, dressing, and grooming; was independent with eating; and was often incontinent of urine. Medical record review of nursing notes dated 8/14/16 at 1:19 PM revealed .Resident heard yelling Help in room. CNA (Certified Nursing Aide) went to assess, as she walks in, Agency CNA leaves room. Resident then asked CNA for nurse, Nurse for 300 hall enters room. Resident states She hit me, in the face. And she grabbed me. Resident then extended her arms showing bruised areas to bilateral forearms. Resident noted with bruise to left forearm (1.3 cm (centimeters) x (by) 0.8 cm) and bruise to right forearm (1 cm x 0.9 cm). No other bruising noted. Agency CNA asked to leave building. CNA cooperated. MD notified . Medical record review of nursing notes dated 8/14/16 at 1:53 PM revealed .Head to toe assessment completed by floor LPN (Licensed Practical Nurse). Resident allowed nurse to see arms, torso, chest, back, feet, and bilateral lower extremities. Resident would not allow nurse to assess peri area or thighs. Resident states I'm fine, my pants have been on all day . Medical record review of a note by the Assistant Director of Nursing (ADON) dated 8/15/16 at 4:57 PM, revealed .Notified on Sunday, 8/14/16 at 10:15 AM, resident saying the agency CNA had grabbed her and hit her in the face. CNA immediately escorted out of building. Resident was assessed by LPN on shift at that time and as noted. Resident assessed and noted to have discolored purplish areas to bilateral forearms, discoloration area to her left forearm measures 1.2 cm x 0.8 cm with pin point abrasion noted and discoloration to right forearm measures 1.0 cm, x 1.0 cm. Face without any areas notes . Interview with the Administrator and Director of Nursing (DON) on 2/6/17 at 1:30 PM, in the conference room revealed there was no investigation available for this incident of abuse. Continued interview revealed the former owners removed all communications as well as personnel files so the Administrator was unable to state who the Agency CNA was. Further interview revealed the DON stated they were only able to retrieve the information forwarded to the state agency. Medical record reivew revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #1 scored 12 on the Brief Interview for Mental Status indicating some memory impairment. Continued review revealed Resident #1 required extensive assistance with transfers, dressing, eating, and grooming; was dependent for bathing; and was always incontinent of bowel and bladder. Review of the facility investigation revealed a statement by the Director of Nursing (DON) .On 1/19/17 a resident's spouse reported the CNA #1 had refused to change her husband until after she had her lunch and she hated changing old peoples' diapers because she did not like old people. Employee was suspended; allegation investigated per Abuse Prevention Policy. Completed investigation revealed substantiation of allegation; employee was terminated 1/24/17 and refused to cooperate with process of investigation . Reveiw of a facility investigation of a written statement from the resident's spouse dated 1/19/17 revealed .(CNA #1) has always been difficult to deal with, there have been many instances where she has refused to change (Resident #1) or even put him to bed before she had her lunch break. She is very rude and hateful. She has said many times she did not like to change old peoples' diapers. And I asked her why. She told me because they were old. And I told her she was in the wrong line of work. She is very arrogant and hateful. I have never been pleased with her. She had rather talk than get her work done . Review of the facility investigation revealed CNA #1 was asked to submit a written statement detailing her side of the story. On 1/20/17 CNA #1 wrote she could not write a statement on this situation because she was not given any information on the case to be able to defend herself. Continued review revealed a note from the Administrator stating on 1/19/17 he, the DON, and ADON provided CNA #1 with details of the allegations. She was asked to provide a statement within 24 hours to document her side of the alleged incident and she has refused to do so. Review of the facility investigation dated 1/20/17 revealed the Administrator and DON were asked by the union representative for information sbout the CNA #1 and the people who filed an allegation of abuse and neglect against her. The union representative had advised CNA #1 to hold off turning in her statement of the event because she wanted more information. The DON advised the union representative the facility has a duty by law to protect the resident from retaliation and will not provide CNA #1 or union representatives the private confidential information of the resident or their family that brought forward the allegation. To date there is still no statement from CNA #1. Interview with the Administrator on 2/8/17 at 1:30 PM, in the conference room confirmed CNA #1 had been disrespectful to Resident #1 and also refused to care for him. She was appropriately suspended pending investigation then terminated.",2020-03-01
2086,SIGNATURE HEALTHCARE OF SOUTH PITTSBURG REHAB & WE,445343,201 EAST 10TH STREET,SOUTH PITTSBURG,TN,37380,2017-09-26,225,D,1,0,13X011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of a facility investigation, and interview, the contracted facility staff failed to report an allegation of abuse timely for 1 resident (#3) of 5 residents reviewed for abuse. The findings included: Review of the facility policy Abuse, Neglect, Exploitation, and Misappropriation of Property dated 8/24/17 revealed .Reporting Requirements 1. Every Stakeholder, contractor, and volunteer immediately shall report any 'allegation of abuse .injury of unknown origin .or suspicion of crime' . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident scored a 15 (cognitively intact) on the Brief Interview for Mental Status. Further review revealed the resident required extensive assist with transfers, dressing, and personal hygiene with 1-2 person assist. Continued review revealed the resident was always incontinent of bowel and frequently incontinent of urine. Review of a facility investigation dated 8/30/17 revealed Housekeeper #1 (contracted employee) reported to his supervisor he overheard Certified Nurse Assistant (CNA) #2 use profanity in the presence of Resident #3 on 8/29/17. Continued review revealed the Housekeeper was instructed by his supervisor to report the incident to the Administrator. Further review revealed the housekeeper reported the incident to the Administrator on 8/30/17 (next day). Interview with Housekeeper #1 on 9/26/17 at 11:45 AM, in the conference room, revealed .went right then and reported to (Housekeeping Supervisor) told me to go report what she (CNA #2) said to the Administrator .could not locate him .told him (Administrator) the next morning .yes had received training on abuse .knew was supposed to report immediately . Interview with the Housekeeping Supervisor on 9/26/17 at 12:00 PM, in the conference room, revealed . (Housekeeper #1) came to me and told me he had overheard (CNA #2) cussing a resident out .told him to go talk to (Administrator) .found out the later he had not reported it till the next morning .should of gone with him . Interview with the Administrator on 9/26/17 at 2:00 PM, in the conference room, confirmed the facility failed to report an allegation of verbal abuse for Resident #3 and the facility failed to follow facility policy.",2020-09-01
2139,"LAKEBRIDGE, A WATERS COMMUNITY, LLC",445358,115 WOODLAWN DRIVE,JOHNSON CITY,TN,37604,2019-07-23,609,D,1,0,8SW011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of a facility investigation, and interviews, the facility failed to report an allegation of abuse timely for 1 resident (#9) of 8 residents reviewed for abuse of 12 sampled residents. The findings included: Review of facility policy Abuse Prevention Program, last updated on 1/19/17, revealed .Employees are required to report any incident, allegation or suspicion of potential abuse, neglect or mistreatment they observe, hear about or suspect to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator . Medical record review revealed Resident #9 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 had short and long term memory problems and was severely impaired for daily decision making skills. Continued review revealed the resident required extensive assist for bed mobility, transfers, and Activities of Daily Living (ADLs) with 1-2 person assist. Review of a facility investigation dated 7/1/19 revealed Licensed Practical Nurse (LPN) #2 alleged she witnessed LPN #4 and LPN #5 be abusive to Resident #9 on 7/1/19 at approximately 1:00 PM in the Station 2 dayroom. Continued review revealed LPN #2 reported the incident to LPN #7, who then provided LPN #2 with the corporate compliance phone number. Further review revealed LPN #2 called the corporate compliance department and reported the incident. Continued review revealed the facility Administrator was notified of the allegation of abuse by the corporate compliance office on 7/1/19 at approximated 6:42 PM (5 hours and 42 minutes after the alleged incident). Interview with LPN #2 on 7/16/19 at 2:30 PM, in the conference room, revealed .(Resident #9) was leaning forward in her wheelchair (LPN #4) grabbed (the resident) by the shoulders and pulled her back into her wheelchair .(Resident #9) grabbed (LPN #4) and dug in her fingernails into (LPN #4's) arm .(Resident #9) continued to be combative .(LPN #5) tried to give (the resident) medicine .she spit it out and threw the water on (LPN #5) .they (LPN #4 and LPN #5) were going to put (Resident #9) in a (reclining wheelchair) .(LPN #5) put his hand in (Resident #9's) face and his thumb went into her (the resident's) left eye .could not tell if (LPN #5) had his hand on (Resident #9's) throat or chest .(LPN #5) was placing pressure .(LPN #5's) face was red and he was clenching his teeth .I felt bad for not reporting it (incident) that day. I thought we had 24 hours . Interview with Certified Nurse Assistant (CNA) #2 on 7/17/19 at 11:15 AM, in the conference room, revealed .(Resident #9) started having behaviors a couple of days before this .on (7/1/19) she got up hitting and kicking we all took turns trying to keep her in her chair .I tried to feed her (Resident #9) lunch and she threw food in my hair .(Resident #9) was in wheelchair in the hallway .(LPN #4) told her (Resident #9) she was acting inappropriately, (LPN #4) grabbed (the resident's) wheelchair and pushed her into the dayroom .heard (LPN #4) telling (the resident) 'you need to stop doing that' . Telephone interview with the (former) Administrator on 7/22/19 at 3:15 PM confirmed she was notified by the corporate office of the allegation of abuse on 7/1/19 at 6:42 PM (5 hours and 42 minutes after the alleged incident). Continued interview confirmed the facility staff failed to report an allegation of abuse timely.",2020-09-01
1776,CONCORDIA NURSING AND REHABILITATION-NORTHHAVEN,445297,3300 BROADWAY NE,KNOXVILLE,TN,37917,2018-05-08,609,J,1,0,26B911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, 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 5 residents reviewed for abuse. Resident #1 was sexually assaulted and the incident was not reported to the State Survey Agency within 2 hours. The facility's failure 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). F-609 was cited at a scope and severity of J and is Substandard Quality of Care. The Nursing Home Administrator was informed of the Immediate Jeopardy (IJ) on 5/7/18 at 11:00 AM, in his office. The IJ was effective from 2/25/18 through 2/27/18. The IJ was removed on 2/28/18. The facility's corrective action plan which removed the immediacy of the jeopardy was received and corrective actions were validated onsite by the surveyor on 5/7/18 and 5/8/18. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction for those tags. The findings included: Review of the facility policy, Abuse, dated 11/28/17 revealed .2. The center staff reports any alleged violations involving verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, and neglect of the resident as well as mistreatment, injuries of unknown source and misappropriation immediately to a Senior Clinician, or Operational Leader at the facility, or District, or National Level and to other officials in accordance with State regulations through established procedures (including to State survey and certification agency) . 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 Mental Status (BIMS) score of 15 (cognitively intact). Further review revealed the resident required supervision for bed mobility, transfers, and toilet use with 1 person assist, and required limited assist for bathing with 1 person assist. Medical record review of an acute care hospital nurse's triage note dated 2/25/18 at 11:14 PM, revealed .presenting complaint .staff told EMS (Emergency Medical Services) that another resident took pt's (patient's) wondering (wander) bracelet off of her and took her somewhere .pt returned to facility intoxicated . Continued review of a hospital physician's note dated 2/26/18 at 5:01 AM revealed .She was taken out of the NH (nursing home) by another resident's family. She returned intoxicated and stated she had been sexually assaulted . Review of a facility investigation dated 2/26/18 revealed on the evening of 2/25/18, Resident #1 left the facility with the boyfriend of another resident, returned to the facility intoxicated, and alleged she had been sexually assaulted. Interview with the Administrator on 5/3/18 at 11:15 AM, in his office, revealed .I either faxed or called the State Agency that evening (2/25/18) .don't remember . Continued interview revealed the Administrator did not have documentation to support notification of the incident to the State Agency within 2 hours. Review of the facility self-report, and interview with the Director of Nursing on 5/3/18 at 11:15 AM, in the Administrator's office, confirmed the facility reported the incident to the state survey agency on the morning of 2/26/18 (at 8:43 AM, approximately 10 1/2 hours after the incident). The facility's corrective action plan included the following: On 2/26/17 the facility did the following: [NAME] The Nursing Home Administrator, Director of Nursing Services, Director of Social Services, Director of Activities, Director of Nutrition, Business Office Manager, Maintenance Director, Director of Rehabilitation, Medical Director, Minimum Data Set Coordinator, Director of Admissions, and Licensed Practical Nurse (LPN) #3 conducted an ad hoc Quality Assurance Meeting to review the circumstances of the incident and implement an immediate action plan for the investigation of the incident. B. Conducted in-services with staff on abuse, reporting any unusual appearing activity and systemic changes that were implemented to enhance resident/staff safety. Staff was required to complete a post test. Systemic changes and in-services included if staff witness any activity in the facility that they feel is different or odd, they report it to their supervisor immediately. The supervisor is responsible to investigate immediately and notify the Executive Director (ED) and/or Director of Nursing Services (DNS). C. Head to toe skin assessment completed for all non-interviewable residents. D. Safe surveys (interviews with residents to determine their safety) were completed with all alert and oriented residents. E. The DNS or designee initiated a daily walk through on both shifts, on all hallways, and interviews with staff to ensure no unusual behaviors, reported allegations of abuse, or any unauthorized entry/exit of the doors on the Northeast side of the facility had occurred. This process is ongoing. F. The Administrator began an audit of all allegations of abuse or reportable incidents and this process is ongoing. On 2/27/18 the facility did the following: [NAME] Conducted an ad hoc Quality Assurance meeting to ensure all interventions of the immediate action plan were implemented. B. Continued staff in-services and post tests for 100% completion of all staff. The surveyor verified the facility's corrective action plan as follows: [NAME] Review of the Quality Assurance Meeting, Attendance, and Agenda sheets confirmed the facility conducted ad hoc Quality Assurance meetings on 2/26/18, 2/27/18, and began review monthly on 3/21/18 to ensure sustainability of the plan of correction. B. Comparison of the room roster dated 2/26/18 with the completed safe survey individual questionnaires and completed skin assessments revealed all residents were assessed for abuse between 2/26/18 - 2/27/18 with 100% completion on 2/27/18. The facility completed weekly safe survey individual questionnaires through 3/22/18 and weekly skin assessments are ongoing. C. Nursing Home Administrator on 5/2/18 at 2:45 PM, in the conference room, revealed the Administrator began auditing all allegations of abuse or any reportable incident for timely reporting to the state agency and is ongoing. D. Comparison of facility in-service records, employee roster, and post tests for systemic changes and abuse dated 2/26/18 -2/27/18. Interview with the Director of Nursing Services (DNS) on 5/8/18 at 8:00 AM, in the conference room, confirmed staff education was 100% complete on 2/27/18. Further interview with the DNS confirmed the process is monitored daily by DNS or designee which included: a walk through on all hallways, interviews with staff for any unusual behaviors, any allegation of abuse, and monitoring of visitor entrance and exit through the designated entrance door. E. Multiple observations and interviews were conducted by the surveyor with residents, visitors, and employees on both shifts throughout the complaint survey conducted from 5/1/18 through 5/8/18, which confirmed full implementation of the systemic changes to enhance resident/staff safety and the reporting of any unusual appearing activity. F. Review of all of the facility's self-reported incidents to the State Survey Agency and allegations of abuse revealed the facility had no other regulatory deficiencies since implementation of the Plan of Correction.",2020-09-01
2075,SIGNATURE HEALTHCARE OF SOUTH PITTSBURG REHAB & WE,445343,201 EAST 10TH STREET,SOUTH PITTSBURG,TN,37380,2018-03-21,609,D,1,1,481X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of a facility investigation, and interviews, the facility staff failed to report an allegation of abuse timely for 1 resident (#12) of 15 residents reviewed for abuse of 49 residents sampled. The findings included: Review of the facility policy Abuse, Neglect and Misappropriation or Property, undated, revealed .Every Stakeholder immediately shall report any allegation of abuse . Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #12 scored a 13 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assist with transfers, dressing, personal hygiene, and bathing with 1-2 person assist. Review of a facility investigation, not dated, revealed on the evening of 1/9/18 at approximately 7:30 PM Resident #12 reported Certified Nurse Assistant (CNA) #1 and CNA #2 were rough with her when providing care. Continued review revealed CNA #1 and CNA #2 reported the allegation to Licensed Practical Nurse (LPN) #2, but the LPN did not report the allegation to administration. Further review revealed the resident reported the allegation again on 1/10/18 to the Assistant Director of Nursing (ADON) #2. Interview with ADON #2 on 3/13/18 at 12:45 PM, in the Medical Records office, confirmed administration was not aware of the allegation of abuse until 1/10/18 (1 day later). Telephone interview with CNA #1 on 3/20/18 at 6:15 PM revealed .we went right then (1/9/18) and told the nurse she (Resident #12) said we hurt her .and filled out witness statements .",2020-09-01
2211,SIGNATURE HEALTHCARE OF CLEVELAND,445369,2750 EXECUTIVE PARK PLACE,CLEVELAND,TN,37312,2017-06-14,223,G,1,0,6JK211,"**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 interview, the facility failed to prevent verbal abuse for 1 resident (#1) of 5 residents reviewed. The facility's failure resulted in actual harm to Resident #1. The findings included: Review of the facility policy, Abuse, Neglect, Exploitation, and Misappropriation of Property reviewed on 5/22/17 revealed .Abuse Is the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain or mental anguish. Abuse includes physical abuse, mental abuse, verbal abuse .willful means non-accidental, or not reasonably related to the appropriate provision of ordered care and services, depending on the context .Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment .any other statements or behavior that a reasonable person would consider to be humiliating, demeaning or threatening to a resident .Verbal abuse is use of any oral, written or gestured language that includes any threat, or any frightening, disparaging or derogatory language, to residents .or within their hearing distance . 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 the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact and independent with daily decision making, required extensive assistance of 2 persons for bed mobility, transfers, and required extensive assistance of 1 person for toilet use, was always incontinent of bowel and bladder, and required set up assistance for eating. Review of a facility investigation dated 6/2/17 revealed .CNA (Certified Nursing Assistant) had hurt (Resident #1) feelings. When the nurse asked how, resident .stated had turned the call light on and CNA came into the room and said 'How come you are so impatient? Can't you wait a f .ing 30 seconds?' .Abuse Coordinator was notified immediately at 0500 (5:00 AM). Upon CNA's arrival at 0620 (6:20 AM) was sent home by charge nurse .(Resident #1) has not made accusations of this type in the past nor has the staff person been accused of this type of treatment in the past. Incident was substantiated and CNA was terminated on 6/2/17 . Review of a witness statement dated 6/2/17 obtained by the facility from Registered Nurse (RN) #1 revealed .This nurse was in (Resident #1's room) helping CNA (#3) on shift with bed A and bed B .(Resident #1) said this CNA (CNA #1) hurt her feelings when asked how. Resident (#1) said she turned her call light on and CNA (#1) came into room and said 'How come you are so impatient. Can't you wait a (expletive) 30 seconds to get here.' Resident was reassured she could put her light on anytime this was her home and that .she could always ask for the nurse if something bothered her or hurt her feelings . Review of a witness statement dated 6/2/17 obtained by the facility from CNA #1 revealed .After coming in from smoking (Resident #1) (and) (another resident's) call lights were on. (CNA #2) went to get (Resident #1) .needed to be changed .I assisted (CNA #2) in changing (Resident #1) and positioning her in the bed. As (CNA #2) took the trash and linen I assisted (another resident) off the toilet and back to bed. (Resident #1) was yelling my name from her room to which I asked her to give me a moment. After putting (another resident) in the bed I turned (Resident #1) light and TV off telling her that her yelling was waking the other residents and reassuring her that I had come back like I stated I would. I asked her if she needed anything else and she said no so I shut her door on my way out as she had asked me to do so . Review of a witness statement dated 6/2/17 obtained by the facility from CNA #3 revealed .(Resident #1) .stated she pressed her call light and when (CNA #1) came in she said can't you give me a f .ing 30 sec (seconds) charge nurse was in the room when resident was talking . Review of a witness statement dated 6/2/17 obtained by the facility from the Social Worker (SW) revealed .SW spoke (with) (Resident #1) after reports of concern (with) CNA (#1). (Resident #1) told me that on Thursday CNA (#1) .had hurt her feelings. Resident said she pushed call light (at) approximately 12:00 (midnight) to have her light turned off and door closed. She said that CNA (#1) was mean and said, 'Can you wait one f .ing 30 seconds? You are so impatient .' . Medical record review of a Physician's Progress Note dated 6/3/17 revealed .mood and affect .normal mood and affect . Medical record review of a Nurse's Progress Note dated 6/4/17 revealed .Resident is pleasant mood no complaints verbalized . Medical record review of the Social Service Note dated 6/12/17 revealed .A (alert and) O (oriented) x 3, ST (short term)/LTM (long term memory) intact .may require cues/supervision with decision making in certain situations .(no) concerns voiced . Review of CNA #1's termination notice dated 6/2/17 revealed .It was allegedly reported that (CNA #1) cursed at a resident when resident turned her call light on for assistance. This is in violation of Policy and Procedure .Physical mistreatment or abusive language to any individual . Interview with Resident #1 on 6/13/17 at 11:00 AM, in the resident's room, revealed the resident had put her call light on about 12:00 midnight (6/1/17) to have a CNA turn her light off, CNA #1 came in her room and said your so impatient, can't you wait a f .ing 30 seconds. Continued interview confirmed Resident #1 stated made me feel awful. Interview with the Administrator on 6/13/17 at 12:00 PM, in the Administrator's office, revealed there were no witnesses to the incident. Interview with the Administrator on 6/13/17 at 2:25 PM, in the Administrator's office confirmed CNA #1 was terminated for verbal abuse. Interview with the Social Worker on 6/13/17 at 3:00 PM in the Social Worker's Office revealed Resident #1 had told her she had put her call light on to have light turned off and door shut, CNA #1 said to her can't you wait a f .ing 30 seconds you are so impatient, Resident #1 said it really hurt her feelings but other than that she was ok. Interview with CNA #1 on 6/13/17 at 3:15 PM by telephone confirmed she had come in after a smoke break and several call lights were on, went in to change (Resident #1) then told her I would be right back after getting another resident off the toilet. Continued interview revealed the resident was yelling my name and I said f .ing s .t in the hallway. Continued interview revealed (Resident #1) thought it was directed at her. Interview with the Administrator on 6/13/17 at 3:45 PM in the Administrator's Office, revealed CNA #1 stated she might have dropped the f bomb. Further interview revealed CNA #1 stated she may have cursed in the hallway. Interview with Registered Nurse (RN) #1 on 6/13/17 at 3:50 PM by telephone confirmed RN #1 was assisting CNA #3 with Resident #1's roommate when Resident #1 stated her feelings were hurt from a statement CNA #1 made, How come you are so impatient, can't you wait a f .ing 30 seconds.",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
2238,NORTHSIDE HEALTH CARE NURSING AND REHABILITATION C,445373,202 EAST MTCS ROAD,MURFREESBORO,TN,37130,2017-11-30,609,D,1,1,Z9P511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of an Investigation Summary, and interview, the facility failed to timely report resident-to-resident abusive behaviors between 2 residents (#11, #37) of 13 residents reviewed The findings included: Review of facility policy, Abuse, Neglect, Exploitation, effective 1/27/2016 revealed .Report allegations or suspected abuse .immediately to (the) Administrator .Other Officials in accordance with State Law .State Survey and Certification agency through established procedures . Medical record review revealed Resident #11 was admitted [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Continued medical record review revealed a quarterly Minimum Data Set ((MDS) dated [DATE] revealed severe cognitive impairment with no moods or behaviors exhibited. Medical record review revealed Resident #37 was admitted [DATE] with [DIAGNOSES REDACTED]. Continued medical record review revealed a quarterly MDS dated [DATE] revealed moderate cognitive impairment with poor decision making. Review of an Investigation Summary dated 11/6/17 at 10:00 AM revealed, .Altercation was observed by employee #1 (Licensed Practical Nurse (LPN) #3) at around 10:00 AM on 11/6/17 . Interview with Certified Nurse Aide (CNA) #2 on 11/30/17 at 10:40 AM in the 300 hall revealed Resident #37 hit and made an obscene gesture to Resident #11 on the left arm for not getting out of his way. Continued interview revealed CNA #2 stated the event happened on 11/6/17 at around 10:00 AM. Interview with LPN #1 on 11/30/17 at 10:45 AM in the 300 hall revealed Resident #37 was upset about the possibility of getting a roommate and acted-out. Continued interview revealed LPN #1 stated Resident #37 slapped Resident #11 on 11/6/17 close to 10:00 AM. Interview with the Social Services Director on 11/30/17 at 1:35 PM in her office revealed Resident #37 was upset at the possibility of getting a roommate and this probably triggered him to act out. Continued interview revealed the event occurred on 11/6/17 around 10:00 AM. Interview with the Director of Nursing (DON) on 11/30/17 at 1:45 PM in her office confirmed the event between Resident #11 and #37 occurred 11/6/17 around 10:00 AM and the facility failed to timely report the occurrence to the State Agency until 11/7/17 at 11:18 AM.",2020-09-01
742,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2018-09-25,609,D,1,0,YCKB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility documentation and interview, the facility staff failed to report a suspicion/allegation of abuse to the administrator for 1 of 3 residents (Resident #1) reviewed for abuse. The findings include: Review of the facility policy, Abuse Prevention Program, updated 1/19/17, revealed .It is the policy of this facility to prevent abuse .The following Procedures shall be implemented when an employee or agent becomes aware of abuse .or of an allegation of suspected abuse .Procedure .Abuse Reporting .This facility will not tolerate abuse .by anyone, including staff members .All alleged violations involving .abuse .MUST be reported to the Administrator and Director of Nursing. The Administrator is the Abuse Coordinator .the person(s) observing the incident of resident abuse or suspected resident abuse must IMMEDIATELY report such incidents to the Charge Nurse, regardless of the time lapse since the incident occurred. The Charge Nurse will immediately report the incident to the Administrator .The Charge Nurse must complete an incident report and obtain written, signed and dated statement from the person reporting the incident. A completed copy of the incident report and written statements from witnesses, if any, will be provided to the Administrator .within twenty-four (24) hours of the occurrence of such incident .Identification .Employees are required to report any incident, allegation or suspicion of potential abuse .to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator .All residents, visitors, volunteers, family members or others are encouraged to report their concerns or suspected incidents of potential abuse .to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator .Supervisors will immediately inform the Administrator or in absence of the Administrator, the person in charge of the facility of all reports of incidents, allegations or suspicion of potential mistreatment. Upon learning of the report, the Administrator or .the person in charge of the facility shall initiate an incident investigation Investigation .For any incident involving suspicion of abuse .the Administrator or person appointed .will gather further facts prior to making a determination conduct an abuse investigation .Once the Administrator or designee determines there is a reasonable cause for suspected abuse, the Administrator or designee will investigate the allegation The final report shall include facts determined during the process of the investigation, review of the medical records, personnel files and interview of witnesses. The final investigation shall also include a conclusion of the investigation based on known facts . Medical record review revealed Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum (MDS) data set [DATE] revealed Resident #1 had minimal difficulty hearing, had clear speech, could make herself understood, could understand others; scored 9 out of 15 on the Brief Interview for Mental Status, indicating moderate cognitive impairment; exhibited no [MEDICAL CONDITIONS], or behaviors; exhibited feeling down/depressed 2-6 days of the review period; exhibited little interest/pleasure, sleep issue, and concentration issue for 7-11 days of the review period; exhibited change in energy for 12-14 days of the review period; required extensive 2+ person assistance for bed mobility, dressing, toileting; total dependence with 2+ person assistance for transfers, hygiene and bathing; was always incontinent bowel and bladder; and received antianxiety, antidepressant and diuretic medication for 7 days of the review period. Review of the staffing assignments for 9/15/18 for the 7:00 PM to 7:00 AM shift revealed Certified Nurse Aide (CNA) #1, #2, #3, #4, #6; Registered Nurse (RN) #2, and Licensed Practical Nurse (LPN) #1 were on duty. Review of the facility documentation revealed staff had written statements or responses to questionnaires regarding the 9/16/18 allegation of abuse. Review of the facility Abuse Questionnaire completed by Resident #1 dated 9/17/18 revealed .Has staff, a resident or anyone else here abused you, this includes verbal, physical, financial or sexual abuse? .Yes. If Yes, ask who the abuser was, what happened, when it occurred, where it happened, and how often .'I got hit several times. Big hands, big fists.' Further review revealed the person had 'Short hair (blonde) large in posture. Hit her in her head, hit face. Chest hit her with a big hand & fist hit her hand several times happened-several months ago. did not happen Sat. (Saturday) or Friday-happened 6 mo (months) ago happened at night.' When asked Did you tell staff? Yes. Who did you tell? Told friends-Told nurses. Also included in the Questionnaire was a diagram of a person with No new bruises anywhere else. Review of the facility documentation included the statement written by CNA #1 revealed .When I entered the room the tech (CNA #2) was turning patient (Resident #1) trying to clean her, the patient was yelling at tech to get away from her. The patient told me the tech was being rough with her and hurting her. The tech begin to argue with patient saying she didn't do anything to her. The patient became more agitated and told the tech if she hits her again she will get out of bed and whoop her . Review of the facility documentation included the statement written by RN #2 revealed .CNA (#2) came to desk to ask other CNA (#1) for assist (with) pt (patient/Resident #1) because she was agitated. After CNA's provided care this nurse went in to (check) on pt. Pt agitated .Asked pt what was wrong pt stated 'I don't want her in here ever again' (described CNA #2). Asked pt why she didn't want her in there. Pt stated ' .she (CNA #2) just starts bossing me around-saying do this, do that, roll over .and if she ever hits me I'm gong to knock her block-off .' Asked pt has she ever hurt her. Pt stated 'No, but she doesn't have to be so bossy, I'm not going to put up with that, I don't want her in here anymore, she is just rough and rude' . Review of the facility documentation included thestatement written by RN #1 dated 9/17/18 revealed .(Resident #1's) daughter approached me in the hallway with a concern. Her mother had told her Saturday night there was a tech (CNA) smacking on her. She said it was a fat tech and that she kept smacking her. I did report immediately to ADON (Assistant Director of Nursing) /Abuse Coordinator (Administrator) @ (at) which time immediate actions were taken . Telephone interview with CNA #1 on 9/24/18 at 11:47 AM revealed .I was charting at the nursing station when (CNA #2) came up to me and said (Resident #1) was agitated and she needed help .I walked down with her .and resident said 'You're rough with me, you hurt me' and (CNA #2) stepped back. Resident talk with me calm like and said (CNA #2) 'rough, hurt me' and 'I'll get out of bed if she hurts me again' and 'If you ever hit me again I'll whoop your ass.' (CNA #2) said 'I never hit you, just took care of you and cleaned you up.' They argued back and forth 'You hit me, no I didn't hit you' .I went to the nursing station and (CNA #2) there and said she already told the nurse what happened . Telephone interview with CNA #2 on 9/24/18 at 12:16 PM revealed .(Resident #1) was agitated .she was cursing, aggressive, combative, and not cooperative .so I went to the Charge Nurse (RN #2) and tell her what was going on and ask if another tech (CNA #1) to help me. The resident could be heard hollering .Both (CNA #1) and I went into the room .the resident turned over the bedside table onto herself in bed and all the stuff on it went everywhere, on her, on the floor, in the bed. It was a mess and resident agitated made it worse .She was hollering about being abused and I told her no one doing that or anything like that to her . Resident kept saying she was being abused .I went straight to nurse and told her resident said I was hitting her . Telephone interview with RN #2 on 9/24/18 at 4:38 PM and 5:28 PM revealed .around 2:00-3:00 AM, I think, (CNA #2) was doing rounds and came up to the desk and asked (CNA #1) to help her because (Resident #1) being agitated .After care (to Resident #1) both (CNAs) came out and told me about resident's statement .to (CNA #1) that (CNA #2) slapped her .I said I would go and talk with (Resident #1) myself. She was agitated. She never told me (CNA #2) hit her. I asked her if (CNA #2) had been hurt her and she 'no, just hateful, comes in here looking like a bulldog.' (Resident #1) said 'if she (CNA #2) does I'll knock her block off.' (Resident #1) did not tell me (CNA #2) hurt her in any way .(Resident #1) described (CNA #2) as 'blonde, bigger older lady.' She never said (CNA #2) hit her . Further interview revealed when asked why she did not report the allegation to the Administrator or the Director of Nursing the RN stated .She (Resident #1) never said (CNA #2) hit her to me. Said she was rough and rude and I took that to mean bossy. I personally felt no harm came out of it. I did full body check and no marks except her usual stuff, nothing new . Interview with the Administrator on 9/25/8 at 11:15 AM in the conference room when asked if (RN #2) was to report the allegation/suspicion of abuse alleged involving Resident #1 on 9/16/18 to the Administrator or designee, the Administrator stated .should have been reported to me the morning of 9/16/18 .",2020-09-01
743,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2018-09-25,610,D,1,0,YCKB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility documentation and interview, the facility staff failed to thoroughly investigate a suspicion/allegation of abuse to the Administrator or designee for 1 of 3 residents (Resident #1) reviewed for abuse. The findings include: Review of the facility policy, Abuse Prevention Program, updated 1/19/17, revealed .It is the policy of this facility to prevent abuse .The following Procedures shall be implemented when an employee or agent becomes aware of abuse .or of an allegation of suspected abuse .Procedure .The Charge Nurse must complete an incident report and obtain written, signed and dated statement from the person reporting the incident. A completed copy of the incident report and written statements from witnesses, if any, will be provided to the Administrator .within twenty-four (24) hours of the occurrence of such incident .Upon learning of the report, the Administrator or .the person in charge of the facility shall initiate an incident investigation Investigation .For any incident involving suspicion of abuse .the Administrator or person appointed .will gather further facts prior to making a determination conduct an abuse investigation .Once the Administrator or designee determines there is a reasonable cause for suspected abuse, the Administrator or designee will investigate the allegation The final report shall include facts determined during the process of the investigation, review of the medical records, personnel files and interview of witnesses. The final investigation shall also include a conclusion of the investigation based on known facts . Medical record review revealed Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum (MDS) data set [DATE] revealed Resident #1 had minimal difficulty hearing, had clear speech, could make herself understood, could understand others; scored 9 out of 15 on the Brief Interview for Mental Status, indicating moderate cognitive impairment; exhibited no [MEDICAL CONDITIONS], or behaviors; exhibited feeling down/depressed 2-6 days of the review period; exhibited little interest/pleasure, sleep issue, and concentration issue for 7-11 days of the review period; exhibited change in energy for 12-14 days of the review period; required extensive 2+ person assistance for bed mobility, dressing, toileting; total dependence with 2+ person assistance for transfers, hygiene and bathing; was always incontinent bowel and bladder; and received antianxiety, antidepressant and diuretic medication for 7 days of the review period. Medical record review of the Physician Orders revealed the following: From 6/23/18 to the present [MEDICATION NAME] HCL ER ([MEDICATION NAME]-antidepressant) 150 milligrams by mouth 1 time a day for depression. On 8/13/18 [MEDICATION NAME] ([MEDICATION NAME]-antianxiety) 0.5 milligrams by mouth 3 times a day for anxiety. On 8/19/18 Discontinue [MEDICATION NAME] 0.5 milligrams by mouth 3 times a day for anxiety. On 8/19/18 Restore [MEDICATION NAME] back to 1 milligram by mouth three times daily, note in chart GDR (Gradual Dose Reduction) failure. On 8/20/18 [MEDICATION NAME] 1 milligram by mouth three times a day related to anxiety disorder. Medical record review of the (MONTH) and (MONTH) (YEAR) Medication Administration Records revealed the medications noted above were administered as ordered. Behavior monitoring for the antianxiety mediation was done every shift with no documentation of a behavior during (MONTH) and (MONTH) (YEAR). Medical record review of the physician orders dated 9/12/18 revealed .Check UA (urinalysis) . Medical record review of the Urinalysis, Culture and Sensitivity laboratory results dated [DATE] the UA revealed .SL (slightly) cloudy .Many Bacteria . indicating possible urinary tract infection. Further review revealed on 9/15/18 the Culture and Sensitively result .Escherichia Coli (EColi) and Extended Spectrum B-Lactamase (ESBL) . indication the resident had a urinary tract infection requiring contact isolation. Medical record review of the physician orders dated 9/13/18 revealed .Contact Isolation for ESBL until antibiotics complete . Further review of the physician orders dated 9/16/18 revealed [MEDICATION NAME] (antibiotic) 100 milligrams by mouth two times daily times 10 days for Urinary Tract Infection. Medical record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The facility reported an allegation of abuse occurring on 9/15/18 at 1:00 AM involving Resident #1 and a staff member. Review of the staffing assignments for 9/15/18 for the 7:00 PM to 7:00 AM shift revealed Certified Nurse Aide (CNA) #1, #2, #3, #4, #6; Registered Nurse (RN) #2, and Licensed Practical Nurse (LPN) #1 were on duty. Review of the facility documentation revealed Resident #1 had responded to a questionnaire regarding the 9/16/18 allegation of abuse. Review of the facility Abuse Questionnaire completed by Resident #1 dated 9/17/18 revealed .Has staff, a resident or anyone else here abused you, this includes verbal, physical, financial or sexual abuse? .Yes. If Yes, ask who the abuser was, what happened, when it occurred, where it happened, and how often .'I got hit several times. Big hands, big fists.' Further review revealed the person had 'Short hair (blonde) large in posture. Hit her in her head, hit face. Chest hit her with a big hand & fist hit her hand several times happened-several months ago. did not happen Sat. (Saturday) or Friday-happened 6 mo (months) ago happened at night.' When asked Did you tell staff? Yes. Who did you tell? Told friends-Told nurses. Also included in the Questionnaire was a diagram of a person with No new bruises anywhere else. Review of facility documentation of the statement written by CNA #1 revealed .When I entered the room the tech (CNA #2) was turning patient (Resident #1) trying to clean her, the patient was yelling at tech to get away from her. The patient told me the tech was being rough with her and hurting her. The tech begin to argue with patient saying she didn't do anything to her. The patient became more agitated and told the tech if she hits her again she will get out of bed and whoop her . Review of the undated staff questionnaire completed by CNA #1 after the 9/16/18 event asking Do you know of any abuse? had NO. Review of facility documentation included the email dated 9/18/18 from CNA #2 to the facility revealed On Saturday the 15th of (MONTH) as I was giving care to (Resident #1) she was very agitated and aggressive, cursing and smaking (sic) at me refusing care and knocking her bedside table over all on table stuff was in floor (Resident #1) had been digging and playing in her bm (bowel movement) was trying to get out. Of bed I went immediately to the charge nurse (RN #2) and told her what was going on and ask the other tech (CNA #1) could she help me attend to (Resident #1) she agreed then the nurse asked us to switch patient and I did so. Further review revealed no interview with CNA #2. Review of facility documentation of the statement written by RN #2 revealed .CNA (#2) came to desk to ask other CNA (#1) for assist (with) pt (patient/Resident #1) because she was agitated. After CNA's provided care this nurse went in to (check) on pt. Pt agitated .Asked pt what was wrong pt stated 'I don't want her in here ever again' (described CNA #2). Asked pt why she didn't want her in there. Pt stated ' .she (CNA #2) just starts bossing me around-saying do this, do that, roll over .and if she ever hits me I'm gong to knock her block-off .' Asked pt has she ever hurt her. Pt stated 'No, but she doesn't have to be so bossy, I'm not going to put up with that, I don't want her in here anymore, she is just rough and rude' . Review of the staff questionnaire completed by RN #2 dated 9/18/18 asking Do you know of any abuse? had NO. Review of facility documentation of the statement written by RN #1 dated 9/17/18 revealed .(Resident #1's) daughter approached me in the hallway with a concern. Her mother had told her Saturday night there was a tech (CNA) smacking on her. She said it was a fat tech and that she kept smacking her. I did report immediately to ADON (Assistant Director of Nursing) /Abuse Coordinator (Administrator) @ (at) which time immediate actions were taken . Review of facility documentation of the undated staff questionnaire completed after the 9/16/18 event by CNA #3, #4, #6, and LPN #1 asking Do you know of any abuse? had NO. Telephone interview with CNA #1 on 9/24/18 at 11:47 AM revealed .I was charting at the nursing station when (CNA #2) came up to me and said (Resident #1) was agitated and she needed help .I walked down with her .and resident said 'You're rough with me, you hurt me' and (CNA #2) stepped back. Resident talk with me calm like and said (CNA #2) 'rough, hurt me' and 'I'll get out of bed if she hurts me again' and 'If you ever hit me again I'll whoop your ass.' (CNA #2) said 'I never hit you, just took care of you and cleaned you up.' They argued back and forth 'You hit me, no I didn't hit you' .I went to the nursing station and (CNA #2) there and said she already told the nurse what happened . Telephone interview with CNA #2 on 9/24/18 at 12:16 PM revealed .(Resident #1) was agitated .she was cursing, aggressive, combative, and not cooperative .so I went to the Charge Nurse (RN #2) and tell her what was going on and ask if another tech (CNA #1) to help me. The resident could be heard hollering .Both (CNA #1) and I went into the room .the resident turned over the bedside table onto herself in bed and all the stuff on it went everywhere, on her, on the floor, in the bed. It was a mess and resident agitated made it worse .She was hollering about being abused and I told her no one doing that or anything like that to her . Resident kept saying she was being abused .I went straight to nurse and told her resident said I was hitting her . Telephone interview with RN #2 on 9/24/18 at 4:38 PM and 5:28 PM revealed .around 2:00-3:00 AM, I think, (CNA #2) was doing rounds and came up to the desk and asked (CNA #1) to help her because (Resident #1) being agitated .After care (to Resident #1) both (CNAs) came out and told me about resident's statement .to (CNA #1) that (CNA #2) slapped her .I said I would go and talk with (Resident #1) myself. She was agitated. She never told me (CNA #2) hit her. I asked her if (CNA #2) had been hurt her and she 'no, just hateful, comes in here looking like a bulldog.' (Resident #1) said 'if she (CNA #2) does I'll knock her block off.' (Resident #1) did not tell me (CNA #2) hurt her in any way .(Resident #1) described (CNA #2) as 'blonde, bigger older lady.' She never said (CNA #2) hit her . Further interview revealed when asked why she did not report the allegation to the Administrator or the Director of Nursing the RN stated .She (Resident #1) never said (CNA #2) hit her to me. Said she was rough and rude and I took that to mean bossy. I personally felt no harm came out of it. I did full body check and no marks except her usual stuff, nothing new . Interview with Resident #1's daughter on 9/24/18 at 3:23 PM in the conference room revealed Resident #1 .complained of lady for past couple of weeks. Said 'she (Resident #1) didn't like her (CNA #2), (CNA #2) was rough with me, argues with me, I might have wanted something and press the call light and lady (CNA #2) comes in argues with me and turns call light off and leaves.' (Resident #1) said one night the CNA (#2) stuck her head in the door and said 'I heard you were talking about me, you need to stop talking about me.' I told Mom they don't need to be arguing with you and you not argue with them. She has dementia. This went on for a couple of weeks, then she calmed down for a week. Sunday I was here and she said '(CNA #2) slapped her and was rough with me last night . I told her 'Mom, tell me the truth, are you sure? Why would she slap you?' Mom said 'she was rough with me, I told her to stop and she slapped me. She's rough with me when she changes me and I don't like it.' I told her to tell me the truth and she said the same thing again. I told her it was Sunday and I can't do anything today. I checked her skin and there were no marks on her face. I checked her skin the next day but she bruises all the time anyway. I couldn't go by that .Mom told me was a heavy set red head .I ran into RN #1 up front .When I said a red head to RN #1 she didn't know that person name either. RN #1 said she would take care of it right now. RN #1 went to the Administrator and came back to me and the Administrator and ADON (Assistant Director of Nursing) .talked . Review of the facility documentation regarding the allegation of abuse on 9/16/18 revealed no evidence the UA was considered, the [MEDICAL CONDITION] medications adjusted in 8/2018 were considered, failed to have interview with staff on duty on 9/16/18 at 1:00 AM to 3:00 AM addressing the allegation, failed to have an interview with the alleged perpetrator and residents in the vicinity of the Resident #1, failed to have documentation of Resident #1's multiple interviews with different information, failed to have an interview with the family member reporting the allegation on 9/17/18 and clarifying the details, and failed to clarify why RN #2, CNA #1 and #2 answered No to the employee questionnaire asking Do you know of any abuse? Interview with the Administrator on 9/25/8 at 1:15 PM in the conference room when asked if the facility had the multiple interviews with the resident with different versions of the event, he stated No; if they had the staff interviews of all on duty and clarification of discrepancies, he stated No, but see where should have; if there was an interview with the reporting family member for clarification of information, he stated No; if there were interviews with residents in the vicinity of the event for information, he said No; for there was a medication review considering [MEDICAL CONDITION] medication had recently been changed, he said NO; and if the laboratory results of urinary tract infection was considered to contribute, he said NO.",2020-09-01
1070,SIGNATURE HEALTHCARE OF ELIZABETHON REHAB & WELLNE,445217,1200 SPRUCE LANE,ELIZABETHTON,TN,37643,2018-11-07,558,D,1,1,3QH211,"**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 accommodate the request to transfer to bed timely for 1 resident (#49) of 3 residents reviewed for activities of daily living needs of 28 residents reviewed. The findings include: Review of the facility's policy Answering Call Light, undated, revealed .If you have promised the resident you will return with the item or information, do so promptly . Medical record review revealed Resident #49 was admitted to the facility on [DATE] and discharged home on[DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data set ((MDS) dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was independent with daily decision making, and required extensive assistance of 2 persons with transfers. Review of facility documentation revealed on 10/18/18 at approximately 6:15 PM the resident had requested Certified Nursing Assistant (CNA) #1's assistance to transfer to the bed. Continued review of facility documentation revealed CNA #1 told the resident she would return to assist the resident to transfer to bed after picking up dinner trays from the residents on the hall. Continued review of facility documentation revealed CNA #1 forgot to return to Resident #49's room to assist her to bed and when CNA #1 returned to the resident's room to put her to bed the resident was mad. Interview with the Director of Nursing on 11/5/18 at 1:45 PM, in the conference room, revealed it was approximately 45 minutes to an hour before the resident's request/need for transfer to the bed was completed. Further interview confirmed the resident's need was not met in a timely manner. Telephone interview with CNA #1 on 11/6/18 at 4:05 PM, revealed Resident #49 had requested assistance to transfer to bed on 10/18/18 at approximately 6:15 PM, and CNA #1 told the resident she would return after picking up dinner trays. Continued interview revealed CNA #1 had forgotten about the resident's request for assistance to bed and confirmed it was approximately an hour before CNA #1 returned to the resident's room to assist the resident to bed.",2020-09-01
3264,WEST HILLS HEALTH AND REHAB,445501,6801 MIDDLEBROOK PIKE,KNOXVILLE,TN,37919,2018-03-28,558,D,1,1,CYTG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility documentation, observation, and interview, the facility failed to answer the call light in a timely manner for 2 residents (#61 and #9) of 40 residents reviewed. The findings included: Review of the facility policy Resident Rights, undated, revealed .It is our belief that you as a resident have the right to expect certain standards of care and considerations while at our facility. You have the right to: 1. Expect reasonable responses to requests for services within our capacity . Medical record review revealed Resident #61 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 (cognitively intact) on the Brief Interview for Mental Status. Further review revealed the resident was independent with daily decision making, required extensive assistance of 2 persons with bed mobility, and had limitation in range of motion on 1 side upper and lower extremities. Interview with Resident #61 on 3/26/18 at 3:35 PM, in the resident's room, revealed a few weeks ago he and his roommate turned on the call light during the night. Further interview revealed Resident #61 wanted assistance with repositioning and a staff member told him and his roommate (Resident #9) they were using the call light too frequently. Continued interview revealed on the night in question it took about an hour for the call light to be answered. Further interview revealed the resident was unable to reposition in bed without assistance. Medical record review revealed Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #9 (Resident #61's roommate) on 3/26/18 at 2:24 PM, in the resident's room, revealed a few weeks ago on the night shift the resident placed his call light on because he needed a clean brief. Further interview revealed the call light was answered by a nurse, approximately an hour after turning the call light on, and the nurse told him he was on the call light. Interview with the Interim Director of Nursing (DON) on 3/28/18 at 10:55 AM, in the DON's office, confirmed call lights should be answered within 5 minutes.",2020-09-01
2512,ETOWAH HEALTH CARE CENTER,445422,"409 GRADY ROAD, PO BOX 957",ETOWAH,TN,37331,2017-05-03,323,D,1,1,5KJC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility interview documentation, observation, and interview, the facility failed to use safe transfer techniques for 1 resident (#66) of 28 residents reviewed. The findings included: Review of the facility policy Guidelines for Resident Transfers dated 11/16/12, revealed, The purpose of these guidelines is to provide .a guide in selecting the appropriate means for transferring a resident in order to maintain residents current functional transfer skill and proper techniques to perform task .Once the resident is assessed for transfers, the appropriate transfer technique will be selected for the resident .Failure to follow these guidelines and using appropriate transfer technique for residents will result in (discipline) . Medical record review revealed Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's current ongoing plan of care with an effective date of 1/17/16 revealed .Interventions .Extensive assist with transfers. Assist PRN (as needed) . Further review revealed the plan of care did not indicate the transfer technique to be used to assist in transferring the resident. Review of the facility document Residents Who Require a Mechanical Lift dated 9/7/16, revealed the document was a list of residents who were to be transferred with use of a mechanical lift and the size sling to be used for each resident. The document indicated Resident #66 required a mechanical lift with a medium sling for transfers. Medical record review of the resident's Quarterly Minimum Data Set assessment dated [DATE] revealed the resident's Brief Interview for Mental Status was 4, indicating the resident was severely cognitively impaired; the resident required extensive assistance of more than two persons for transfers; required extensive assistance for locomotion; and the resident used a wheelchair for mobility. Review of facility interview documentation dated 12/14/16 at 2:40 PM, revealed Certified Nursing Assistant (CNA) #6 stated CNA #1 and CNA #4 had transferred the resident to the wheelchair using a gait belt. Observation and interview with Resident #66 on 5/1/17 at 12:50 PM, in the resident's room, revealed the resident was sitting up in her wheelchair, was not able to answer simple yes and no questions, and had no apparent bruising or injuries. Interview with CNA #2 on 5/2/17 at 2:15 PM, on the C hall, revealed the CNA had transferred the resident to bed on the nights of 12/10/16 and 12/11/16 with CNA #3. Continued interview revealed CNA #2 transferred the resident to the bed from her wheelchair with CNA #3 with a two person transfer. Further interview with CNA #2 confirmed the CNAs had not used a mechanical lift when transferring the resident on 12/10/16 and 12/11/16. Interview with CNA #4 on 5/3/17 at 8:10 AM, on the A hall, revealed CNA #4 worked with Resident #66 on 12/11/16 and transferred the resident with CNA #5 using a gait belt, and not a mechanical lift. Interview with the Director of Nursing (DON) on 5/3/17 at 9:00 AM, in the DON's office, confirmed the resident assessments indicated the resident needed to be transferred utilizing a mechanical lift since 9/7/16. The DON confirmed staff had not been utilizing the appropriate safe transfer techniques for the resident when completing transfers with a gait belt instead of a mechanical lift.",2020-09-01
3386,NASHVILLE CENTER FOR REHABILITATION AND HEALING LL,445512,832 WEDGEWOOD AVENUE,NASHVILLE,TN,37203,2017-09-27,223,G,1,0,9IDG11,"**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 ensure residents remained free from verbal abuse for 1 resident (#17) and neglect for 1 resident (#24) of 22 residents reviewed resulting in HARM for Resident #17 and #24. The findings included: Review of facility policy, Abuse, undated revealed the definition of abuse included it was a willful infliction of injury resulting in physical harm, pain or mental anguish. The abuse should be reported immediately to the charge nurse. The charge nurse was to assure the resident was safe and any needed medical interventions for the resident had been obtained, the charge nurse was to report the Administrator, the Director of Nursing, the physician and the family. Medical record review revealed Resident #17 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 9/5/17 Quarterly Minimum Data Set (MDS) revealed the Brief Interview for Mental Status (BIMS) score was 15 out of 15, indicating the resident was cognitively intact. Review of a facility investigation dated 9/5/17 revealed an allegation of a verbal confrontation between Resident #17 and Certified Nurse Aide (CNA) #7. Continued review revealed the resident overheard CNA #7 talking disrespectfully about the resident and confronted the CNA and an argument ensued. The CNA allegedly raised her voice, used profanity and spoke disrespectfully to the resident and reportedly attempted to relocate the patient to her room against her will. Further review of the facility investigation revealed the Director of Nursing (DON) was notified and CNA #7 was dismissed for conduct that was unprofessional and disrespectful. Review of a witness statement by Resident #17 dated 9/5/17 at 10:45 PM revealed the resident heard CNA #7 talking about her and the CNA and the resident started arguing. Continued review revealed the CNA grabbed the resident's wheelchair and started pushing her real hard and fast down the hall. The resident did not want to go down the hall and grabbed the wooden rail on the wall. Review of a witness statement by Registered Nurse (RN) #6 dated 9/5/17 revealed CNA #7 and Resident #17 were arguing in the hall. The CNA grabbed the resident's wheelchair and proceeded to push her to her room. The resident told CNA #7 to stop and not to touch her or the wheelchair. Continued review revealed the CNA went over to the nurse's station and was speaking about the resident using profanity. CNA #7 totally disrespected the resident. Review of a witness statement by CNA #9 dated 9/5/17 revealed CNA #7 was heard talking loudly to Resident #17 in the hall. She observed CNA #7 behind the resident's wheelchair while the resident was holding onto the railing on the wall to prevent CNA #7 from pushing her down the hall. Interview with Resident #17 on 9/26/17 at 11:30 AM on the 500 unit hall revealed the resident had an argument with CNA #7. She stated they yelled at each other, then the CNA pushed the resident's wheelchair down the hall against her will. Continued interview revealed the resident stated she held onto the rail on the wall. Resident #17 stated the CNA was fired. The resident stated all the other staff were respectful and accommodating. Interview with the Administrator on 9/26/17 at 12:45 PM in the DON office confirmed the staff to resident abuse on 9/5/17 for Resident #17 had occurred according to the resident and witness statements. The staff to resident abuse resulted in HARM for Resident #17. Medical record review of Resident #24 revealed the resident was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 4/19/17 revealed the resident required assistance with activities of daily living (ADLs), had a suprapubic catheter due to [MEDICAL CONDITION] Bladder, [MEDICAL CONDITION], Overactive Bladder, and Bowel Incontinence. Further review revealed the resident was at risk for developing skin breakdown related to impaired mobility, occasional suprapubic catheter leakage and occasional bowel incontinence. There was no skin breakdown included on the Care Plan and no specific interventions to address the resident's needs to prevent skin breakdown. Medical record review of the Quarterly MDS dated [DATE], revealed the BIMS score was 15 out of 15, indicating the resident was cognitively intact. Continued review revealed the resident required extensive assistance to total dependence for ADL except for eating. Continued review revealed the resident was always incontinent of bowel and had a catheter for the bladder. The assessment indicated the resident had no skin integrity concerns. Interview with Resident #24 on 9/26/17 at 10:15 AM in her room revealed the staffing was low. Continued interview with the resident revealed the CNAs had told her they could not get her up due to not enough staff and stated last night (9/25/17) at 10:00 PM she had been incontinent of stool and her indwelling urinary catheter had a large amount of leakage. Resident #24 stated CNA #8, while cleaning the resident, informed the resident she would only clean her up once during the night shift. Further interview with the resident revealed she did not get checked or changed until the dayshift when CNA #5 came in this morning at 7:30 AM and changed and repositioned her. Resident #24 stated the CNA told her she was still dirty on her buttocks. Interview with CNA #5 on 9/26/17 at 10:30 AM on the 500 unit hall revealed Resident #24 was drenched with urine and stool when he went to change her at 7:30 AM today. Continued interview revealed there was a large amount of stool and urine that was almost the consistency of mud. The resident told him what CNA #8 had told her last night, about only clean(ing) her up once during the night shift, and that no one had checked or changed her since 10:00 PM the previous night. CNA #5 continued to state he changed and repositioned the resident, then reported the resident's condition to Registered Nurse (RN) #4. He stated he did not tell the RN what CNA #8 said to Resident #24, about only clean(ing)her up once during the night shift. Further interview with CNA #5 revealed the resident had an indwelling urinary catheter that consistently leaked urine, her buttocks and the back of her thighs were red and there had been an open area on the back of the upper left thigh for a week. Interview with RN #4 on 9/26/17 at 10:35 AM on the 500 unit hall revealed CNA #5 had reported the resident's condition at 8:00 AM this morning. Upon the request of the surveyor, the RN went to assess Resident #24's skin condition. Observation with RN #4 revealed an open area on the left upper thigh with some slough and the buttocks and thighs bilaterally were very red and unblanchable. Interview with RN #4 revealed the Wound Nurse took care of those type of things. Continued interview with RN #4 confirmed she was unaware the resident had any open areas or skin integrity issues and stated CNA #5 had reported the resident's condition to her at 8:00 AM, and she had not reported anything to anyone else .was going to report it, just not immediately. RN #4 confirmed she did not assess the resident until the surveyor's request. RN #4 confirmed the resident .did not get up in the chair because there was not enough staff .the staff were aware the indwelling urinary catheter consistently leaked. Interview with the Assistant Director of Nursing (ADON) on 9/26/17 at 12:15 PM in the Director of Nursing's office revealed RN #4 reported the incident regarding Resident #24 at about 11:00 AM today. She confirmed RN #4 should have reported the incident immediately and that CNA #5 should have reported what CNA #8 said to the resident. Resident #24 did not receive care for 9 1/2 hours resulting in neglect and HARM",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
4772,CREEKSIDE CENTER FOR REHABILITATION AND HEALING,445516,306 W DUE WEST AVENUE,MADISON,TN,37115,2016-08-11,280,D,1,0,S2LI11,"**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 follow the resident's care plan resulting in a fall for 1 resident (#1) of 3 residents reviewed for falls. The findings included: Review of facility policy, Falls Management, revealed .the facility strives to reduce the risk for falls and injuries by promoting the implementation of the Risk Reduction: Falls and Injuries Programs. Residents are assessed for the fall risk factors. The interdisciplinary team works with the residents and family to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence . Medical record review revealed Resident #1 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 #1 scored 15/15 on the Brief Interview for Mental Status indicating he was alert, oriented, and could make his wants known. Continued review of the MDS revealed Resident #1 required extensive assistance of 2 people for bed mobility and transfers; and was dependent on 1 person for bathing. Further review revealed Resident #1 was always incontinent of bowel and bladder. Medical record review of the Certified Nursing Aide's (CNA) care card dated 10/23/15, in use on 7/5/16, revealed .2 staff members needed for bed mobility. Resident is difficult to turn and is unable to assist with turning. Resident has rigid body position r/t (related to) [MEDICAL CONDITION] . Medical record review of the Care Plan dated 6/24/16 revealed a problem of Resident requires assist with ADLs (Activities of Daily Living) with approaches including .Extensive assist of 2 for bed mob (mobility) . Medical record review of the care plan problem with the onset date of 6/6/14 and updated on 7/5/16, revealed a problem of .I am at risk for falls d/t (due to) weakness, [MEDICAL CONDITION], communication deficit, vision deficit, medications that increase risks, hx (history) of previous falls, incontinence .7/5/16 Fall . with approaches including .Mat to floor beside bed for prevention of serious injury r/t falls. Fall risk assessment completed and reviewed quarterly and prn (as needed) .7/5/16 .CNA training, 2 person assist . Review of the facility investigation dated 7/5/16 at 12:11 PM revealed .During bath time resident lost upward seated balance and required staff to physically assist him to floor to prevent fall. Skin tear right small toe. Small bruise to left upper arm. Bruises bilaterally to inner thighs . Review of Post-Incident Actions dated 7/5/16 revealed .Per CNA resident was being bathed on bed and began to lose his balance leaning over to his left side and needed to be assisted to floor to prevent him from falling from bed . with immediate post-incident action to .utilize 2 technicians during bath time to assist with balance and mobility . Review of the Employee Investigation Interview Form completed by the nurse to whom the incident was reported and dated 7/5/16, revealed .Called to rm (room) .by (CNA #1) that resident was in floor at BS (bedside). Upon entering rm noted resident lying on floor on right side noted resident to have a sm (small) skin tear to right sm toe noted a sm bruise on left upper arm also bilateral groin noted to be bruised. Resident lifted back to bed with lift sheet by 6 CNA . Review of a Personnel Consultation Form dated 7/5/16 revealed CNA #1 .was changing resident by herself. Care guide calls for 2 person assist with bed mobility . Interview with Resident #1 on 8/10/16 at 1:15 PM in the resident's room revealed the CNA was giving him a bath and rolled him over on his right side. Continued interview revealed she left him to answer a knock on the door and was not sure if she left the room or not. Further interview revealed he was so far over he started rolling and could not stop. Further interview revealed he was already on the floor when the CNA said Hold on then I'm in trouble now and 6 people picked him up and put him in bed. Continued interview revealed he hurt all over the next day. Interview with CNA #1 on 8/10/16 at 2:20 PM, on the Capitol(NAME)unit, revealed .I was giving (Resident #1) his bath and had turned him on his side facing the window .he began to shake and fell off the bed, landing on the floor on his right side . Further interview revealed it was her first time to care for him and she did not know he required 2 people for bed mobility. Continued interview revealed CNAs can find information on the amount of assistance residents need with ADLs in the computer on the care guide. Further interview revealed CNA #1 stated she did not look at the care guide before providing care for Resident #1 on 7/5/16. Interview with the Administrator on 8/10/16 at 3:35 PM, in the conference room, confirmed CNA #1 failed to follow the care guide and the facility policy to have another person to assist her with the resident, resulting in the resident falling out of bed onto the floor.",2019-08-01
3784,STARR REGIONAL HEALTH & REHABILITATION,445277,886 HWY 411 NORTH,ETOWAH,TN,37331,2017-02-22,155,D,1,0,IXF411,"**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 honor resident rights to refuse administration of a medication for 1 resident (#1) of 10 residents reviewed. The findings included: Review of the facility's policy titled Refusal of Treatment dated (MONTH) 2013, revealed .Our facility shall honor a resident's request not to receive medical treatment as prescribed by his or her physician .The resident is not forced to accept any medical treatment and may refuse specific treatment even though it is prescribed by a physician . 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 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. Medical record review of the physician's orders [REDACTED]. Medical record review of a nursing progress note dated 11/6/16, written by Licensed Practical Nurse (LPN) #2, revealed .new order for [MEDICATION NAME] 5 mg IM was received and given . Further review of the progress notes revealed LPN #2 documented [MEDICATION NAME] 5 mg IM was administered at 9:50 PM. Review of the note, documented by LPN #2, revealed the resident's response to the medication was .Still mad .refusal of meds . Review of a facility investigation witness statement dated 11/7/16, completed by the Occupational Therapist (OT), revealed the resident reported to the OT .after dinner he (Resident #1) was in dining room and the security guard told him he will be getting a shot because of his behaviors .(Resident #1) reported he was getting upset and said 'I'll take my pills but you are not giving me a shot.' (Resident #1) reported the nurse stated 'you're going to take that shot no matter what . Review of the facility's investigation revealed an interview was conducted by the Director of Nursing (DON) with Resident #1 on 11/7/16; .(Resident #1) stated he received a shot after refusing it from the nurse (LPN #2) .(Resident #1) stated nurse (LPN #2) came in and told him he was going to get a shot and he said he refused the shot . Continued review revealed Resident #1 stated the security guard and two Certified Nurse Aides (CNAs) were in the dining room when the nurse gave him the shot and he was trying to scoot out of the chair to get away from the shot. Review of the facility's investigation witness statement dated 11/7/16, completed by LPN #2, revealed .(LPN #2) called the physician and got an order for [REDACTED].#2) went and got two CNAs and the security guard and lifted the resident up in a semi-standing position so I could give him the shot .(resident) said he wasn't taking a shot .we just turned him up on to the right side so I could get the shot in the left hip . Review of the facility's investigation witness statement dated 11/8/16, completed by a Security Guard, revealed .after I returned from my rounds I was requested to assist with the shot .I went to the dining room where (Resident #1) was sitting .About 5-10 minutes later 3 nurses entered and told (resident) the doctor had ordered a shot .(the resident) became very upset and said he would take some pills but he wouldn't take a shot .the nurse was able to administer the shot in his left hip . Review of the facility's investigation witness statement dated 11/9/16, completed by CNA #4, revealed .(CNA #10) came to me and said (LPN #2) was ready to give (Resident #1) the shot .(LPN #2) told (Resident #1) she had a shot for him to calm him down .He stated he did not want the shot .(Resident #1) tried sliding out of the chair to get away from the shot .(LPN #2) stated to turn him up and she gave him the shot . Review of the facility's investigation written statement dated 11/9/16, completed by CNA #9, revealed .(Resident #1) was sitting in the dining room calmly when (LPN #2) came in .(Resident #1) immediately began swinging at the nurse and telling her he wasn't taking any shot but he would take a pill .(Resident #1) was tilted enough to administer the injection in his left hip . Medical record review revealed no documentation of distress by the resident and no changes in behavior or mood were noted. Review of a psychotherapy note on 11/10/16 revealed the resident was managing his chronic ongoing symptoms well and there was no change in his mental health. Interview with CNA #4 on 2/16/17 at 11:30 AM, in the Board Room, revealed CNA #10 asked CNA #4 to come help the nurse give the resident a shot and .(Resident #1) stated he didn't want the shot because he doesn't know what is in it . CNA #4 stated the security guard and CNA #9 assisted with positioning the resident for the shot administration. Interview with Resident #1 on 2/16/17 at 2:25 PM, in his room, revealed he .after getting out of bed I went to the nurses station and me and (LPN #2) had a few more words .(LPN #2) came in and told me she was giving me a shot to calm down and I told her I ain't taking no dern thing . Resident #1 stated LPN #2 administered the medication after he refused. Interview with CNA #9 on 2/21/17 at 7:15 AM, in the Board Room, revealed on the evening of 11/6/16, .(CNA #9) went into the dining room. (Resident #1) was watching TV and when (LPN #2) came in (Resident #1) said .you are not giving me a (expletive) shot .I'll take a pill . Interview with the Administrator and the DON on 2/22/17, at 11:15 AM, in the Board Room, confirmed LPN #2 did not follow the facility's policy related to refusal of treatment and administered the injection of [MEDICATION NAME] after the resident refused.",2020-02-01
2658,MT JULIET HEALTH CARE CENTER,445439,2650 NORTH MT JULIET ROAD,MOUNT JULIET,TN,37122,2017-06-07,431,D,1,0,W48711,"**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 maintain accurate medication reconciliation for narcotics for 1 resident (#4) of 3 residents reviewed for medication administration on 3 of 4 halls of 18 sampled residents. The findings included: Review of the facility's policy Controlled Drug Accountability Procedure dated 4/22/14 revealed .Each dose administered is to be signed out by the nurse on the controlled drug record and on the patient's eMAR (electronic Medication Administration Record) .The count of each controlled substance must be audited at every shift change by the nurse coming on duty and the nurse going off duty . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 scored 08/15 (severely cognitive impaired) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required limited assistance for transfer and hygiene/bathing with extensive assistance for dressing. Medical record review of a Patient Medication Profile (physician's recapitulation of Resident #4's medications), not dated, revealed on 7/23/16 a physician's orders [REDACTED].FENTANYL (pain medication) 25 MCG (micrograms) APPLY 1 PATCH TRANSDERMAL (through the skin) Q (every) 3 DAYS . Medical record review of the Administration History (computerized documentation system) of the Fentanyl Patch for Resident #4 revealed it was documented as given on 5/7/17, 5/13/17, and 5/16/17. Continued review revealed the dosage due on 5/10/17 was not documented as administered. Medical record review of the Controlled Drug Receipt/Record/Disposition Form (paper form) revealed the Fentanyl Patch was signed out on the controlled substance log and documented as administered on 5/7/17, 5/11/17, 5/13/17, and 5/16/17. Review of a facility investigation dated 5/30/17 revealed .(named nurse) on (MONTH) 11th, (YEAR) .signed out a Fentanyl Patch for a resident but did not document the administration in Vision (computerized system) . Interview with the Interim Director of Nursing (DON) on 6/5/17 at 3:25 PM, in the Social Services office, confirmed the facility signed the medication out on the narcotic controlled drug sheet, but failed to document the administrationof the medication in the electronic medication record and the facility failed to follow facility policy.",2020-09-01
15,ASBURY PLACE AT MARYVILLE,445017,2648 SEVIERVILLE RD,MARYVILLE,TN,37804,2018-01-18,602,E,1,0,GSLM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigation, and interview, the facility failed to prevent misappropriation of resident's medication for 5 residents (#1, #3, #4, #5, and #6) of 9 residents reviewed for abuse. The findings included: Review of the facility policy Resident Rights - Abuse of Residents revised [DATE] revealed, .any type of resident abuse .or misappropriation of resident property is strictly prohibited .misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful (temporary or permanent) use of a resident's belonging or funds without the resident's consent . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was moderately cognitively impaired. Medical record review of Resident #1's Physicians Orders revealed an order dated [DATE] for [MEDICATION NAME] (pain medication) 0.25 milliliters (ML) sublingual (under the tongue) as needed (PRN) every 1 hour for pain. Continued review revealed the order was discontinued on [DATE]. Further review revealed an order dated [DATE] for [MEDICATION NAME] 0.5 ml sublingual PRN every 3 hours as needed for pain. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #3 was moderately cognitively impaired. Medical record review of the Physician Orders revealed an order for [REDACTED]. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #4 expired on [DATE]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 3 indicating Resident #4 was severely cognitively impaired. Medical record review of the Physician Orders revealed an order dated [DATE] for [MEDICATION NAME] 0.25 ML orally every 2 hours as needed for pain. Continued review revealed the order was discontinued on [DATE]. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 2, indicating Resident #5 was severely cognitively impaired. Medical record review of the Physician Orders revealed an order dated [DATE] for [MEDICATION NAME] 0.25 ML sublingual every 4 hours as needed for pain. Continued review revealed the order was discontinued on [DATE]. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #6 expired on [DATE]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 0 (zero), indicating Resident #6 was severely cognitively impaired. Medical record review of the Physician Orders revealed an order dated [DATE] for [MEDICATION NAME] 0.25 ML orally every 4 hours as need for pain. Review of a facility investigation dated [DATE] revealed the facility became aware of a possible drug diversion at approximately 11:45 PM on [DATE]. Further review revealed during the narcotic count at shift change between 2nd and 3rd shift, Licensed Practical Nurse (LPN) #3 observed a vial of [MEDICATION NAME] prescribed for Resident #1, which appeared to have the tamper resistant seal altered. Continued review revealed the vial was full as if no medication had been administered. Further review revealed LPN #3 immediately notified LPN #2, the night shift supervisor, of her concern and at that time LPN #2 immediately notified the Director of Nursing (DON). Continued review revealed the vial of [MEDICATION NAME] was delivered to the facility the afternoon of [DATE] and Resident #1's Medication Administration Record [REDACTED]. Continued review revealed on [DATE] the DON began a facility wide investigation. Further review revealed during a narcotic audit the facility identified 3 additional residents' (#4, #5, and #6) vials of [MEDICATION NAME] were altered. Further review revealed, after reviewing the staffing assignment sheets and schedules, the facility was able to identify Registered Nurse (RN) #1 provided care to, and had access to, the residents' medications. Further review revealed on [DATE], during the facility's monthly narcotic waste, the DON and the Pharmacist found a vial of [MEDICATION NAME] prescribed for Resident #3, which had been placed in the narcotic waste bin after the order was discontinued on [DATE]. Continued review revealed the vial of [MEDICATION NAME] was noted to have been altered. Further review revealed the DON reviewed the staffing assignment sheets and RN #1 provided care to Resident #3 on [DATE], the day the [MEDICATION NAME] was discontinued. Review of the police report dated [DATE] revealed .responded to (facility) in reference to a theft of medication .advised (RN #1) .had stolen liquid [MEDICATION NAME] from four different residents at the facility. (RN #1) stole the medication .While on scene I observed a bottle of [MEDICATION NAME] that had been diluted .(RN #1) was subjected to a drug screen, in which the first sample showed invalid due to the temperature of the urine at the time. (RN #1) was subjected to a second drug screen, in which she tested positive for [MEDICATION NAME] . Continued review revealed RN #1 admitted to stealing the [MEDICATION NAME]. Review of the Urine Drug Screen Laboratory Report dated [DATE] revealed RN #1 was positive for [MEDICATION NAME]. Interview with RN #1 via phone on [DATE] at 10:33 AM, confirmed she had taken [MEDICATION NAME] from various residents over a two week period in (MONTH) (YEAR). Continued interview confirmed she was unable to identify the residents specifically. Interview with the DON on [DATE] at 9:16 AM, in the conference room, confirmed she was made aware of possible drug diversion on [DATE] at approximately 11:45 PM by LPN #2. Further interview confirmed LPN #2 reported the vial of [MEDICATION NAME] ordered for Resident #1 was delivered to the facility on [DATE], the tamper resistant seal showed signs of having been tampered with, and Resident #1's MAR indicated [REDACTED]. Continued interview confirmed during the course of their investigation the facility identified 4 additional residents (Residents #3, #4, #5, and #6) whose vials of [MEDICATION NAME] were altered. Further interview confirmed after reviewing the staffing assignment sheets and schedule, the facility was able to determine RN #1 provided care to the affected residents. Continued interview confirmed initially RN #1 denied having any knowledge of the altered [MEDICATION NAME] but eventually admitted to the misappropriation of the [MEDICATION NAME]. Further interview confirmed RN #1 was suspended on [DATE] and remained on suspension until being terminated on [DATE]. Interview with the DON on [DATE] at 10:10 AM, in the conference room, confirmed through the facility's investigation they were able to identify RN #1 had taken [MEDICATION NAME] from 5 residents (Residents #1, #3, #4, #5, and #6) and the facility had failed to prevent misappropriation of resident's medication.",2020-09-01
2074,SIGNATURE HEALTHCARE OF SOUTH PITTSBURG REHAB & WE,445343,201 EAST 10TH STREET,SOUTH PITTSBURG,TN,37380,2018-03-21,600,D,1,1,481X11,"**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 resident to resident physical abuse for 1 resident (#1) of 15 residents reviewed for abuse of 49 residents sampled. The findings included: Review of facility policy, Abuse, Neglect, and Misappropriation of Property, not dated, revealed .it is Signature's policy to prevent the occurrence of abuse .will be no tolerance for Abuse, Neglect, Exploitation of residents or the misappropriation of resident's property. The facility will investigate all allegations of Abuse, Neglect, Exploitation and Mistreatment of [REDACTED]. Medical record review revealed Resident #1 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored a 6 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident was resistive to care. Medical record review revealed Resident #11 was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE] revealed Resident #11 had short and long term memory loss and was severely impaired in decision making. Continued review revealed the resident did not have documented behaviors. Review of a facility investigation dated 3/6/18 revealed on 3/6/18 at 5:30 PM staff heard Resident #1 yell for help and when staff entered the resident's room, Resident #1 was lying on the floor under the sink and Resident #11 was standing over Resident #1 hitting him. Continued review revealed Resident #1 stated Resident #11 pushed him out of his wheelchair and started hitting him. Interview with the Director of Nursing (DON) and Assistant DON (ADON) on 3/13/18 at 11:40 AM, in the Medical Records office, revealed Resident #11 was the aggressor and shoved his roommate (Resident #1) out of his wheelchair onto the floor and was punching him. Continued interview revealed Resident #1 was removed from the room and Resident #11 was placed on 1 to 1 supervision until he was discharged to a psychiatric facility. Telephone interview with Licensed Practical Nurse (LPN) #5 on 3/14/18 at 2:55 PM, in the Medical Records office, revealed Resident #1 was on the floor under the sink and Resident #11 was standing over him not saying anything. Continued interview revealed Resident #1 stated Resident #11 pushed him out of his wheelchair. Interview with CNA #10 on 3/14/18 at 3:40 PM, in the Station 3 employee breakroom, revealed she responded to the incident and found Resident #1 lying on the floor under the sink. Continued interview revealed Resident #1 stated Resident #11 pushed Resident #1 out of his wheelchair. Interview with CNA #11 on 3/14/18 at 3:45 PM, in the Station 3 employee breakroom, revealed she was the first to the room after the altercation started and when she got to the room Resident #1 was lying on the floor and Resident #11 was sitting in a wheelchair holding the handles of Resident #1's wheelchair. In summary, Resident #11 willfully pushed Resident #1 out of his wheelchair and onto the floor, then Resident #11 started hitting Resident #1 until staff intervened.",2020-09-01
2532,CENTER ON AGING AND HEALTH,445424,880 SOUTH MOHAWK DRIVE,ERWIN,TN,37650,2018-06-06,609,D,1,0,D6NO11,"**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 report an allegation of abuse timely to the State Survey Agency for 1 resident (#1) of 3 residents reviewed for abuse of 12 sampled residents. The findings included: Review of facility policy Abuse Investigation and Reporting dated 12/2016, revealed .All reports of resident abuse, neglect, exploitation, and/or misappropriation of resident property shall be promptly reported to local, state and federal agencies .Policy Interpretation and Implementation .Reporting .1. All alleged violations involving abuse, neglect, exploitation, or misappropriation of property will be reported by the facility Administrator .to the following persons or agencies .a. The State licensing/certification agency responsible for surveying/licensing the facility .will be reported within two hours . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the care plan for Resident #1 dated 3/7/16 revealed the resident was care planned for impaired thought processes, delusions, and hallucinations. Further review revealed the resident was socially inappropriate, had disruptive behavior verbalizations, and made statements related to delusions and accusatory statements of sexual aggressive nature toward staff, family, and others. Medical record review of the resident's Minimum Data Set ((MDS) dated [DATE] revealed the resident scored an 8/15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). Review of a facility investigation dated 5/17/18 revealed the resident reported she had been raped by her brother while in the facility. Continue review revealed the resident stated .I was raped every time I go to the bathroom for the last [AGE] years . Further review revealed the resident was sent to the Emergency Department (ED) for a pelvic exam. Continued review revealed the Social Services Director (SSD) notified the Power of Attorney (POA) of the allegation and the POA stated the resident had been a long history of allegations of abuse toward various family members. Interview with the Administrator on 6/4/18 at 3:40 PM, in the Conference Room, revealed the facility reported the incident to the State Survey Agency on 5/22/18 (5 days later). Further interview confirmed the facility failed to report an allegation of abuse within 2 hours.",2020-09-01
1812,WYNDRIDGE HEALTH AND REHAB CTR,445304,456 WAYNE AVENUE,CROSSVILLE,TN,38555,2018-06-04,600,D,1,0,TNDX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigation, and interviews the facility failed to prevent abuse for 1 resident (#4) of 4 residents reviewed for abuse. The findings included: Review of the facility policy Abuse, Neglect, Misappropriation Protocol revised 2/18 revealed .establish a policy and procedure designed to prohibit abuse .Willful .means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Identify areas within the facility that may make abuse and/or neglect more likely to occur .and monitor these areas regularly . Medical record review revealed Resident #4 was admitted to the facility on [DATE], and discharged on [DATE], with the [DIAGNOSES REDACTED]. Review of Resident #4's Admission Minimum (MDS) data set [DATE], revealed a Brief Interview for Mental Status score of 7, indicating severe cognitive impairment. Further review revealed wandering behavior occurred 1 to 3 days during the look back period. Review of the facility investigation dated 5/5/18, revealed a resident (#3) became agitated with another resident (#4) when the resident was going through her belongs on the dementia unit. Continued review revealed Resident #3 who was agitated slapped resident (#4) on the cheek. Continued review revealed the residents were separated, emotional support given, and the agitated resident (#3) was placed on one-on-one observation with a staff member. Medical record review revealed Resident #3 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's Annual MDS dated [DATE] revealed a BIMS score of 0, indicating severe cognitive impairment. Review of a care plan dated 5/5/13 for Resident #3, revealed impaired mood/behavior/psychosocial well-being .has trouble concentrating, easily annoyed, increased anxiety .resistant to care at times .socially inappropriate behavior/altercations at times with other residents .remove as much distraction as possible .place in area where frequent observation is possible .alert staff to wandering behavior, provide diversional activities .remove from public area when behavior is unacceptable or inappropriate . Interview with Helper #1 on 6/1/18 at 8:48 AM, in the 100 hall dining room revealed she was working in the dining room when she heard the resident (#3) yelling get out of my room. Continued interview revealed Helper #1 went to the resident's her room to see who was in her room. (Resident #4) was standing over her trying to get her remote control. Continued interview revealed that was when (Resident #3) smacked her (#4) in the face. Continued interview revealed the remote control had been lying in (Resident #3's) lap and (Resident #4) was trying to take it. (Resident #3) just slapped her (Resident #4) on the face. Interview with LPN #2 on 6/1/18 at 9:05 AM, in the 100 hall dining room revealed she was the nurse working the unit the day of the altercation. Continued interview revealed, The helper called me and said that (Resident #3) was holding her remote and (Resident #4) tried to take it. (Resident #3) had slapped (Resident #4) in the face. I did a head to toe assessment on both residents. (Resident #4) did have a pink area on her face, but it faded quickly. She reported (Resident #3) had also pinched her neck, but I didn't see any marks on her neck. I didn't witness the event but it appeared (Resident #3) just reached up and slapped her because she was trying to take her remote. Interview with the Director Of Nurses on 6/4/18 at 4:00 PM, in the conference room confirmed Resident #3, had willfully slapped Resident #4 on the face.",2020-09-01
2192,HARRIMAN CARE & REHAB CENTER,445368,240 HANNAH ROAD,HARRIMAN,TN,37748,2018-04-11,600,D,1,0,IG0J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigation, and interviews, the facility failed to prevent abuse for 2 residents (#1 and #5) of 7 residents reviewed for abuse. The findings included: Review of the facility policy Abuse, Neglect and Misappropriation of Property last reviewed on 11/16/17 revealed .(facility) policy to prevent the occurrence of abuse .'Abuse' includes physical abuse .'willful' means non-accidental .Willful as used in the definition of 'Abuse' means the individual must have acted deliberately, not the individual must have intended to inflict injury or harm . Medical record review revealed Resident #1 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored a 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Medical record review of Resident #1's care plan dated 1/23/17 revealed .3/1/18 Resident to Resident altercation (Resident #1) slapped the bill of another residents ball cap and the other resident hit him . Medical record review revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #5 scored a 14 (cognitively intact) on the BIMS. Medical record review of Resident #5's care plan dated 11/24/17 revealed the following problems . 3/1/18 Res (resident) to res Altercation .(other resident) slapped the bill of (Resident #5's) ball cap and (Resident #5) slapped the (other) resident . Review of a facility investigation dated 3/1/18 revealed a witness statement completed by Certified Nursing Assistant (CNA) #12. Further review revealed .(Resident #1) was sitting at nurses station when (Resident #5) came up the hallway .(Resident #1) hit resident (Resident #5) on his hat (Resident #5) then hit (Resident #1) and (Resident #1) hit him (Resident #5) again . Continued review of a witness statement completed by CNA #13 revealed .I saw (Resident #1) hit (Resident #5) on the hat. (Resident #5) hit (Resident #1) back near his leg and (Resident #1) hit (Resident #5) once again on the hat/head again . Interview with the Director of Nursing on 4/9/18 at 12:22 PM, in the conference room, revealed Resident #1 and #5 were in a resident to resident altercation on 3/1/18. Interview with Resident #1 on 4/9/18 at 1:00 PM, in his room, revealed on 3/1/18 Resident #5 hit his wheelchair and then Resident #1 hit Resident #5's hat. Continued interview revealed Resident #5 hit his (Resident #1's) arm and he (Resident #1) then hit Resident #5 in his stomach. Interview with Resident #5 on 4/9/18 at 3:25 PM, in his room, revealed he was in an altercation with Resident #1 about a month ago. Further interview revealed Resident #1 hit Resident #5 on his hat and Resident #5 then hit Resident #1 on his arm. In summary, the facility failed to prevent a resident to resident altercation between Resident #1 and Resident #5 on 3/1/18.",2020-09-01
1155,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2019-05-15,610,D,1,1,NCUY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigation, observation and interview, the facility failed to complete a thorough investigation of an allegation of sexual abuse involving Resident #41. The findings include: Facility policy review Freedom of Abuse, Neglect, and Exploitation dated 11/2017 revealed .this facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse, corporal punishment, involuntary seclusion or misappropriation of resident property by any facility staff member, other residents, consultants, volunteers staff of other agencies service the resident, family members, legal guardians, friends, or other individuals All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint, allegation, observation or suspicion of resident abuse, mistreatment or neglect so that the resident's needs can be attended to immediately and investigation can be undertaken promptly . Facility policy review Resident Rights and Dignity Management dated (MONTH) (YEAR), revealed, .the facility is responsible for the actions of its employees including intentional acts by employees who are aware they are doing something wrong and are in conflict with the facility's policies and procedures . Medical record review revealed Resident #41 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #41's Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. Continued review revealed the resident was totally dependent of two or more staff for toilet use and bathing. Continued review revealed the resident was always incontinent of bladder and bowel. Medical record review of Resident #41's comprehensive care plan dated 4/16/16 and revised 5/24/18 revealed .resident is followed by psych (psychiatric) services for [MEDICAL CONDITION], Anxiety Disorder and [MEDICAL CONDITION] with disturbance of mood and behavior . Review of CNA #4's employee file revealed no concerns with abuse education/training. Continued review revealed CNA #4 was not listed on the abuse registry. Continued review revealed CNA #4 had no previous disciplinary actions regarding abuse/abuse reporting. Continued review revealed CNA #4 was suspended on 5/7/19 for failure to report an allegation of rape. Review of the facility's investigation dated 5/6/19 concerning abuse involving Resident #41 revealed a statement from Certified Nurse Aide (CNA) #4 stating a few months ago Resident #41 alleged she (CNA #4) raped her when she performed perineal care on Resident #41. Continued review revealed the facility suspended CNA #4 related to not reporting the allegation. Continued review of the facility's investigation revealed no reporting to the State Agency of the allegation of rape/sexual abuse for Resident #41. Observations and interview with residents during initial tour on 5/13/19 revealed no concerns with abuse/neglect or resident rights. Interviews with various staff on 5/13/19 and 5/14/19 at various times revealed no concerns with abuse/neglect or resident rights. Continued interview with staff revealed no concerns with staff training of abuse/neglect or resident rights or reporting of abuse. Interview with Resident #41 on 5/13/19 at 10:06 AM revealed when asked of reporting to a Certified Nurse Aide she was raped, she recalled no incident of rape or being touched inappropriately. Continued interview revealed Resident #41 reported no concerns with abuse; she stated I just wanted the tech to stop drying my ears. Telephone Interview with CNA # 4 on 5/14/19 at 4:58 PM she stated a while back maybe 1 and 1/2 months ago when we were doing peri-care (perineal care) on her (Resident #41), she stated we were raping her; I told her we were doing peri-care on her and that was it. Continued interview she stated she (Resident #41) just said 'oh you're raping me', we continued her care and repositioned her and she was fine. Continued interview when asked about training on abuse she stated I was supposed to report it but at the time she (Resident #41) was seeing cats and other things, and there were no cats in her room and I didn't think anything of it; I was suspended and coached for not reporting that the resident stated we raped her. Interview with the Staffing Coordinator on 5/15/19 at 8:28 AM in the dining room revealed CNA #4 was suspended and re-educated on abuse/reporting of abuse, bathing technique, showering and customer service prior to returning to work. Interview with the Director of Nursing on 5/15/19 at 8:40 AM in her office revealed during the investigation of another allegation of staff abuse involving Resident #41, CNA #4 stated Resident #41 had alleged sexual abuse/rape. Continued interview revealed CNA #4 stated the allegation of rape happened months ago (date unknown) while CNA #4 was performing perineal care on Resident #41. Continued interview revealed CNA #4 did not report the allegation to anyone. Continued interview revealed the allegation of sexual abuse was not reported to the state she stated we had no evidence or suspicion this happened and we did not report it to the state; it should have been, we had a lot going on that day. Continued interview revealed any allegation should be reported immediately and an investigation initiated. Continued interview revealed CNA #4 was suspended and re-educated prior to returning to work. Interview with the Administrator on 5/15/19 at 9:04 AM in her office revealed during the an investigation of an allegation of staff to resident abuse involving Resident #41 CNA #4 reported Resident #41 alleged she had been raped. Continued interview revealed CNA #4 stated the allegation of sexual abuse happened months ago and she did not report it. Continued interview revealed CNA #4 was suspended and educated on reporting allegations of abuse. Continued interview she stated I told her (CNA #4) that any allegation like this was to be reported immediately and I needed to know about it; it should have been reported immediately and an ivestigation begun. Continued interview when asked if this was reported to the state and an ivestigation initiated she confirmed no not the rape. Continued interview when asked if Resident #41 was interviewed concerning the incident she cofirmed I did not specifically ask her about the rape, I should have asked her but I didn't; when an allegation of sexual abuse is made we would report it within 2 hours and begin an investigation and I did not.",2020-09-01
1154,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2019-05-15,609,D,1,1,NCUY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigation, observation and interview, the facility failed to report an allegation of sexual abuse for Resident #41. The findings include: Facility policy review Freedom of Abuse, Neglect, and Exploitation dated 11/2017 revealed .this facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse, corporal punishment, involuntary seclusion or misappropriation of resident property by any facility staff member, other residents, consultants, volunteers staff of other agencies service the resident, family members, legal guardians, friends, or other individuals .All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint, allegation, observation or suspicion of resident abuse, mistreatment or neglect so that the resident's needs can be attended to immediately and investigation can be undertaken promptly .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, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law . Facility policy review Resident Rights and Dignity Management dated (MONTH) (YEAR), revealed .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life .Staff to Resident abuse .the facility is responsible for the actions of its employees including intentional acts by employees who are aware they are doing something wrong and are in conflict with the facility's policies and procedures . Medical record review revealed Resident #41 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #41's Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. Continued review revealed the resident was totally dependent of two or more staff for toilet use and bathing. Continued review revealed the resident was always incontinent of bladder and bowel. Medical record review of Resident #41's comprehensive care plan dated 4/16/16 and revised 5/24/18 revealed .resident is followed by psych (psychiatric) services for [MEDICAL CONDITION], Anxiety Disorder and [MEDICAL CONDITION] with disturbance of mood and behavior . Review of the facility's investigation dated 5/6/19 concerning abuse involving Resident #41 revealed a statement from Certified Nurse Aide (CNA) #4 stating a few months ago Resident #41 alleged she (CNA #4) raped her when she performed perineal care on Resident #41. Continued review revealed the facility suspended CNA #4 related to not reporting the allegation. Continued review of the facility's investigation revealed no reporting to the State Agency of the allegation of rape/sexual abuse for Resident #41. Review of CNA #4's employee file revealed no concerns with abuse education/training. Continued review revealed CNA #4 was not listed on the abuse registry. Continued review revealed CNA #4 had no previous disciplinary actions regarding abuse/abuse reporting. Continued review revealed CNA #4 was suspended on 5/7/19 for failure to report an allegation of rape. Observations and interview with residents during initial tour on 5/13/19 revealed no concerns with abuse/neglect or resident rights. Interviews with various staff on 5/13/19 and 5/14/19 at various times revealed no concerns with abuse/neglect or resident rights. Continued interview with staff revealed no concerns with staff training of abuse/neglect or resident rights or reporting of abuse. Interview with Resident #41 on 5/13/19 at 10:06 AM in her room revealed when asked of reporting to a CNA she was raped, she recalled no incident of rape or being touched inappropriately. Continued interview revealed Resident #41 reported no concerns with abuse; she stated I just wanted the tech to stop drying my ears. Telephone Interview with CNA #4 on 5/14/19 at 4:58 PM she stated a while back maybe 1 and 1/2 months ago when we were doing peri-care (perineal care) on her (Resident #41), she stated we were raping her; I told her we were doing peri-care on her and that was it. Continued interview she stated she (Resident #41) just said 'oh you're raping me', we continued her care and repositioned her and she was fine. Continued interview when asked about training on abuse she stated I was supposed to report it but at the time she (Resident #41) was seeing cats and other things, and there were no cats in her room and I didn't think anything of it; I was suspended and coached for not reporting that the resident stated we raped her. Interview with the Staffing Coordinator on 5/15/19 at 8:28 AM in the dining room revealed CNA #4 was suspended and re-educated on abuse/reporting of abuse, bathing technique, showering and customer service prior to returning to work. Interview with the Director of Nursing on 5/15/19 at 8:40 AM in her office revealed during the investigation of another allegation of staff abuse involving Resident #41, CNA #4 stated Resident #41 had alleged sexual abuse/rape. Continued interview revealed CNA #4 stated the allegation of rape happened months ago (date unknown) while CNA #4 was performing perineal care on Resident #41. Continued interview revealed CNA #4 did not report the allegation to anyone. Continued interview revealed the allegation of sexual abuse was not reported to the state. Continued interview she stated we had no evidence or suspicion this happened and we did not report it to the state; it should have been, we had a lot going on that day. Continued interview revealed any allegation should be reported immediately. Continued interview revealed CNA #4 was suspended and re-educated prior to returning to work. Interview with the Administrator on 5/15/19 at 9:04 AM in her office revealed during the investigation of an allegation of staff to resident abuse involving Resident #41, CNA #4 reported Resident #41 alleged she had been raped. Continued interview revealed CNA #4 stated the allegation of sexual abuse happened months ago and she did not report it. Continued interview revealed CNA #4 was suspended and educated on reporting allegations of abuse. Continued interview confirmed I told her (CNA #4) that any allegation like this was to be reported immediately and I needed to know about it; it should have been reported immediately. Continued interview when asked if this was reported to the state she confirmed no not the rape; when an allegation of sexual abuse is made we would report it within 2 hours and begin an investigation and I did not.",2020-09-01
1497,LAUGHLIN HEALTH CARE CENTER,445264,801 E MCKEE ST,GREENEVILLE,TN,37743,2018-07-21,867,J,1,0,X9GP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigation, review of Quality Assurance and Performance Improvement (QAPI) Committee meeting documentation, and interview, the QAPI committee failed to identify and correct quality deficiencies resulting in an avoidable elopement in which Resident #1 exited the facility, while wearing a wander guard, fell down an embankment and received injuries to his body. The QAPI Committee's failure placed 1 resident (#1) of 16 residents reviewed for exit seeking behaviors 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 7/3/18 and is ongoing. The findings included: Review of the facility policy, Performance Improvement Plan dated 1/2002, revealed .Provide for a facility wide program that assure the facility designs processes well and systematically measures, assesses and improves its performance to achieve optimal resident health outcomes in a collaborative, cross-departmental, interdisciplinary approach. These processes include mechanisms to assess the needs and expectations of the residents and their families, staff and other. Assure that the improvement process is organizationwide (organization wide), monitoring, assessing and evaluating the quality and appropriateness of resident care and clinical performance to identify changes that will lead to improved performance and reduce the risk of sentinel events . Review of the facility policy, Elopement of Resident revised date 1/2007, revealed .Purpose: To locate as quickly as possible, prevent serious injury or exposure, to any resident that may have wandered away from the facility. To assess residents for the possibility of wandering beyond safe environment and need to wear secure care bracelet (wander guard alarm bracelet) . 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 last updated 11/18/17 and last reviewed on 11/22/17 revealed .Episodes of exit seeking. Episode of wandering when anxious .Wander guard to prevent from exiting building without anyone knowing . Medical record review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8 (moderate cognitive impairment). Continued review revealed the resident needed supervision for transfers and personal hygiene with 1 person assist, and was independent with ambulation. Medical record review of Resident #1's Quarterly Elopement Risk evaluation dated 5/30/18 revealed the resident was at risk for elopement and required continued use of a wander guard alarm bracelet. Review of a facility investigation of an incident that occurred on 7/3/18 revealed Resident #1 exited the facility through the front doors of the facility alongside 2 contracted landscapers. Further review revealed Resident #1 was wearing a wander guard, causing the alarm to sound as the resident exited the facility. Continued review revealed the Receptionist heard the alarm, left her desk and walked to the front lobby, looked out through the doors without exiting the building and because she did not see anyone, reset the alarm, and returned to her desk. Further review revealed one of the landscapers returned to the receptionist desk and reported he thought a resident had gotten out of a facility and had fallen down the embankment into the woods. Interview with the Receptionist on 7/11/18 at 10:20 AM, in the front hallway, revealed .I peeped through the doors and didn't see anyone so I reset the alarm . Interview with Unit Clerk #1 on 7/11/18 at 11:00 AM, in the conference room, revealed .we have a half a dozen or so (residents) on the east wing that wear wander guards .no one is actively exit seeking .most are just confused and might accidently go out the door .(Resident #2) goes to the door often and looks out .I try to keep a close eye on her . Interview with East Wing Manager (Registered Nurse) on 7/11/18 at 11:15AM, in the conference room, revealed .residents are at risk of elopement if they are actively exit seeking . Interview with the Administrator on 7/11/18 at 3:00 PM, in the Administrator's office, revealed .we have annual in-services for our employees and contract workers .we try to get as many contract workers to come as possible .no I don't think the landscape workers attended .we have signs on the doors telling our visitors to not let anyone out they don't know .she (Receptionist) saw a few people pass by then the alarm went off .she looked around and didn't see anything .turned the alarm off .no she did not go outside .probably been better if she had . Interview with the Director of Nursing (DON) on 7/12/18 at 1:00 PM, in the DON's office, revealed .we put new employees with a mentor in their department for 3-4 weeks until the new employee feels comfortable .a mentor is the person in each department that has worked here the longest .no formal orientation .the wing manager completes a checklist after 90 days for the nurses .Certified Nurse Assistants (CNA) train CNAs .have annual in-service .or if something comes up we may have a meeting . Interview with the Receptionist on 7/12/18 at 2:00 PM, in the front office, revealed .if the alarm sounds I respond .it's usually just a CNA pushing someone out or a family member, or therapy taking someone for a home evaluation, never had an elopement .no one ever told me to go outside and look around but looking back I should have . Interview with the Administrator on 7/17/18 at 1:15 PM, in the conference room, revealed .not sure we have covered that (to check outside when alarm sounds) in the annual in-service . Telephone interview with the Social Services Assistant on 7/18/18 at 3:25 PM revealed she conducted the Patient Rights/Ethics/Abuse in-service in (YEAR), but the in-service did not include training on resident elopement (Code Orange). Telephone interview with the Administrator on 7/18/18 at 3:30 PM revealed .yes we tell them to check the area where the alarm sounds and to go outside if they do not see anyone .not sure that is in writing anywhere . Interview with Unit Clerk #2 on 7/20/18 at 11:15 AM, in the West Wing Nurses' Station, revealed .have worked here [AGE] years .if they don't get up and walk but are at risk of elopement we put it (wander guard alarm) on the wheelchair . Interview with CNA #8 on 7/20/18 at 11:45 AM, in the West Wing Nurses' Station, revealed .during a Code Orange .they usually take one of our residents and hide them in (DON) office .have never gone outside to look for someone .usually by the time I know anything is going on (Administrator) is coming around to have us sign the paper (code orange participation log) .no additional information is shared at that time. Just sign the paper . Interview with the DON on 7/21/18 at 1:30 PM, in the conference room, confirmed the QAPI committee failed to ensure all staff were educated on the assessment of residents at risk for elopement and failed to recognize wander guards were utilized incorrectly for residents at risk of elopement. Refer to F-689",2020-09-01
326,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2017-09-08,224,D,1,0,HIQ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigation, review of personnel files, observation, and interview, the facility failed to prevent neglect of 1 resident (#1) of 3 residents reviewed for neglect. The findings included: Review of the facility policy, Care Rounding & Risk Prevention Continuous And Responsive Engagement Rounding Review, undated, revealed .Actively, not passively, provide care and do so continuously. Hourly rounding is not as important as continuous rounding that moves with purposeful intent .Round at shift change .Typically, a round includes checking on the status of the 4 Ps: Pain Assessment Potty (toileting) needs Positioning Possessions (in reach of the Resident, including call button) . Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the care plan dated 2/6/17 revealed .Reposition every 2 hours during the day when in bed or chair. Reposition during the night every 2 hours . Further review revealed the resident required supervision with transfer, mobility using a walker, bed mobility (and at times 1 staff support with bed mobility) and toileting. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Medical record review of the MDS, Functional Abilities dated 7/14/17 revealed bed mobility, transfer, and toilet use coded 2 (limited assistance); walk in room and corridor, locomotion on and off unit, dressing and personal hygiene coded 1 (supervision, oversight). Medical record review of the Medication Record for 8/2017 revealed .[MEDICATION NAME] 3 mg (milligrams) tablet- 1 tab by mouth at bedtime ([MEDICAL CONDITION]) .[MEDICATION NAME] 30 mg tablet- 1 tab by mouth at bedtime .Major [MEDICAL CONDITION] .[MEDICATION NAME] (anti-anxiety medication) 2 mg tablet .Hour of Sleep For Anxiety .Monitor for [MEDICAL CONDITION]- Hour of sleep . Continued review revealed on 8/18/17 the nurse had initialed the resident had been monitored for [MEDICAL CONDITION] after receiving medications for anxiety and sleep. Review of the Safety Event Entry dated 8/19/17 at 7:30 AM revealed the resident was found on the floor, covered with a blanket, by the Day Nurse. The resident told her she had been .laying there all night . The resident was not harmed and the family and physician were notified with neuro (neurolgical) checks initiated. Review of the personnel files for Registered Nurse (RN) #1 dated 8/19/17 revealed .Written Warning .Medication was documented as being given to Resident #1 at 2116 (9:16) pm and was actually given at approximately 10 pm. Per [MEDICAL CONDITION] flow sheet, nurse documented that resident was not having difficulty sleeping without having physically checked the patient who had fallen in the floor . Review of the Associate Corrective Action Form for Certified Nursing Assistant (CNA) #3 dated 8/19/17 revealed .Final Written Warning .CNA failed to make walking rounds with night shift and physically check on residents. One of the residents (#1) she was accepting care for had fallen onto the floor. This patient was not found for another 1.5 hrs . Continued review revealed CNA #1 was terminated for not following the facility's policy for rounding. Review of the General Investigation Form dated 9/3/17 revealed Resident (#1) was on the floor for an undetermined about (amount) of time. She had not been rounded on since 10 pm the previous night. CNAs did not do walking rounds. Resident found at 0730ish (around 7:30 AM). No injury. Formal investigation done by DON (Director of Nursing) and ED (Executive Director) .what led to this event .Laziness on the part of CNAs involved. They did not check on resident for 10 hours .Per .night shift RN, she was still in her regular clothes when she received her night meds . Observation and interview of Resident #1 on 9/5/17 at 11:25 AM, in the resident's room, revealed the resident was sitting in her chair with her son present. Interview confirmed she did have a fall during the night of 8/18/17 but was not injured. Continued interview confirmed she was unable to get herself up or get to the call light and she laid on the floor until the next morning when a nurse entered her room. Further interview confirmed she expected a staff member would check on her during the night. Interview with CNA #1 on 9/5/17 at 1:12 PM, by telephone, confirmed she was one of the two CNAs responsible for the care of Resident #1 on 8/18/17 on night shift. Continued interview confirmed Resident #1 was independent and rang the call bell if she needed assistance. Further interview confirmed the nurse gave her medication at 10:00 PM and her door was closed. Continued interview confirmed no one told her she had to go into every room on every round. Further interview confirmed she did not enter Resident #1's room after 10:00 PM on 8/18/17. Interview with RN #1 on 9/5/17 at 3:50 PM, by telephone, confirmed she was working the night shift on 8/18/17 and was responsible for the care of Resident #1. Further interview confirmed she administered medications to the resident at 10:00 PM and neither she or the 2 CNAs entered the residents room for the duration of the night shift. Continued interview confirmed she checked on every resident when the shift started and the CNAs were to make rounds on every resident every 2 hours and at shift change. Interview with CNA #2 on 9/5/17 at 4:00 PM, by telephone, confirmed she was pulled from the 7th floor to work on the 5th floor on 8/18/17 for the night shift to help out. Continued interview confirmed CNAs were expected to check on all residents every 2 hours. Further interview confirmed they went in residents' rooms to do rounds together, but did not enter Resident #1's room to check on her because CNA #1 knew the residents so, I just followed her lead. Interview with the Director of Nursing (DON) on 9/6/17 at 12:35 PM, in the conference room, confirmed Resident #1 had a fall on 8/18/17, sometime after 10 PM, and was found in her room lying on the floor by the day nurse at approximately 7:30 AM on 8/19/17. Continued interview confirmed CNA #1 and CNA #2 did not check on the resident all night. Further interview confirmed RN #1 administered medication to the resident at approximately 10:00 PM and did not check on the resident after that time. Continued interview confirmed CNA #1 and #2 were suspended pending the investigation and then terminated because they did not follow the facility protocol. Further interview confirmed CNAs were expected to make Continuous and Responsive Engagement Rounding, which assessed the 4 P's and were to see each resident approximately every 2 hours.",2020-09-01
655,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2017-09-14,225,D,1,0,TNU911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigations, and interview, the facility failed to complete a thorough investigation following an allegation of abuse for one resident (#8) of eight residents reviewed for abuse. The findings included: Review of the facility Abuse Policy dated (MONTH) (YEAR), revealed .Investigation .the investigation shall include interviews of team members, visitors, residents/patients, volunteers .who may have knowledge of the alleged event . Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's Care Plan dated 6/14/17 revealed .requires staff assistance for all ADL's (activity of daily living) .[DIAGNOSES REDACTED]. Medical record review revealed Resident #8 was unable to complete the Brief Interview for Mental Status due to a Dementia diagnosis. Review of a facility abuse investigation beginning 6/18/17, revealed Resident #8's daughter reported an allegation a staff member was mean as a snake to Resident #8 and squeezed his sore arm. The daughter alleged it occurred when the staff member positioned Resident #8 in bed on 6/17/17 on the third shift. Interview with the accused staff member on 9/12/17 at 10:40 AM, by phone, revealed she denied harming the resident and stated she no longer worked for the facility. Continued interview revealed she was not questioned about the alleged abuse and was not asked to provide a statement regarding the alleged abuse. Interview and review of the facility investigation with the Administrator and Social Worker on 9/12/17 at 10:45 AM, in the Administrator's office, confirmed the alleged perpetrator was not interviewed regarding the alleged abuse. Continued interview confirmed the facility failed to follow the facility abuse policy for investigating allegations of abuse.",2020-09-01
2439,COMMUNITY CARE OF RUTHERFORD,445406,901 COUNTY FARM RD,MURFREESBORO,TN,37127,2017-07-12,225,D,1,1,UY5C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigations, and interview, the facility failed to report an allegation of abuse timely for 1 (#114) resident, of 2 residents reviewed for abuse, of 31 residents reviewed. The findings included: Review of the facility policy Abuse, Neglect and Exploitation, undated, revealed .Report allegations or suspected abuse, neglect or exploitation immediately to .Administrator . Medical record review revealed Resident #114 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Significant Change in Status Minimum Data Set ((MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) was 3, indicating the resident had severe impairment in cognitive skills, and the resident required extensive assistance for bed mobility and transfers. Review of a statement from Licensed Practical Nurse (LPN) #1 dated 5/5/17, obtained by the facility, revealed, .LPN (#1) states she was standing at her medication cart on F wing when she heard a lot of commotion in the day area. She says she heard CNA (Certified Nursing Assistant #1) .state to the resident 'you kicked me in my knee you are about to get manhandled old man.' When she looked up to see what was happening she claims she witnessed CNA (#2) .looking through the window towards where she was standing at the medication cart as if she was checking to see if she was watching. The LPN (#1) alleges CNA (#2) used her fist and hit the resident in the upper right arm x 2 (2 times). She states that is when she went over to the resident to assist. When asked why she did not report this immediately she stated she 'was afraid' and 'didn't know who to trust' because of experiences she had with her mother, who she states was abused in a nursing home . Review of a statement from Registered Nurse (RN) #1, undated, obtained by the facility, revealed, .Employee pulled me to side evening of (MONTH) 5 (and) told me about an incident she had witnessed in early morning that day. She stated she had heard 2 techs (CNAs) talking (with) (Resident #114) that morning (and) overheard one say 'you kicked me in my bad knee.' She said she looked over at that time (and) saw (CNA #2) 'look up' then punch resident in his right arm two times. I asked her (LPN #1) why she did not report this at that time (and) she stated she was afraid of retaliation. I told her this should have been reported immediately. I then assessed resident (and) noted 2 purple bruises with nodules in center to right bicep area. I then went (and) reported to the weekend supervisor (and) asked nurse to come with me to get investigation started. Review of the facility investigation dated 5/5/17 revealed, .7:15 pm received voicemail message (Administrator) from (LPN #1), reporting alleged abuse .8 pm Returned to facility to begin investigation into allegations of abuse . Interview with RN #1 on 7/11/17 at 2:00 PM, in the conference room, revealed LPN #1 told the RN she had witnessed CNA #2 hit Resident #114 in the arm that morning. RN #1 looked at the resident's arm and noted 2 purple bruises on the right upper arm. Continued interview revealed LPN #1 reported this to the RN after 7:00 PM that night. Interview with the Administrator on 7/11/17 at 3:00 PM, in the conference room, confirmed the allegation of abuse was not reported to the Administrator until 7:30 PM (approximately 13 hours later), at which time the investigation began. Interview with LPN #1 on 7/12/17 at 7:45 AM, in the conference room, revealed the LPN was doing med pass about 5:45 AM on F hall. The LPN heard a commotion; heard CNA #1 say to Resident #114, you kicked me in my knee. You're about to be manhandled old man. The LPN looked through the glass and saw Resident #114 in a recliner, CNA #1 was on his left side, CNA #2 was on his right side, and CNA #2 turned and looked toward the glass. LPN #1 saw CNA #2 punch the resident in the right arm twice, with a closed fist, in the bicep area. Continued interview revealed the LPN asked the CNAs if they needed help. The LPN helped change his bottoms, the CNAs continued to change his brief and pulled up his bottoms the rest of the way, and they repositioned him in the chair. Continued interview revealed LPN #1 reported the abuse allegation to RN #1 when she came back to work on that evening shift.",2020-09-01
4933,LAUGHLIN HEALTH CARE CENTER,445264,801 E MCKEE ST,GREENEVILLE,TN,37743,2016-06-22,225,E,1,0,HP3N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigations, and interviews, the facility failed to timely report to the state agency as required and failed to conduct a complete investigation for 3 (#1, #2, #3) residents of 3 residents with injuries of unknown origin of 11 sampled residents. Findings included: Review of the undated facility policy Abuse, Neglect and Misappropriation of Property revealed all personnel and volunteers shall be responsible for identifying and reporting suspected cases of abuse, neglect, involuntary seclusion, and misappropriation of property. The facility policy included unexplained or suspicious bruises, fractures, dislocations, lacerations and those injuries such as bilateral bruises on upper arms indicating holding or shaking as potential indicators of abuse. The facility abuse policy documented that all reports of alleged abuse, neglect or misappropriation of property shall be investigated and reported to the Department of Health. Review of the policy Abuse Identification and Reporting Reference #1025 effective (MONTH) 2001 and revised on (MONTH) 2005, revealed all personnel will be responsible for reporting all suspected cases of abuse, neglect or exploitation. Assessment Criteria included physical findings such as fractures, dislocations, lacerations. The nurse may act in conjunction with physician in suspected abuse. Intervention included employee who suspects an instance of abuse shall report to their immediate supervisor after removing the resident from harm's way. The supervisor will report then to the Director of Nursing. The Director of Nursing will inform the Administrator, the attending physician, Social Services and the Human Resources Director. An investigation will be made into the allegations immediately. The Human Resources Director will report the suspected abuse to the appropriate State agency. Review of the facility policy for Abuse Identification and Reporting dated 3/05, revealed it did not identify the timeframe the facility should follow for reporting an incident to the state agency. Further review of this policy revealed it lacked interventions for completing an investigation to rule out abuse and neglect. Medical record review revealed Resident #1 was admitted to the facility on [DATE] and the [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, (cognitively intact) and displayed no behaviors. The MDS further revealed the resident required extensive assistance with transfers, bed mobility, toileting, dressing, and personal hygiene. The resident required the use of a wheel chair, had no skin issues, and received anticoagulant medication 7 days of the 7 day look back period. Medical record review of the care plan in place on 1/20/16 listed the interventions: administer Eliquis (anticoagulant) as ordered, labs as ordered, observe for signs of active bleeding (nosebleeds, bleeding gums, petechiae, purpura, ecchymotic areas, hematoma, blood in urine, blood in stools, hemoptysis, elevated temperature, pain in joints, abdominal pain, epistaxis), notify physician if signs/symptoms are present, protect resident from injury/trauma, use caution when assisting with transfers, ambulation, toileting, bed mobility, and activities of daily living to decrease risk of injury, staff assist with 2 people for ambulation, bed mobility, toileting and transfers, and gait belt for stability. Review of a facility investigation for Resident #1, with a date of occurrence of 1/20/16 at 9:45 PM, revealed the date of the report to the state agency was 1/26/16, 6 days after the date of occurrence. Further review of the investigation revealed the nurse was applying oxygen to Resident #1 and observed bruising, small redness under the left eye and swelling of the left upper lip, and small abrasion on the left cheek. The resident was on blood thinners two times a day. When the nurse asked the resident what happened to the eye the resident stated, A girl hit me, I told her to stop going behind my back and seeing my husband. The resident's husband was no longer living. The resident told another staff member, something fell on me. The resident had a [DIAGNOSES REDACTED]. The resident was total care and immobile and was lifted with a mechanical lift by 2 staff members at all times. The 2 staff who assisted the resident into bed with the lift were interviewed and stated no part of the lift struck the resident and no bruising or swelling was noted when they left the room. The resident was assessed by the family nurse practitioner on 1/21/16. Review of the Director of Nursing (DON) statement dated 1/21/16, revealed Resident #1 was getting more confused and weak. The injury could have been from rolling over onto the bed rail. The resident was also on blood thinners which increased the risk of bruising. Review of Direct Care Staff #10's statement, dated 1/21/16 with no time, revealed at approximately 7:00 PM, Direct Care Staff #6 asked for help to transfer Resident #1 to the bed. They used the Hoyer lift to transfer the resident without any problems. Review of Direct Care Staff #6's statement, dated 1/21/16 with no time, revealed at approximately 7:45 PM, Direct Care Staff #10 and Direct Care Staff #6 teamed up to put Resident #1 to bed using the Hoyer lift. Direct Care Staff #10 held the handle of the lift removing the lift pad and continued to hold it while Direct Care Staff #6 pulled the lift out. They did not observe any bruises to Resident #1's face and the lift did not come into contact with the resident's face at anytime. When they turned the resident to her side she was already in the middle of the bed and her face did not come into contact with the side rails. The resident was not combative and drifted off to sleep almost immediately. Review of the 1/21/16 facility investigation revealed no evidence of additional staff interviews regarding the bruising and no evidence of interviews with interviewable residents regarding the allegation. Interview with Licensed Nurse #4 on 6/22/16 at 10:43 AM, in the conference room, revealed after she gets a report of an injury, she gathers the staff together that took care of the resident in the last week and tries to pinpoint the exact time it occurred. The nurse stated she has the staff write a statement or she writes up what they tell her. The facility looks at other possibilities of what could have happened. The nurse confirmed the facility investigation usually does not include talking with other residents to see if they have any concerns related to the allegation. Interview with Licensed Nurse #4 on 6/21/16 at 4:05 PM, in the conference room, revealed the nurse thought the facility had 5 days to report an incident to the state agency and some literature stated they had 7 days to report to the state agency. The nurse stated the facility did not have a policy for conducting investigations but followed the Questions that should be answered when completing an incident report document provided by the state agency. Review of the document revealed #14 of the report stated, For incidents involving abuse or alleged abuse, did the facility interview alert and oriented residents that the accused cared for? Interview with Administrative Staff #1, on 6/21/16 at 4:30 PM, in his office, confirmed he thought the facility had 5 or 7 days to report an incident to the state agency. The facility failed to report the allegation of injury of unknown origin to the state agency as required and failed to conduct a complete investigation for this dependent resident with bruising. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and was discharged on [DATE]. Further review of the medical record revealed the Diagnoses: [REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident's BIMS score was 3 (severe cognitive impairment) and the resident did not display any behaviors. The resident required limited assistance with bed mobility and required extensive assistance with transfers, locomotion, dressing, toilet use, and personal hygiene. The MDS further identified the resident used a wheelchair and had no skin alterations. Medical record review of the care plan in place on 3/2/16 revealed the interventions: assist with 1 to 2 staff with activities of daily living, transfers, ambulation, dressing, grooming, personal hygiene, bathing, and toileting, and used a wheel chair for mobility. The care plan also listed the interventions: staff to use care when assisting the resident with activities of daily living, transfers, toileting, and bathing to prevent skin tears and/or bruises, and staff to observe skin daily during routine care for sign/symptoms of impairments. Review of a facility investigation for Resident #2 revealed the date of occurrence was 3/2/16 at 7:00 PM, and the date of the report to the state agency was 3/8/16, 6 days after the incident. Further review of the investigation revealed on 3/2/16 a direct care staff reported to the licensed nurse that she had observed bruising under the resident's right arm and around the mid chest. The bruise was approximately 8 centimeters (cm) by 12 cm. The resident was not on blood thinner/anticoagulant therapy. On 3/3/16 the nurse informed the DON, Administrator and Family Nurse Practitioner of the bruising and the DON examined the resident. X-rays were obtained and were negative for any fractures. Upon interview with the staff, the bruising was not observed on Monday 2/29/16, while the resident was receiving a shower. The resident had severe dementia, was non-ambulatory, and care planned for a 2 person gait belt lift. Staff were using the correct transfer method but the resident was becoming weaker and unable to bear weight on feet and legs. The investigation documented the injury possibly could have been caused by the gait belt use and the mode of transfer had been changed to full body Hoyer lift. Review of the (MONTH) 3, (YEAR) Report on (Resident #2) unsigned, but Licensed Nurse #4 identified as completing, revealed the licensed nurse reported that in shift report she was told the staff who put the resident to bed on 3/2/16 had observed areas of bruising under the resident's right arm and around the mid chest. Upon examination in the shower room, the resident was found to have an area of discoloration/bruising that appeared to be somewhat old, there were some yellowing and greenish areas noted around the center chest, and the right underarm area was bluish appearing. Direct care staff, not identified in the report, stated they did not see this on Monday during the shower. Review of the facility investigation revealed no evidence of additional staff interviews regarding the bruising and no evidence of interviews with interviewable residents regarding the allegation. Interview with Licensed Nurse #4 on 6/21/16 at 4:05 PM, in the conference room, confirmed the facility thought they had 5 days to report an incident to the state agency. The nurse confirmed the facility did not have a policy for conducting investigations but followed the Questions that should be answered when completing an incident report provided by the state agency, which stated, For incidents involving abuse or alleged abuse, did the facility interview alert and oriented residents that the accused cared for? Interview with Administrative Staff #1, in his office, on 6/21/16 at 4:30 PM, revealed the facility had 5 or 7 days to report an incident to the state agency. Interview with Licensed Nurse #4 on 6/22/16 at 10:43 AM, in the conference room, confirmed the facility usually does not talk to other residents to see if they have any concerns related to the allegation. The facility failed to report the allegation of injury of unknown origin to the state agency as required and failed to conduct a complete investigation for this dependent resident with bruising. Medical record review revealed Resident #3 was admitted to the facility on [DATE]. Resident #3's [DIAGNOSES REDACTED]. Resident #3 received hospice services. Medical record review of the Admission MDS for Resident #3 dated 2/17/15 revealed a BIMS Score of 3 which indicated severe cognitive impairment. Review of a facility investigation for Resident #3 revealed an incident dated 3/22/16. The date of the report to the State was 3/28/16, 6 days later. According to the report Resident #3 showed signs and symptoms of left hand pain while in the shower room on 3/22/16. Upon examination Resident #3's fifth finger on the left hand was red and tender to the touch. The staff that provided care to Resident #3 on 3/21/16 were questioned and denied knowledge of trauma to Resident #3's left hand. The Social Worker, DON, Administrator and Nurse Practitioner were notified. An X-Ray of Resident #3's injured hand revealed a [MEDICAL CONDITION] fifth finger. The left side of Resident #3 was flaccid due to paralysis and therefore had the potential for falling down to his side when sitting up in a chair. Medical record review of the Final Medical Imaging Report dated 3/22/16 revealed Resident #3 had a minimally displaced fracture along the lateral margin of the proximal epiphesis of the middle fifth phalanx. This extended into the joint space and may represent incomplete avulsion. Soft tissue swelling was seen within the finger. There was chronic fusion of the distal interphalangeal joint of the fifth finger. Impression was a fracture middle fifth phalanx. Review of the facility's investigation revealed the facility limited the investigation of Resident #3's fracture injury to interviews and written statements by the certified nursing assistant (CNA) staff with direct care responsibility on 3/22/16 and 3/23/16. The facility failed to interview other residents and family members to determine whether there were concerns of staff treatment of [REDACTED].#3. Interview with Licensed Nurse #4 on 06/21/20 at 4:10 PM, in the conference room, revealed that she found out about resident injuries by incident reports. The timing of the incident report would depend on the severity of the injury. For minor things on the weekend it would be Monday before notification but for severe injury, Licensed Nurse #4 might be notified on the weekend. Resident #3's injury was discovered on a Tuesday in the shower room. Licensed Nurse #4 stated we didn't know how it happened so the Unit Manager was assigned to look into it. Licensed Nurse #4 stated she reviews the incident reports after the investigations. Resident #3's injury was of an unknown cause, that was why it was reported to the State. Licensed Nurse #4 stated she thought the facility had 5 days to report to the State.",2019-06-01
1649,GRACE HEALTHCARE OF WHITES CREEK,445281,3425 KNIGHT DRIVE,WHITES CREEK,TN,37189,2018-03-02,600,J,1,1,GWBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigations, observation and interview, the facility failed to provide goods and services necessary to treat pain and provide prompt medical attention for 3 residents (#24,#61,#32) failed to prevent resident to resident abuse for 8 residents (#43, #62, #64, #67, #75, #81, #93, #167) reviewed for abuse of 48 sampled residents. The facility's failure to prevent neglect placed Resident #24, Resident #61, and Resident #32 in Immediate Jeopardy (a situation where 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 4:05 PM in the Administrator's office. F-600 is Substandard Quality of Care. An Acceptable Allegation of Compliance which removed the immediacy of the jeopardy was received and corrective actions were validated through review of documents, observations, and staff interviews conducted onsite on [DATE]. The Immediate Jeopardy was effective from [DATE] through [DATE]. The findings included: Review of facility policy, Abuse Prevention Policy and Procedure, revised [DATE] revealed, The facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse, corporal punishment, involuntary seclusion or misappropriation of resident property by any staff member, other residents .It is the policy of this facility .to protect the residents from harm at all times, including protection from physical and verbal abuse from other residents .A resident to resident altercation should be reviewed as a potential situation of abuse .Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions . Medical record review revealed Resident #24 was admitted to the facility on [DATE], readmitted on [DATE] and [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #24 scored 9 on the Brief Interview for Mental Status (BIMS) indicating she was moderately cognitively impaired. Continued review of the MDS revealed Resident #24 required extensive assistance of 2 people for transfers and dressing; extensive assist of 1 person for grooming and bathing; and was always incontinent of bowel and bladder. Further review revealed Resident #24 was non-ambulatory; was placed in a wheelchair; and was unable to propel the wheelchair. Medical record review of Wound Care Notes revealed Resident #24 was admitted to the facility with a Stage IV pressure ulcer (full thickness wound where the wound extends below layers of healthy skin) to the right heel, measuring 1.2 centimeters (cm) x (by) 1.5 cm x 1.3 cm with undermining (wound beneath healthy tissue) of 2 cm at 11:00 (using a face of a clock showing 11:00 anatomically). Continued review of Nurses' Notes revealed Resident #24 went to an off-site Wound Clinic once weekly for treatment of [REDACTED]. Medical record review of Wound Clinic notes revealed Resident #24 had a pressure ulcer on her right heel which was necrotic and was debrided on [DATE] (prior to her admission to the facility). Continued review of the Wound Clinic notes dated [DATE] revealed the wound had deteriorated and the upper edges were necrotic. Further review of the Wound Clinic notes dated [DATE] revealed the wound had undermining; was debrided; and an x-ray was ordered to rule out osteo[DIAGNOSES REDACTED]. Continued review of the Wound Clinic notes dated [DATE] revealed Resident #24 had a Stage III pressure ulcer on the right heel longer than 9 months and the facility had been using [MEDICATION NAME] with minimal improvement. Further review revealed the ulcer measures 0.9 cm x by 0.6 cm x 1.8 cm with red granulation in the wound bed. Medical record review of the Medication Administration Record [REDACTED]. Medical record review of Nurses' Notes dated [DATE] at 9:22 AM revealed Resident #24 complained of heel pain and was medicated with Tylenol 650 mg by Licensed Practical Nurse (LPN) #9. Medical record review of the MAR for ,[DATE] revealed no documentation of the Tylenol administration. Review of a facility investigation dated [DATE] revealed Resident #24 went to the Wound Clinic weekly. Continued review revealed when Certified Nursing Assistant (CNA) #1 and CNA #17 were getting the resident ready for her appointment when she complained of leg pain. Further review revealed CNA #1 notified Licensed Practical Nurse (LPN) #9 of the resident's pain and slight swelling and LPN #9 assessed Resident #24. Continued review revealed upon return from the wound care clinic the resident's knee appeared swollen with the knee cap leaned over. CNA #3 reported her observations to the nurse. Further review revealed LPN #3 assessed the resident who complained of heel pain when questioned. Continued review revealed CNA #1 later transferred the resident who complained of leg pain; LPN #3 was notified and assessed the resident, but did not observe excessive swelling to the leg. Medical record review of Nurses' Notes dated [DATE] revealed no documentation of an assessment of the resident's knee by either LPN #9 or LPN #3. Medical record review of Nurses' Notes dated [DATE] at 3:19 PM revealed Resident #24 had no complaints of pain or discomfort. Medical record review of Nurses' Notes dated [DATE] at 8:45 AM revealed Resident #24 had no complaint of pain voiced. Continued review of the Nurses' Notes revealed at 1:07 PM the resident had no complaint or indication of pain. Further review of the Nurses' Notes at 1:11 PM revealed the resident's right heel had deteriorated with the wound being smaller but the depth had increased. Medical record review of the Comprehensive Care Plan revealed an update on [DATE] with a problem of swelling of the right knee and painful to touch. Continued review revealed approaches included cool compresses as needed; administer pain medications; inform provider; and X-ray if ordered and inform provider of results. Review of a PT evaluation dated [DATE] revealed Resident #24 was wheelchair bound prior to admission. Continued review revealed the resident required maximum assistance to go from supine to sitting as well as to roll from side to side for care. Further review revealed the resident required total assistance of 2 people to scoot up in bed. Review of a facility investigation dated [DATE] revealed CNA #3 was showering the resident and noted the resident's right knee was swollen and the knee was not sitting straight up the way it was on [DATE]. Continued review revealed CNA #3 informed LPN #3 of the swollen knee who agreed the knee was swollen and said she would have Physical Therapy (PT) look at it. Further review revealed LPN #5 observed the knee to be swollen, painful to move, warm to touch, and notified the Charge Nurse (LPN #4). Continued review revealed LPN #4 assessed the right knee of Resident #24 and agreed it was swollen, warm, and painful, notified the Physician who ordered transfer to the Emergency Department (ED). Further review of the facility investigation revealed the ED nurse called the facility to find out if the resident had fallen because she had a femur fracture. Review of the Emergency Department (ED) record dated [DATE] at 12:02 AM, revealed Resident #24 had a history of [REDACTED]. Continued review revealed a statement there was no trauma and the resident is non-ambulatory. Further review od the ED record revealed the resident suffered a .comminuted interarticulated displaced angulated distal femoral fracture extending into the knee joint . (fracture of femur into many parts and extending into the knee separating the surface of the bone into many parts). Review of the ED information sheet revealed .Elderly people typically have poor bone quality and a fall from a standing position can cause such a fracture. Symptoms of this type of fracture include pain with weightbearing; swelling and bruising; tenderness to touch; knee may look out of place and the leg may appear shorter and crooked . Review of the hospital record of a consult from the Infectious Diseases Physician dated [DATE], revealed the right heel wound was necrotic and had an odor suggesting infection. Continued review revealed the Physician documented would require further medical or surgical debridement or right [MEDICAL CONDITION]. Further review revealed the Physician documented Resident #24 had very poor nutritional intake which was a risk factor for poor healing of a wound or surgical site. Continued review revealed the resident was very frail with Dementia and was expected to have poor quality of life. Further review revealed the Physician hoped the amputation could be done within the next week to avoid prolonged use of antibiotics with their side effects. Review of hospital notes dated [DATE] revealed Resident #24 underwent an .above the knee amputation of the right leg due to non healing distal right femoral shaft fracture, [MEDICAL CONDITION], non-healing right foot wound . Medical record review revealed Resident #24 returned to the facility on [DATE] with a right above the knee amputation, [DEVICE] (used to instill feeding directly into the stomach) and tube feeding infusing, as well as a Stage III pressure ulcer on the coccyx. Medical record review of Nurses' Notes dated [DATE] revealed Resident #24 was admitted to the hospital with [REDACTED]. Continued review revealed Resident #24 was diagnosed with [REDACTED]. Review of a Physician's Note dated [DATE] revealed the resident had been doing poorly for the last few months and was expected to have poor quality of life. Continued review revealed the Hospitalist discussed the resident's medical condition with the family but they wanted aggressive measures. Further review of a Physician's Note dated [DATE] revealed .had long discussion with daughter and son. They want to continue full code and aggressive therapy. Patient is lethargic and encephalopathic . Medical record review of Nurses' Notes dated [DATE] revealed Resident #24 had returned from the hospital. Medical record review of Nurses' Notes dated [DATE] revealed Resident #24 was .found by a CNA and it looked as if she was not breathing . Further review revealed the Nurse was notified and Cardiopulmonary Resusitation (CPR) was begun. Continued review revealed Resident #24 was transferred to the hospital where she expired. Review of the Certificate of Death revealed the cause of death included [MEDICAL CONDITION], Diabetes Mellitus with [MEDICAL CONDITIONS], and [MEDICAL CONDITION]. Telephone interview with LPN #9 on [DATE] at 10:35 AM revealed she had no idea Resident #24 had a [MEDICAL CONDITION] because no one had told her about it. Continued interview revealed Resident #24 had pressure ulcers on both heels and usually complained of heel pain. Further interview revealed when the resident complained of pain she assumed it was from the heel. Continued interview revealed the facility was unable to find a cause for the fracture. Interview with CNA #3 on [DATE] at 2:30 PM on the 100 hall revealed when Resident #24 came back from the Wound Clinic on [DATE], her knee was swollen. Continued interview revealed she notified LPN #3 about the knee. Further interview revealed CNA #3 took Resident #24 to her room and put her in bed. Medical record review of the ,[DATE] MAR indicated [REDACTED]. Medical record review of Nurses' Notes revealed no documentation LPN #9 or LPN #3 assessed the resident to determine her pain level or the status of the resident's knee. Interview with CNA #5 on [DATE] at 6:20 AM in the conference room revealed when Resident #24 returned from the Wound Clinic on [DATE], her legs looked different. Continued interview revealed she asked LPN #5 to look at the resident's legs and the knee was turned inward and the resident complained of severe pain. Continued interview revealed LPN #5 stated the resident's knee was not right and she would notify the Charge Nurse (LPN #4). Further interview revealed LPN #5 asked PT if they could help with positioning and the therapist stated not to bother doing anything because the leg didn't look right. Interview with CNA #1 on [DATE] at 6:35 AM in the conference room revealed Resident #24 had an appointment at the Wound Clinic on [DATE] and she asked a co-worker to help get the resident dressed and into a wheelchair for pickup. Continued interview revealed about 2:00 PM Resident #24 complained of leg pain and the Nurse assessed the leg but found no concerns. Medical record review of the ,[DATE] MAR indicated [REDACTED]. Medical record review of Nurses' Notes dated [DATE] revealed no documentation LPN #5 assessed the resident's knee. Interview with the Director of Nursing (DON) on [DATE] at 4:03 PM in her office revealed Resident #24 had a heel pressure ulcer which was treated at the Wound Clinic. Continued interview revealed she complained of foot pain regularly. Further interview revealed the CNA notified the Nurse of the knee swelling who thought a PT consult was needed. Continued interview revealed when swelling was reported a second time the resident was transferred to the hospital and the femur fracture was diagnosed . Interview revealed Resident #24 returned to the facility in late ,[DATE] with a right above the knee amputation and a PEG tube and was unstable at the time. Continued interview revealed a few days later the resident's blood pressure and glucose became unstable so she was sent to the hospital again. Further interview revealed Resident #24 returned to the facility on [DATE]; coded on [DATE]; and expired. Interview revealed there was no conclusion as to the cause of the fracture. Continued interview revealed the DON called the Wound Clinic to find out how the resident was transferred and interviewed the CNA who accompanied the resident to the appointment, finding out Resident #24 was transferred using a stand-pivot method. Interview the DON confirmed there was a delay in obtaining medical treatment for [REDACTED]. Telephone interview with CNA #2 on [DATE] at 5:35 PM revealed there was no problem observed with the van ride or getting Resident #24 in and out of the clinic. Continued interview revealed once inside the clinic the wound clinic staff stood the resident up; used a stand-pivot method to ease her to the treatment bed; eased her legs onto the bed; and propped her right leg on a pillow. Interview revealed the CNA (#5) who initially saw the knee upon return from the Wound Clinic knew something was wrong and told both the Charge Nurse and the facility Wound Care Nurse but no action was taken. Further interview revealed the Charge Nurse assessed Resident #24 and decided there was nothing wrong so took no action. Continued interview revealed from [DATE] - [DATE] there was little documentation of observation of the resident's knee and no treatment was provided. In summary, Resident #24 was admitted to the facility on [DATE] with a right heel Stage IV pressure ulcer. The resident had co-morbidities of Diabetes Mellitus and [MEDICAL CONDITION]. On [DATE] upon return from the Wound Clinic, the CNA noted the resident's right knee was swollen. The LPN assessed the knee; saw no significant swelling; and failed to document her assessment. The resident was also complaining of pain in her legs; the LPN stated in interview she administered Tylenol; but she failed to document the administration. The CNAs stated they told the nurses about Resident #24's swollen knee and pain but the Nurses failed to document any assessment of the resident's knee; Nurses failed to document administration of pain medication; and Nurses failed to notify the Physician of the resident's complaint of pain. On [DATE] Nurses' Notes revealed the first documentation of the resident's knee being swollen, painful, and warm to touch. There is no documentation pain medication was administered when the resident was complaining of pain; the Physician was notified; Resident #24 was transferred to the ED where a comminuted interarticulated displaced angulated distal femoral fracture extending into the knee joint was identified. During this time the pressure ulcer on the heel deteriorated and the resident underwent [REDACTED]. The resident subsequently developed pneumonia [MEDICAL CONDITION]; coded; and died . The failure to notify the Physician in a timely manner of the swollen knee; failure to administer pain medication when the CNAs notified the Nurses the resident was complaining of pain; and the failure of the Nurses to document assessments of the resident's knee constituted neglect for Resident #24 at an Immediate Jeopardy level. Medical record review revealed Resident #61 was admitted to the facility on [DATE] and readmitted on [DATE] and [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged to the hospital on the evening of [DATE]. An additional [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #61 had a BIMS score of 1 indicating the resident was severely cognitively impaired. Further review revealed Resident #61 required extensive assistance with bed mobility and was totally dependent for transfer, dressing, toilet use, personal hygiene and bathing. Continued review revealed the resident had range of motion limitation in the upper and lower extremities on both sides. Further review revealed the resident received PRN (as needed) pain medication. Medical record review of a Care Plan dated [DATE] revealed Resident #61 was at risk for poor nutritional status related to [DIAGNOSES REDACTED]. Medical record review of a Care Plan dated [DATE] revealed Resident #61 was at risk for alteration in comfort related to a history of right leg pain, decreased mobility, and multiple chronic disease processes. Continued review of the Care Plan revealed the resident was at risk for falls related to decreased mobility, cognitive and physical function deficits. Further review revealed approaches for the Care Plan included bed in low position and safety mats at bedside. Continued review revealed Resident #61 required assistance with Activities of Daily Living (ADL's) due to decreased mobility, multiple chronic disease processes, generalized weakness and Above the Knee Amputation of the Left Leg. Further review revealed the resident had .Decreased vision related to: blind in left eye and poor vision in right eye. I do not wear glasses as they do not help me . Continued review revealed Resident #61 had cognitive loss present as evidenced by her short term memory loss. Medical record review of the MAR for (MONTH) (YEAR) revealed Resident #61 had an order dated [DATE] for [MEDICATION NAME]/[MEDICATION NAME] (pain medication) ,[DATE] mg one tablet by mouth three times daily (TID) prn. Continued review revealed no [MEDICATION NAME] pain medication was administered [DATE] through [DATE]. Medical record review of the Nurses' Notes for [DATE] revealed no documentation by LPN #9 regarding the voiced pain, that a man had dropped her, or that any pain medication was administered. Review of a witness statement signed by CNA #10 dated Saturday, 9, (YEAR) revealed .(Resident #61) was in the bed .This morning, [DATE] she complain(ed) that her knee was hurting .As I was changing her she complain(ed) of pain in her knee . Continued review of the witness statement revealed an addendum dated [DATE] at 8:21 PM and signed by the DON and documented .CNA reported that Nurse on ,[DATE] was made aware around 5 AM of residents complaint of pain to right knee . Review of a witness statement signed by LPN #9 dated [DATE] included in the facility investigation revealed, .When I went in (the) resident's room to give pain med (medication) for rt (right) leg that (CNA #10) told me she was hurting she mentioned that man dropped me .This occurred between 5:30 AM and 6:00 AM on [DATE] . Review of an interview conducted by LPN #2/Unit Manager with Resident #61 on [DATE] at 5:50 PM revealed .1. Can you tell me what happened? 'I fell out of bed and that man picked me up. I fell last night.' 2. Date and Time of day/night when the incident occurred? 'Last night.' 3. Who was involved? Give name and/or description of person(s). 'Tall boy, brown skinned, with uniform on. 4. ' Were there witnesses? 'No.' 5. When did you report this incident? 'My leg hurt all day.' 6. Who did you report this incident to? 'I told a nurse.' 7. Is this the first time this incident or a similar incident has occurred? If no, explain: 'My leg hurt lady.' . Medical record review of a Physician's Telephone Order dated [DATE] at 12:30 PM revealed Stat (immediately) right knee x-ray due to swelling and pain . and signed by LPN #7. Medical record review of a Nurses' Note dated [DATE] at 12:43 PM by LPN #7 revealed .resident complain(ed) of R (right) knee pain stated she was drop(ped) by a man last night right knee noted to be swollen painful to touch or move MD (Medical Doctor) made aware order to have x-ray done and call him .will continue to monitor waiting on mobile x-ray to come to facility for x-ray . Medical record review of a Social Service Note dated [DATE] revealed .SSD (Social Services Director) met with resident in room. Resident resting in bed with eyes open .Is HOH (hard of hearing) and suffers with vision problems which can make communication difficult at time(s), even when getting down at resident's level . Medical record review of a Social Servise Note dated [DATE] revealed .SSD met with resident in room .Could be heard yelling out which is baseline for resident . An interview was attempted with Resident #61. Although she was able to speak at the time of the incident, she had been in the hospital in the interval and was now unable to speak. Interview with LPN #7 on [DATE] at 7:55 AM on the 200 hall revealed she was passing medications the morning of [DATE] and she heard Resident #61 hollering out. Continued interview revealed the resident hollered out a lot but this was a different tone. Further interview revealed the LPN went to Resident #61's room to check on her and staff were getting the resident up in her geri-chair. Continued interview revealed Resident #61 said her leg hurt and that a man had dropped her. Surveyor asked What did her leg look like? and the LPN stated the resident's knee was swollen but no bruising, she had pain with movement. Continued interview revealed Once she was in her chair she was ok referring to her pain level. The LPN stated she called the doctor and received an order for [REDACTED]. Interview with LPN #9 on [DATE] at 10:18 AM by telephone revealed she worked the 11:00 PM to 7:00 AM shift which began on [DATE] and completed on the morning of [DATE]. Surveyor asked LPN #9 what she remembered about Resident #61 the morning of [DATE] and LPN #9 stated the resident complained of foot and leg pain a lot and then stated I gave her Tylenol that morning. Medical record review of the physician's orders [REDACTED]. Interview with CNA #10 on [DATE] at 11:08 AM by telephone revealed Resident #61 complained of leg pain in the early morning hours on [DATE] and he notified LPN #9 and she went in to check on her. Interview with LPN #2 on [DATE] at 3:35 PM in the Restorative Nursing office revealed she came to the facility on [DATE] about dusk dark and assessed Resident #61 upon arrival. Continued interview revealed the resident told her that her leg was hurting. The Surveyor asked What medication did (LPN #9) give to this resident? and LPN #2 stated there was nothing charted, we went back and did narcotic counts and nothing was given. Interview with the DON on [DATE] at 3:50 PM in the Assistant Director of Nursing (ADON)'s office, confirmed the facility failed to follow their policy on administering pain medication. Continued interview with the DON confirmed the facility failed to promptly notify the resident's Physician when the resident had a change of status. These failures resulted in neglect, which is classified as abuse, due to Resident #61 not receiving pain medication and a delay in treatment of [REDACTED]. Interview with the Administrator on [DATE] at 5:08 PM in the ADON's office, after reviewing Resident #61's care regarding the reporting of pain with no pain medication given, and the neglect in the delay in reporting and a change in status in the resident's condition, stated You're not telling us anything we didn't know, that's why we fired them. (LPN #9, CNA #10) Medical record review revealed Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #32 had a BIMS of 14 indicating he was cognitively intact. Medical record review of the MAR indicated [REDACTED].[MEDICATION NAME] (opioid) 12 MCG (Micrograms)/HR (Hour) Patch apply on epatch (one patch) every 3 days for apin (pain). Rotate site . Was not documented as administered. Medical record review of the MAR for ,[DATE] revealed on [DATE] at 3:00 PM the resident's scored ,[DATE], (pain level scored from 1 - 10 with 1 being the lowest pain level and 10 being the highest pain level); on [DATE] at 3:00 PM it was ,[DATE]; on [DATE] it was ,[DATE], and on [DATE] it was ,[DATE]. Observation of Resident #32 on [DATE] at 12:20 PM in his room with the DON present revealed she performed a skin assessment. Continued observation revealed no [MEDICATION NAME] Patch could be located on the resident. Resident #32 stated .I was wondering why my hip was hurting . Interview with LPN #1 on [DATE] at 12:25 PM in Resident #32's room, revealed staff are notified to check placement of [MEDICATION NAME] Patch, when it pops each shift on the computer . Interview with LPN #1 on [DATE] at 2:33 PM in the Medication Room at the back Nurses' Station revealed Resident #32 needed another written prescription to be faxed to the pharmacy. I don't believe he got a [MEDICATION NAME] Patch on that day ([DATE]) Interview with LPN #2 on [DATE] at 3:15 PM revealed the Pharmacy was called regarding filling the Fenatyl patch. The original order was faxed on [DATE]. But mg was placed on the order instead of mcg. Continued interview revealed Resident #32 did not have a [MEDICATION NAME] Patch on and the correct order was faxed on [DATE]. Interview with the DON on [DATE] at 3:30 PM at the back Nurses Station confirmed the facility failed to ensure Resident #32 received his [MEDICATION NAME] Patch, which resulted in Resident #32 not receiving pain medication for 10 days and while experiencing pain. Medical record review revealed Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #43 scored 8 on the BIMS indicating she was moderately cognitively impaired. Medical record review revealed Resident #62 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 #62 scored 12 on the BIMS, indicating she was mildly cognitively impaired. Review of the facility investigation revealed on [DATE] two residents (#43, #62) had an altercation. Continued review of a statement from the Activity Aide dated [DATE] revealed .At or around 4:05 PM while finishing up the movie matinees, I witnessed two residents (#43, #62) in a fist fight in the middle of the room. As I was trying to separate the two (#62) would not let go of (#43) arm and would not stop hitting her . Further review of the facility investigation on [DATE] revealed a statement from Resident #85 who stated she witnessed both residents hitting one another but (Resident #62) started it. Continued review of the facility investigation revealed a statement from another resident who stated .Resident #62) pinched (Resident #43) and (Resident #43) pinched back and they started fighting . Medical record review of Nurses' Notes dated [DATE] revealed LPN #2 was called to the dining room by the Activity Director and found Resident #62 in a physical altercation with Resident #43. Continued review revealed Resident #62 stated She hit me. Further review revealed the residents were separated but Resident #62 hit Resident #43 on the back of the shoulder. Continued review revealed Resident #62's son requested the resident be sent to the ED. Interview with the DON on [DATE] at 2:30 PM in the DON's office, confirmed Resident #43 and Resident #62 were involved in a resident-to-resident altercation. Medical record review revealed Resident #167 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #167 had a BIMS of 3 indicating the resident as severely cognitively impaired. Review of facility investigation dated [DATE] revealed Resident #43 was in the dining when she was hit with a coffee cup by Resident #167. Interview with Resident #43 on [DATE] at 8:15 AM in her room revealed Resident #167 hit Resident #43 on the head with a coffee cup and Resident #43 hit Resident #167 on the shoulder. Interview with the LPN #2 on [DATE] at 10:57 AM at the front Nurses Station revealed LPN #2/Unit Manager was called to the dining room because Resident #167 threw a coffee cup at Resident #43. When LPN #2/Unit Manager got to the dining room she observed Resident #167 was agitated and was slinging her arms and trying to self-propel. Resident #43 was seated at another table. Continued interview with LPN #2/Unit Manager confirmed the facility failed to prevent the resident to resident altercation. Medical record review revealed Resident #64 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED].",2020-09-01
4038,BROOKHAVEN MANOR,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2016-12-07,493,K,1,0,E8N511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigations, observation, and interview, the Governing Body failed ensure wound care protocols were available and followed to assess and treat all wounds; to ensure residents with medical devices (immobilizers) did not develop pressure ulcers related to use of the device; to ensure the physician was notified for changes in condition and to obtain treatment orders; to ensure facility policy was followed so all residents were protected from neglect and abuse and all allegations of neglect and abuse were reported and investigated; to ensure residents were safe from accidents; and to ensure adequate staffing to provide care and services to residents according to their needs and care plans. The facility's failure placed 10 residents (#106, #123, #75, #103, #65, #27, #68, #21, #45, #12, #145) in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirement of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Corporate Director of Clinical Services and the Administrator were informed of the Immediate Jeopardy (IJ) in the conference room on 12/7/16 at 9:30 AM. The facility was cited an Immediate Jeopardy at F-157 (J); F-223 (K); F-224 (J); F-225 (K); F-280 (J); F-309 (J); F-312 (J); F-314 (J); F-353 (K); F-490 (K); F-493 (K); F-501 (K); and F-520 (K). The facility was cited Substandard Quality of Care (SQC) at F-223 (K), F-224 (J), F-225 (K), F-241 (J), F-309 (J), F-312 (J), and F-314 (J). The IJ was effective on 2/6/16 and is ongoing. The findings included: Interview with the Director of Nursing (DON) on 11/8/16 at 5:05 PM, in her office, confirmed the facility did not have a protocol the nursing staff could refer to for the identification, assessment and treatment of [REDACTED]. Interview with the Nurse Practitioner on 11/9/16 at 10:25 AM, in the small conference room, revealed she thought standing orders for Decubitus Care stated refer to wound care protocol and were to be followed. She was unaware the facility did not have a wound care protocol to follow. Interview with the Administrator on 11/28/16 at 3:55 PM, in the conference room, confirmed he would expect the facility to follow the procedures outlined in the facility Abuse policy. Interview with the DON on 12/5/16 at 11:40 AM, in the conference room, confirmed the facility had failed to obtain an order for [REDACTED].#106's wound declined between the time it was first identified and the time treatment was initiated. Further interview revealed the DON was unaware of the online protocols for the treatment of [REDACTED]. Interview with the Medical Director on 12/5/16 at 1:55 PM, in his office, confirmed he was unaware the facility did not have protocols in place for wound care. Continued interview confirmed he does not do training or teaching on wound care with the Director of Nursing or the Treatment Nurse. Continued interview confirmed the facility did not have enough staff to care for the residents. Further interview confirmed he has been the Medical Director at this facility for [AGE] years and it had always been an issue. Interview with the Regional Director on Clinical Services on 12/6/16 at 10:00 AM, at the 100-200 hall nurses station, confirmed the facility did have access to wound care protocols and they were located on the company's website portal, available to staff, and could be printed out. Refer to F-157 (J); F-223 (K); F-224 (J); F-225 (K); F-280 (J); F-309 (J); F-312 (J); F-314 (J); F-323 (G); F-353 (K); F-490 (K); F-501 (K); and F-520 (K).",2019-11-01
4037,BROOKHAVEN MANOR,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2016-12-07,490,K,1,0,E8N511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigations, observation, and interview, the facility failed to be administered in a manner to ensure wound care protocols were available and followed to assess and treat all wounds; to ensure residents with medical devices (immobilizers) did not develop pressure ulcers related to use of the device; to ensure the physician was notified for changes in condition and to obtain treatment orders; to ensure all residents were protected from neglect and abuse and all allegations of neglect and abuse were reported and investigated; to ensure residents were safe from accidents; and to ensure adequate staffing to provide care and services to residents according to their needs and care plans. The facility's failure placed 10 residents (#106, #123, #75, #103, #65, #27, #68, #21, #45, #12, #145) in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirement of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Corporate Director of Clinical Services and the Administrator were informed of the Immediate Jeopardy (IJ) in the conference room on 12/7/16 at 9:30 AM. The facility was cited an Immediate Jeopardy at F-157 (J); F-223 (K); F-224 (J); F-225 (K); F-280 (J); F-309 (J); F-312 (J); F-314 (J); F-353 (K); F-490 (K); F-493 (K); F-501 (K); and F-520 (K). The facility was cited Substandard Quality of Care (SQC) at F-223 (K), F-224 (J), F-225 (K), F-241 (J), F-309 (J), F-312 (J), and F-314 (J). The IJ was effective on 2/6/16 and is ongoing. The findings included: Interview with the Director of Nursing (DON) on 11/8/16 at 5:05 PM, in her office, confirmed the facility did not have a protocol the nursing staff could refer to for the identification, assessment and treatment of [REDACTED]. Interview with the Nurse Practitioner (NP) on 11/9/16 at 10:25 AM, in the small conference room, revealed she thought standing orders for Decubitus Care stated refer to wound care protocol and were to be followed. She was unaware the facility did not have a wound care protocol to follow. Interview with the Administrator on 11/28/16 at 3:55 PM, in the conference room, confirmed he would expect the facility to follow the procedures outlined in the facility Abuse policy. Interview with the DON on 12/5/16 at 11:40 AM, in the conference room, confirmed the facility had failed to obtain an order for [REDACTED].#106's wound declined between the time it was first identified and the time treatment was initiated. Further interview revealed the DON was unaware of the online protocols for the treatment of [REDACTED]. Interview with the Medical Director on 12/5/16 at 1:55 PM, in his office, confirmed he was unaware the facility did not have protocols in place for wound care. Continued interview confirmed he does not do training or teaching on wound care with the Director of Nursing or the Treatment Nurse. Continued interview confirmed the facility did not have enough staff to care for the residents. Further interview confirmed he has been the Medical Director at this facility for [AGE] years and it had always been an issue. Interview with the Regional Director on Clinical Services on 12/6/16 at 10:00 AM, at the 100-200 hall nurses station, confirmed the facility did have access to wound care protocols and they were located on the company's website portal, available to staff, and could be printed out. Refer to F-157 (J); F-223 (K); F-224 (J); F-225 (K); F-280 (J); F-309 (J); F-312 (J); F-314 (J); F-323 (G); F-353 (K); F-493 (K); F-501 (K); and F-520 (K).",2019-11-01
2438,COMMUNITY CARE OF RUTHERFORD,445406,901 COUNTY FARM RD,MURFREESBORO,TN,37127,2017-07-12,223,D,1,1,UY5C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility investigations, observation, and interview, the facility failed to prevent abuse for 1 (#114) resident, of 2 residents reviewed for abuse, of 31 residents reviewed. The findings included: Review of the facility policy Abuse, Neglect and Exploitation, undated, revealed .Each resident has the right to be free from verbal, sexual, physical and mental abuse .Verbal Abuse means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend, or disability .Physical Abuse includes, but not limited to hitting, slapping, pinching and kicking . Medical record review revealed Resident #114 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Significant Change in Status Minimum Data Set ((MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) was 3, indicating the resident had severe impairment in cognitive skills, and the resident required extensive assistance for bed mobility and transfers. Review of a facility investigation dated 5/5/17 revealed, .7:15 pm received voicemail message (Administrator) from (Licensed Practical Nurse #1 (LPN)), reporting alleged abuse .8 pm Returned to facility to begin investigation into allegations of abuse. With resident's permission looked at right arm noting an area of bruising to the right inner bicep area .5/8/17 (Director of Nursing (DON)) spoke with CNA (Certified Nursing Assistant) who had given resident his shower the evening prior to the alleged incident. CNA states no bruising to the right upper arm area was present during this shower . Review of a statement dated 5/5/17, obtained by the facility from CNA #1, revealed, .CNA (#1) states she was asked by another CNA (CNA #2) .to assist with changing resident. Resident had been in recliner at the nurses' station sleeping for most of the night. CNA (#1) states she let him know they needed to change his clothes because he had urine on his pants. She says he was cooperative at first and joking around with her. CNA (#1) states they began to assist him up from the chair and he raised his foot and hit her on the knee. She reports she jokingly told him 'you kicked me in my bad knee' and he replied 'I did' and started to laugh. The CNA (#1) states they continued to attempt to raise him up with the lift but he became aggressive with the other CNA (#2) and hitting her. She reports she did not know why he became so agitated but 'he just doesn't like her (CNA #2)' and 'fights with her all the time' .Because she did not feel he was safe to transfer they sat him back in his recliner and the Charge Nurse (LPN #1) came to assist. CNA (#1) explained to the nurse he was agitated and hitting at them and asked if she could assist while they stood him up and changed his clothes . Review of a statement from LPN #1 dated 5/5/17, obtained by the facility, revealed, .LPN (#1) states she was standing at her medication cart on F wing when she heard a lot of commotion in the day area. She says she heard CNA (#1) .state to the resident 'you kicked me in my knee you are about to get manhandled old man.' When she looked up to see what was happening she claims she witnessed CNA (#2) .looking through the window towards where she was standing at the medication cart as if she was checking to see if she was watching. The LPN (#1) alleges CNA (#2) used her fist and hit the resident in the upper right arm x 2 (2 times). She states that is when she went over to the resident to assist . Review of a statement from Registered Nurse (RN) #1, undated, obtained by the facility, revealed, .Employee pulled me to side evening of (MONTH) 5 (and) told me about an incident she had witnessed in early morning that day. She stated she had heard 2 techs (CNAs) talking (with) (Resident #114) that morning (and) overheard one say 'you kicked me in my bad knee.' She said she looked over at that time (and) saw (CNA #2) 'look up' then punch resident in his right arm two times .I then assessed resident (and) noted 2 purple bruises with nodules in center to right bicep area . Medical record review of the Departmental Notes dated 5/5/17 revealed .720 PM Res (Resident) up in W/C (wheelchair) at nurse's station observed purplish discoloration to right upper arm 3 inch long by 2 inch wide with small nodules noted . Observation on 7/11/17 at 4:10 PM, revealed the resident was seated in a wheelchair in the hall. Interview with LPN #1 on 7/12/17 at 7:45 AM, in the conference room, revealed the LPN was doing med pass about 5:45 AM on F hall, heard a commotion, and heard CNA #1 say to Resident #114, you kicked me in my knee. You're about to be manhandled old man. LPN #1 looked through the glass and saw Resident #114 in a recliner, CNA #1 was to the right, facing Resident #114 (his left side), CNA #2 was facing Resident #114 on the left side (his right side), and CNA #2 turned and looked toward the glass. The LPN saw CNA #2 punch the resident in the right arm twice, with a closed fist, in the bicep area. Continued interview revealed the LPN asked the CNAs if they needed help. CNA #1 said the resident was refusing to get up. LPN #1 stated she didn't hear the resident refuse. The LPN then helped change his bottoms, the CNAs continued to change his brief and pulled up his bottoms the rest of the way, and they repositioned him in the chair. Interview with the Administrator on 7/12/17 at 8:05 AM, in the conference room, confirmed abuse had occurred. Further interview confirmed I do believe something happened, obvious bruise, never should have happened. Interview with the DON on 7/12/17 at 8:15 AM, in the DON's Office, revealed the CNA who gave the resident a shower the night before the incident said the bruise was not on the Resident's arm the night before. Interview with CNA #4 on 7/12/17 at 8:30 AM, in the conference room, confirmed the CNA worked the day prior to the incident and did not recall seeing a bruise on the resident.",2020-09-01
798,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2018-03-21,837,J,1,0,9RON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility records and interview, the Governing Body failed to ensure the facility followed the discharge policy to develop a safe and orderly discharge for 1 resident (#123) of 3 residents reviewed for discharge. The facility's failure to ensure a safe and orderly discharge resulted in Resident #123 being discharged to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The findings included: Review of facility policy, Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .10. At the time of notification, the facility will provide each resident .with the following information: a. The plan for the transfer and adequate relocation of the resident .c. Assurances the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, services and location . Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the facility admission followed an acute care hospital stay due to a Traumatic Subdural Hemorrhage requiring surgery. Further review revealed 2 additional [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, out of a possible 15, indicating the resident was cognitively intact. Review of an Interdisciplinary Progress Note dated 12/21/17 at 9:20 AM revealed .Staff brought to administrator team concern that resident may have been smoking in one of the common areas of the facility this morning. Administrator and this writer met with resident in his room to discuss .Resident denies smoking in common area. Initially he refused to allow administrator to search his room but then consented (and) also submitted a blue lighter that he had on his person .Smoking policy/agreement reviewed with resident (and) he was informed that smoking privileges are now suspended. Resident acknowledged this. Also informed resident that he would be issuing him a 30 day discharge . Continued medical record review revealed no evidence the resident had received education and training on the smoking policy and the consequences of noncompliance, prior to this incident. Review of the facility's Notice of Involuntary Discharge revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the Notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Interview with the Interim Administrator and the Social Services Director (SSD) in the Social Services office on 3/7/18 at 10:50 AM, revealed Resident #123 filed an appeal on 1/3/18 for the Involuntary Discharge issued 12/21/17. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Commissioner's Designee for the Tennessee Department of Finance and Administration, and the presiding Administrative Law Judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Continued interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the Social Services office, revealed the SSD notified the resident's sister by phone on 2/9/18, at 4:00 PM after the resident's discharge and gave her his hotel room number. Further interview revealed the sister was not the resident's responsible party. Continued interview revealed the facility paid for 3 nights in a hotel (Friday, Saturday, and Sunday from 2/9/18-2/11/18). Further interview revealed .the hotel provided a phone and complimentary breakfast meal. Continued interview confirmed the SSD did not know if Resident #123 had any money, and no other arrangements had been made for Resident #123 to receive meals. Continued interview confirmed the resident's prescribed medications were called to a local pharmacy for delivery to the resident at the hotel. Further interview confirmed the medications had not been delivered to the resident, and the facility did not know this prior to the Ombudsman's visit on 2/12/18. Continued interview revealed the facility had not made a plan to check on the resident's wellbeing. Telephone interview with the Ombudsman for the facility, on 3/20/18 at 10:30 AM, confirmed the Ombudsman was not aware Resident #123 was discharged on [DATE] and stated, No one knew he was being discharged . Interview continued and revealed, .the attorney from Legal Aid came to my office early on Monday (2/12/18) and told me he had a voice mail from the resident's sister about the discharge .I went to (the facility's proper name) .I told them he didn't have a phone .I saw the social worker (SSD) call his room in front of me and then call the front office of the hotel about his phone not working .I told them he didn't have his meds . Interview with the Supervisor Administrator on 3/21/18 at 3:00 PM, in room [ROOM NUMBER], revealed the Supervisor Administrator provided oversight of the facility as needed. Continued interview with concurrent review of the organizational chart revealed the Supervisor Administrator reported directly to the President of the Governing Body. Further interview revealed the Supervisor Administrator was not onsite on 2/9/18 and did not have full knowledge of the circumstances of Resident #123's discharge, and stated .I didn't know he didn't have his medications . In summary, Resident #123 had a discharge from the nursing facility planned and executed on the day of 2/9/18. The attending physician and Medical Director were not consulted prior to Resident #123's discharge to a hotel room. The facility paid for 3 nights over the weekend (Friday, Saturday, Sunday). By the time the family was notified, Resident #123 had already been discharged to the hotel and plans for more appropriate living arrangements could not be pursued prior to the opening of business on Monday, 2/12/18 . The facility had not ensured the resident received his medications. The facility had not made any arrangements for meals, and did not know if the resident had funds to purchase meals. The facility failed to ensure the resident had a working phone. The facility Interim Administrator and SSD had not contacted anyone in the Choices program who was able to pursue alternative living arrangements. The facility did not become aware of the resident not having a working phone and not receiving his medications from the pharmacy until the Ombudsman's visit to the facility on [DATE] at 9:00 AM. The facility had made no plans to check on the resident's wellbeing and had not visited the resident until 2/13/18, when the SSD and Licensed Practical Nurse (LPN) #4 delivered some medications to the resident at the hotel. Refer to F-622 (J), F-623 (J), F-624 (J), F-745 (J), F-835 (J) and F-867 (J).",2020-09-01
794,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2018-03-21,623,J,1,0,9RON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility records, and interview, the facility failed to notify the Long Term Care Ombudsman of 1 resident (#123) who had an ongoing appeal of a 30 day Involuntary Discharge Notice, of 3 residents reviewed for discharge. The facility's failure to provide advance notice as well as a plan resulted in Resident #123 being discharged to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The findings included: Review of facility policy Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman . Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the facility admission followed an acute care hospital stay due to a Traumatic Subdural Hemorrhage requiring surgery. Further review revealed 2 additional [DIAGNOSES REDACTED]. Review of an Interdisciplinary Progress Note dated 12/21/17 at 9:20 AM revealed .Staff brought to administrator team concern that resident may have been smoking in one of the common areas of the facility this morning. Administrator and this writer met with resident in his room to discuss .Resident denies smoking in common area. Initially he refused to allow administrator to search his room but then consented (and) also submitted a blue lighter that he had on his person .Smoking policy/agreement reviewed with resident (and) he was informed that smoking privileges are now suspended. Resident acknowledged this. Also informed resident that he would be issuing him a 30 day discharge . Review of the facility's Notice of Involuntary Discharge revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the Notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Review of the Nurse Practitioner's (NP #1, employed by the resident's attending physician) progress note dated 2/9/18 revealed, I am seeing pt (patient/Resident #123) today to discharge. Pt was caught again smoking in restricted area. Pt is hostile at assessment. Refuses to give name of PCP (primary care physician) or pharmacy. Has letter of court date continuation and believes he can stay here by law. He allows me to assess him, but tells me 'you cannot discharge me!!' Has general body pain, but denies C/P (chest pain), N&V (nausea and vomiting), chills or fever. SS (social services) to arrange for hotel .meds (medications) will be faxed to a local pharmacy .transfer care to Dr. (formal name) . Medical record review of a NP order dated 2/9/18 revealed .DC (discharge) patient (Resident #123) .today (to hotel) . Interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the social services office, confirmed Resident #123 filed an appeal for the Involuntary Discharge on 1/3/18. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Tennessee Department of Finance and Administration Commissioner's Designee, and the presiding Administrative Law judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Continued interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the social services office, confirmed a previous Administrator had not provided documentation of notification to the Long Term Care Ombudsman of the Notice of Involuntary Discharge issued to Resident #123 on 12/21/17. Continued interview confirmed the current IA and the SSD had not notified the Ombudsman of the Notice of Involuntary Discharge, the pending appeal, or of the resident's discharge on 2/9/18 to a hotel room. Interview with Resident #123's NP #1 on 3/20/18 at 9:30 AM, in room [ROOM NUMBER], confirmed the NP cared for the resident on behalf of his attending physician. Continued interview revealed, .the physician on call, not sure if it was (name of the resident's attending physician) was called and notified that day . Further interview confirmed the notification was after the resident had been discharged to a hotel. Interview by telephone with the Ombudsman for the East Tennessee Region, District 1, on 3/20/18 at 10:30 AM, confirmed the Ombudsman was not aware Resident #123 was discharged on [DATE] and revealed, No one knew he was being discharged . Interview continued and revealed, .the attorney from Legal Aid came to my office early on Monday (2/12/18) and told me he had a voice mail from the resident's sister about the discharge .I went to the nursing home .I told them he didn't have a phone .I saw the social worker (SSD) call his room in front of me and then call the front office of the hotel about his phone not working .I told them (the nursing home) he didn't have his meds when I was there (at the nursing home ) .there about 9:00 AM .the sister paid for another night at the hotel .After I got back (to her office) I called the State Director of the Ombudsman Program . Interview with the Interim Administrator on 3/20/18 at 11:40 AM, in room [ROOM NUMBER], revealed .He was discharged because he had continued to violate the smoking policy . were not aware of a plan for him to visit (group homes) the following Thursday (2/15/18). Continued interview confirmed the facility's Ombudsman had not been notified prior to the discharge of Resident #123 to a hotel room on 2/9/18. Interview continued and the IA responded to the question of why the Commissioner's Designee was not informed of the impending discharge, I am not required to contact them . Refer to F622, F624",2020-09-01
5948,TRINITY HEALTH AND REHABILITATION CENTER,inf,700 WILLIAMS FERRY RD,LENOIR CITY,TN,37771,2018-08-29,610,D,1,1,FP2211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility reporting form, review of personnel file, and interview, the facility failed to conduct an investigation of an allegation of abuse for 1 resident (#34) of 3 residents reviewed for abuse of 24 sampled residents. The findings include: Review of the facility Abuse Prevention/Reporting Policy and Procedure updated 5/9/18 revealed .facility management is required to accept all allegations of abuse and conduct a complete and thorough investigation .facility staff/supervisors will immediately intervene, identify and correct reported or identified situations .an Event Report will be initiated .any accused staff members will be immediately removed from contact .placed on administrative leave .the Administrator and the D.O.N. (Director of Nursing) will conduct a comprehensive investigation . Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual Minimum (MDS) data set [DATE] revealed a Brief Interview of Mental Status of 9 (indicating moderate cognitive impairment). Medical record review of the Staff Incident Witness Form dated 7/5/18 revealed Resident #34 informed Certified Nursing Assistant (CNA) #1 of an allegation of sexual and physical abuse naming CNA #2. Further review revealed Resident #34 reported the incident to the Social Service Director (SSD). Record review of CNA #2 personnel file revealed no disciplinary action, suspension, or witness statement in regards to an allegation of abuse of Resident #34. Interview with Resident #34 on 8/27/18 at 9:30 AM, in the resident's room, revealed she notified the facility .4 to 5 weeks ago . of an accusation of physical and sexual abuse (CNA #2/alleged perpertrator and unknown individual). Continued interview revealed Resident #34 informed the Social Service Director of the allegation of abuse. Interview with CNA #1 on 8/27/18 at 11:10 AM, in the back hallway revealed Resident #34 informed her of the allegation of abuse .about 6 weeks ago .the facility already knew . Further interview revealed CNA #1 reported the allegation of abuse to the SSD. Interview with the SSD on 8/27/18 at 11:50 AM, in her office, confirmed Resident #34 informed her of the alleged abuse. Continued interview confirmed the SSD informed the Administrator .the next day . Interview with the Administrator on 8/28/18 at 10:00 AM, in his office, confirmed the facility failed to suspend CNA #2 after the facility became aware of the allegation of abuse, and failed to conduct a thorough investigation of the allegation of physical and sexual abuse of Resident #34. Interview with the DON on 8/29/18 at 9:50 AM, in the Conference Room, confirmed she was aware of Resident #34 abuse allegation. Further interview confirmed no event report or investigation was completed.",2018-11-01
1406,SUMMIT VIEW OF ROCKY TOP,445259,204 INDUSTRIAL PARK RD,ROCKY TOP,TN,37769,2020-01-17,689,G,1,0,XWNL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of facility's investigation, and interview, the facility failed to complete a fall risk assessment and failed to implement interventions to prevent falls for 1 resident (Resident #2) of 4 residents reviewed for accidents. The facility's failure to ensure interventions to prevent accidents were implemented resulted in Resident #2 receiving a [MEDICAL CONDITION] (Harm). The findings include: Review of the facility policy titled, Falls-Clinical Protocol, dated 3/2018 showed .The staff and practitioner will review each resident's risk factors for falling and document in the medical record.the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.the staff and physician will monitor and document the individual's response to the interventions intended to reduce falling.risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented. Review of the facility policy, Fall Risk Assessment, dated 3/2018, showed .The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident centered falls prevention plan based on relevant assessment information.upon admission, the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Admission Evaluation and Interim Care Plan dated 12/6/2019 showed the section Screen for Fall Risk was left blank. Review of Resident #2's Fall Risk Assessment form dated 12/6/2019 showed it was left blank. Review of the admission Minimum Data Set ((MDS) dated [DATE] showed Resident #2 was moderately cognitively impaired, inattentive, required limited assistance of 1 staff member for activities of daily living (ADLs); except toileting, which required extensive assistance of 1 staff member and eating, which required supervision and set up. The resident's gait was unsteady, but the resident was able to stabilize without staff assistance during transitions and walking. The resident did not use mobility devices, had a urinary catheter, was frequently incontinent of bowels, and had a previous fall with minor injury. Review of a facility's fall investigation dated 12/29/2019 showed Resident #2 fell in another resident's room on 12/29/2019, resulting in a skin tear to the elbow. Interventions that were to be implemented after the fall included a physical therapy evaluation, bed in low position, and fall mats placed on both sides of the resident's bed. Review of Resident #2's Current Care Plan dated 12/29/2019 showed .Fall-Resident was found by another resident lying on the side of his bed. Resident notified staff that (Resident #2) had fallen.Interventions.Will receive total assistance with transfers to reduce the risk of falls.will receive total assistance with locomotion.will receive total assistance with walking to reduce the risk for falls.Provide safe, clutter free environment.Call light within reach, with prompt response to all requests.Resident's bed is low and locked; fall mats placed on both sides of bed; PT/OT (physical therapy/occupational therapy) to eval (evaluate) and treat.Mobility devices/equipment geri chair.Rehab to evaluation (evaluate) and follow up as ordered.Safety training and education as needed.Prompt to ask for assistance. Medical record review showed no PT/OT evaluation was completed after Resident #2 fell on [DATE]. Review of facility documentation dated 1/2/2020 at 9:30 PM showed .(Resident #2) Fall.fell into floor next to bed.bruising to R (right) leg and extreme pain.resident lying in floor on R side next to bed.Recommendations/Interventions to prevent recurrence: fall mats (an intervention that was to have been in place since the 12/29/2019 fall). Review of a Nurse's Progress note dated 1/2/2020 at 9:30 PM showed .CNA (Certified Nurse Assistant) informed this nurse that this resident (Resident #2) was in the floor at this time. This nurse observed resident lying in floor on right side next to bed. Head to toe assessment done at this time. Noted bruise to right hip and resident had right leg drawed (drawn) up. Resident moaning and groaning in pain at this time. Called (Nurse Practitioner) and orders for stat (immediate) x-ray to right hip and pelvis. Order for [MEDICATION NAME] (pain medication) 5/325 mg (milligrams) po (by mouth) x (times) 1 dose only for pain now. Neuro check done at this time and WNL (within normal limits). Awaiting mobile images at this time. Review of a Physician's Telephone Order (TO) dated 1/2/2020 showed .stat x-ray to R hip + (and) R pelvis.[MEDICATION NAME] 5/325 mg x 1 dose now for pain.fall.dementia.(decreased) mobility.TO per (named NP). Review of a Mobile Images Patient Report for Resident #2 dated 1/2/2020 showed Resident #2 had an Acute Right Femoral Neck fracture ([MEDICAL CONDITION]). Review of a Nurse's Progress note dated 1/2/2020 at 11:54 PM showed .(Resident #2) sent to ER (emergency room ) via E[CONDITION] (emergency medical services) at 11:45 PM as ordered by (named NP) on fall that happened on second shift. X-ray results confirms right head of femur fracture. V/S (vital signs) 108/[AGE] bp (blood pressure) [AGE].2 temp (temperature) 98 pulse 24 resp (respirations) 95 o2 (oxygen saturation) facial grimacing noted. Review of an Acute Care Hospital Emergency Department Physician's report dated [DATE] at 6:55 AM showed .Pt (patient) has right hip fx (fracture).CT (computed tomography) of pelvis showed minimally displaced.[MEDICAL CONDITION] femur with non-displaced femoral neck fracture. Review of a Hospital discharge summary dated 1/6/2020 showed Resident #2 had an Open Reduction Internal Fixation (open surgical repair of the hip) and Right Hip Pinning on [DATE] without complications. The resident was discharged back to the facility on [DATE]. Interview with Licensed Practical Nurse (LPN) #2 on 1/14/2020 at 2:51 PM confirmed .I arrived on shift.at 9:50 PM.got report from (LPN #1).(Resident #2) had fallen about 10 minutes before I came on shift.he (Resident #2) was laying on the ground.she (LPN #1) told me that the patient was ambulating to the bathroom and slipped and fell and he was on the floor and not to move him from doctor's orders for a suspected hip break.no fall mat (was beside the resident's bed). During interview on 1/14/2020 at 3:35 PM, CNA #1 confirmed the fall mats were not in place when Resident #2 was found on the floor. CNA #1 stated .was going to put (Resident #2) back into his bed but the nurse (LPN #1) said.looks like a fracture.(the resident) couldn't move it.appeared to be in severe pain.no pain except when moving him.NP wanted to get x-ray. During interview on 1/14/2020 at 3:46 PM, the Director of Nursing (DON) confirmed fall mats on both sides of the resident's bed was supposed to be implemented after Resident #2's fall on 12/29/2019. The DON stated she did not know if fall mats were in use when the resident fell on [DATE]. The DON confirmed Resident #2's admission fall risk assessment was not completed. During interview with the NP on 1/14/2020 at 4:52 PM, NP stated .a fall with pain I will typically order an x-ray and if there is a fracture, I will send them out.if there is a fall.may just be soft tissue injury.jarred from a fall, but not a fracture.I was told by the nurse.he was found in the floor.had pain in his leg.they said they don't know if there was an injury.they didn't give me a pain scale.didn't say how much leg pain.they were concerned enough they wanted an x-ray.there was a possible injury.So I gave an order for [REDACTED]. During telephone interview with CNA #2 on 1/21/2020 at 3:10 PM, CNA #2 stated .me and the other CNA walked in the room.he (Resident #2) was on the floor.no floor mats.(Resident #2) never had floor mats. During telephone interview with LPN #1 on 1/21/2020 at 4:05 PM, LPN #1 stated .(Resident #2) was in the floor next to his bed on his right side.no floor mats.when I was doing head to toe.he was favoring that right side.excruciating pain.at that time never saw them (fall mats).",2020-09-01
1854,SIGNATURE HEALTH OF PORTLAND REHAB & WELLNESS CENT,445306,215 HIGHLAND CIRCLE DRIVE,PORTLAND,TN,37148,2017-09-21,312,E,1,0,DUCD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the Shower List and Bathing Report, interview, and observation, the facility failed to provide staff assistance for hygiene and/or bathing for 6 residents (#3, #4, #5, #6, #22, #23) of 8 residents reviewed requiring shaving and/or bathing assistance. The findings included: Review of the facility policy, Skin Assessments and Evaluations At-A-Glance,undated, revealed, .On resident shower/bath days, CNAs (Certified Nurse Aides) will complete total body skin observations and document them on the CNA Skin Alert Form . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident expired on [DATE]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 required extensive 1 person assistance with hygiene, and was total dependence with 1 person assistance for bathing. Review of the Quarterly MDS dated [DATE] revealed Resident #3 was total dependence with 1 person assistance for hygiene and bathing. Review of the Station 1 Shower List revealed Resident #3 was scheduled on Tuesdays and Fridays for a shower. Review of the ,[DATE] Bathing Report revealed Resident #3 failed to receive a shower on Tuesday, [DATE]; on Friday, [DATE]; and on Tuesday, [DATE] as scheduled. Further review revealed the resident failed to receive any form of bathing on [DATE], [DATE], [DATE], [DATE] and [DATE]. Interview with the Director of Nursing (DON ) on [DATE] at 2:35 PM in the conference room, and on [DATE] at 2:25 PM in the conference room, confirmed Resident #3 was scheduled to receive showers every Tuesday and Friday. Further interview confirmed the facility staff failed to provide a shower as scheduled to a resident with total dependence of 1 staff member to provide bathing assistance. When asked if the failure for staff to bathe a resident requiring total staff assistance was an acceptable practice the DON stated No. 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 required extensive 1 person assistance for hygiene and bathing. Review of the Station 1 Shower List revealed Resident #4 was scheduled on Tuesdays and Fridays for a shower. Review of the ,[DATE] Bathing Report revealed from [DATE]-[DATE] Resident #4 failed to receive a shower on Tuesday, [DATE]; on Friday, [DATE]; and on Tuesday, [DATE] as scheduled. Further review revealed the resident failed to receive any form of bathing on [DATE], [DATE], [DATE], [DATE], and [DATE]. Interview with the DON on [DATE] at 2:25 PM in the conference room confirmed Resident #4 was scheduled to receive showers every Tuesday and Friday. Further interview confirmed the facility staff failed to provide a shower as scheduled to a resident requiring extensive staff assistance. When asked if the failure for staff to bathe a resident requiring extensive staff assistance was an acceptable practice the DON stated No. 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 Resident #5 was moderately cognitively impaired; could hear adequately, had clear speech, made self understood and understood others; and required extensive 1 person assistance for hygiene and bathing. Interview with Resident #5 on [DATE] at 10:53 AM in his room revealed he liked to be clean shaven and had not had a shave in ,[DATE] days. Observation on [DATE] at 10:53 AM, 11:25 AM, 12:00 PM, 3:10 PM, and 4:40 PM revealed Resident #5 in various locations in the facility with long facial hair. Observation and interview with Resident #5 on [DATE] at 7:45 AM and 9:20 AM in the dining room revealed he was clean shaven and he said he .wanted a shave and shower 2 times a week at least . Interview with direct care Certified Nurse Aide (CNA) #8, on [DATE] from 8:30 AM to 8:55 AM on the Station 1 unit revealed she was assigned to the resident last Thursday and came back Monday to find .my men on (resident's) hall need a shave . Review of the Station 1 Shower List revealed Resident #5 was to have a shower on Tuesdays and Fridays. Review of the Bathing Report for Resident #5 revealed he received 1 shower in ,[DATE] and all other bathing was a half bath. Interview with the DON on [DATE] at 7:30 AM in her office confirmed Resident #5 received 1 shower the entire month of ,[DATE] and there was no documentation of the resident refusing a shower. Further interview confirmed residents were to be shaved as requested or as needed. Further interview confirmed the facility staff failed to provide a shower and shave as scheduled to a resident requiring extensive staff assistance. When asked if the failure for staff to bathe and shave a resident requiring extensive staff assistance was an acceptable practice the DON stated No. Medical record review of Resident #6's Admission Record Face Sheet revealed she was admitted [DATE]. She had [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE], revealed Resident #6 had a Brief Interview for Mental Status score (BIMS), of 8 out of 15 indicating moderate cognitive impairment. The Activities of Daily Living (ADL), revealed Resident #6's total dependence of one person assistance for bathing. Review of the facility's undated Bathing Schedule revealed she should have received a bath or shower every Wednesday and Saturday. Resident #6's Bathing Reports and C.N.[NAME] Skin Care Alert sheets from (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) revealed: December, she should have received a bath or shower 9 times. There were 2 baths or showers documented. January, she should have received a bath or shower 8 times. There were 2 baths or showers documented. August, she should have received a bath or shower 9 times. There were 5 baths or showers documented. September, she should have had 5 baths or showers to-date for the month. There were 2 baths or showers documented. Medical record review of Resident #22's Admission Record Face Sheet revealed she was admitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE], revealed Resident #22 had a BIMS score of 8 out of 15 indicating moderately cognitively impaired. She required total dependence of one person assistance for bathing. Review of the facility's undated Bathing Schedule revealed Resident #22 should have received a bath or shower every Monday and Thursday. Review of her Bathing Reports and C.N.[NAME] Skin Care Alert sheets, from (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) revealed: December, she should have received a bath or shower 9 times. There were 2 bed baths documented. January, she should have received a bath or shower 9 times. There was 1 bed bath documented. August, she should have received a bath or shower 9 times. There were 3 full baths or showers documented. September, she should have received 5 baths or showers to-date for the month. There were 2 full baths or showers documented. Medical record review of Resident #23's Admission Record Face Sheet revealed she was admitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #23 had a BIMS score of 15 out of 15, indicating she was cognitively intact. She required total dependence of one person. assistance for bathing. Review of the facility's undated Bathing Schedule revealed she should have received a bath or shower every Tuesday and Friday. Review of her Bathing Reports and C.N.[NAME] Skin Care Alert sheets from (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) revealed: December, she should have received a bath or shower 9 times. There were 4 showers documented. January, she should have received a bath or shower 9 times. There were 2 showers documented. August, she should have received a bath or shower 9 times. There were 5 showers documented. September, she should have received 5 baths or showers to-date for the month. There was 1 shower documented. Interview with Certified Nurse Aide (CNA) #8 on [DATE] at 3:00 PM at the main nurses' station revealed C.N.[NAME] Skin Care Alert sheets should have been filled out every time a bath or shower was given, or if the resident refused. Interview with the Director of Nursing on [DATE] at 3:15 PM in her office revealed C.N.[NAME] Skin Care Alert sheets should have been filled out every time a resident was given a bath or shower. A Bathing Report should have been documented if a shower or bath was given. Refused should have been marked in the reports if the resident refused a bath or shower on any bath day. If the resident refused, refused should have been documented on one of the alert sheets. If Bathing Reports had documented a half type of bathing, that could mean peri care after an incontinence episode or a bed bath. There was no way to tell which occurred, unless there was a C.N.[NAME] Skin Care Alert sheet with the same date of the bath report. She thought some staff had just not filled out the C.N.[NAME] Skin Care Alert sheets every time they had given a bath or shower. Review of staff training In-Services from dated [DATE] revealed .We understand staff issues but do your best to complete showers as much as possible. If families ask about showers don't become defensive, just simply say I haven't gotten to it yet but I will before the day is over. Then try your best to complete that shower .",2020-09-01
1358,HARTSVILLE CONVALESCENT CENTER,445256,649 MCMURRY BLVD,HARTSVILLE,TN,37074,2019-09-19,689,K,1,0,2T6811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the facility fall investigation, interview and observation, employee record review, the facility failed to investigate falls thoroughly, failed to supervise the Nurse Aides (a noncertified Nurse Aide (NA) is an employee performing direct resident care without completing the certification and competency evaluation), failed to provide staff supervision and failed to provide resident supervision and assistance necessary to prevent a fall for 5 residents (#1 #2, #8, #9 and #13) of 9 residents reviewed for falls. The facility's noncompliance resulted in a fall for Resident #1, the fall resulted in a laceration to the head requiring 10 sutures. The facility's noncompliance resulted in a fall for Resident #2 due to 3 different facility staff leaving Resident #2 unattended in the bathroom on 3 separate occasions. The fall resulted in a [MEDICAL CONDITION]. This failure placed Resident #1 and Resident #2 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 and facility owner were notified of the Immediate Jeopardy on 9/18/19 at 5:10 PM in the Conference Room. An acceptable Allegation of Compliance was received on 9/19/19 at 5:10 PM which removed the immediacy of the jeopardy. Corrective actions were validated through review of documents, observation and staff interviews conducted on site on 9/19/19. The Immediate Jeopardy was effective from 6/3/19 - 9/19/19. Noncompliance continues at a scope and severity of [NAME] to monitor the effectiveness of the corrective actions. F689 is Substandard Quality of Care. The findings include: Review of the undated facility policy, Fall Risk, revealed .All residents are considered to be a fall risk .Implementation: 1. Use Fall Risk Assessment form to identify each resident for risk upon admission/readmission/as needed .Fall Investigation Process .all falls/Incidents will be investigated to determine cause and Possible interventions .Procedure: When a resident has a fall/incident: The Charge Nurse will fill out the appropriate incident packet. The charge nurse will notify the physician of any major injuries (fractures, major bleeding, hematomas, etc.) .The DON (Director of Nursing) or designee will review falls/incidents in the morning meeting Monday thru (through) Friday . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Nursing assessment dated [DATE] revealed Resident #1 had a score of 20 on the Fall Risk Assessment indicating the resident was at high risk for falls. Medical record review of the Admission Physician Orders dated 4/29/19 revealed Resident #1 was to have .Bed pad (pressure) alarm (alarm alerts care giver with audio alarm when the resident gets out of the bed or chair) on bed @ (at) all times for safety, tab alarm (A pull string attached to the secured alarming device and to the resident. When the pull string contact is disrupted the alarm alerts care giver with audio alarm when the resident gets out of the bed or chair) @ all times when up in w/c (wheelchair) for safety .Bed in lowest position @ all times . Review of the facility investigation documentation, written by Licensed Practical Nurse (LPN) #6, dated on 5/1/19 at 7:00 PM revealed Resident #1 was found on the dining room floor with a very small scratch bleeding on right cheek which stopped bleeding immediately after cleansing. Further review of the facility investigation documentation, written by LPN #5, revealed on 5/1/19 at 7:00 PM LPN #5 heard the alarm sounding and noted Resident #1 on floor in a fetal position on the right side in dining room. As a result of the fall the resident had a .very small scratch to R (right) side of face . The new intervention implemented was .continuous supervision while up out of bed, remove from DR (dining room) after meals, at NS (nursing station) . Further review revealed NA #4, Certified Nurse Aide (CNA) #8 and LPN #5 were providing Resident #1 care as nurse aides/certified nurse aides. Telephone interview with NA #4 on 8/13/19 at 9:21 AM revealed .I'm the one that found (named Resident #1) .I was doing rounds, (Resident #1) had alarm but at the time he took it off. Looked like he had slid out of the wheelchair in the dining room .I saw him when he was on the floor .and presented to (nurse). The nurse (LPN #5) checked the resident and we got him in the chair and reattached alarm . Interview with CNA #8 on 8/12/19 at 4:40 PM in the conference room revealed CNA #8 was in the dining room and saw Resident #1 seated in the wheelchair. Further interview revealed the resident .usually sat in the wheelchair after eating for a little bit and .just that quick he was on the floor .I remember resident on the floor and (named LPN #5) checking the resident .he was fine and got resident up into the wheelchair . Review of the fall investigation involving Resident #1 on 5/1/19 revealed no statement from CNA #8 or NA #4. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had moderately impaired hearing and vision with no devices; unclear speech, rarely or never made self understood, and rarely or never understood others. The resident had a score of 3 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The resident had no change in mental status, had exhibited inattentive and disorganized thinking continuously with no fluctuation. The resident required extensive 2+ (or more) person assistance with transferring and required extensive 1 person assistance for bed mobility. Resident #1 required total 1 person assistance for locomotion on/off unit and for toileting. The resident's balance was not steady and required staff assistance for stabilization when moving from a seated to a standing position, when walking, and when doing surface to surface transferring. The resident did not turn around or move self on/off the toilet. The resident had fallen 1 month and 2-6 months prior to admission. The resident had a fall with injury after the admission. The resident had alarms on the bed and the chair daily. Medical record review of the Nurse's Notes, written by LPN #6, for Resident #1 dated 6/3/19 revealed .Called to room by (NA #2), resident laying on floor beside bed, no apparent injury, assisted back to bed, neurochecks all WNL (within normal limits) . Review of the investigation documentation dated 6/3/19 at 9:00 PM revealed the pressure pad alarms were used in the chair and the bed. Further review of the investigation by the interdisciplinary team revealed .check alarm functionality q (every) shift, to ensure proper working order . Telephone interview with LPN #6 on 8/12/19 at 3:30 PM confirmed the LPN was assigned to Resident #1 on 6/3/19 when the fall occurred. Further interview revealed .I .was called to the resident's room by (named NA #2). First she told me she had put the resident in the bed. Later she told me she had left the resident in the wheelchair. From what I saw it looked like the resident had rolled out of the wheelchair. The resident was constantly playing with something down on the floor, leaning over to touch something there or not. Looked like he had rolled forward out of wheelchair onto the floor by way he was on the floor. The back of the wheelchair was against the bed, the resident's feet were in front of the opening of the wheelchair and his head was toward a wall. I don't recall now if the alarm was sounding or not. He had a pad alarm in the chair if I remember right .He was non-compliant with safety measures . Telephone interview with NA #2 on 8/12/19 at 5:28 PM and on 8/13/19 at 11:06 AM confirmed the NA was assigned to Resident #1 on 6/3/19. Further interview revealed .I took (named Resident #1) to his room and put him into the bed by myself .I left the room, went to another resident's room and then heard (named Resident #1) talking. I seen him on the floor and I said 'Why you on the floor?' and he said 'Didn't you hear me yelling for you?' I said 'No' and I got the nurse . Interview with the DON on 8/13/19 at 1:50 PM in the conference room revealed the DON expected the alarm functionality to be monitored every shift and documented on the MAR/TAR (Medication Administration Report/Treatment Administration Report). Further interview revealed . should expect to see functionality checked after the 6/3/19 fall, I hope . Further interview revealed the DON was checking the alarm functionality because .it wasn't working right . Medical record review of the 6/2019 MAR and TAR for Resident #1 revealed no documentation of the alarms functionality monitoring every shift to ensure proper functioning per the 6/3/19 fall intervention. Medical record review of Resident #1's Nurse's Notes, written by Registered Nurse (RN) #1, dated 7/9/19 at 6:45 PM revealed the RN was notified by (named NA #7) that the RN was urgently needed in Resident #1's room. Further review revealed when the nurse entered the resident's room the Assistant Director of Nursing (ADON) was kneeling beside the resident on the floor applying pressure to the resident's forehead. The resident had fallen from the bed and was against the wall on the right side of the bed. The alarm was sounding intermittently. Review of the Incident/Accident Report, written by RN #1, dated 7/9/19 at 6:45 PM revealed Resident #1 was found on the floor by a visitor to the facility. The visitor then notified NA #7 of the fall and NA #7 then notified the ADON. When RN #1 arrived in Resident #1's room the resident was on the .floor bleeding from forehead on right side of bed (with) back to wall next to window . Further review revealed the ADON held pressure to the wound and the RN applied a pressure dressing. Further review revealed the resident was .1. Sent to ER (emergency room ) for eval (evaluation) and treat (treatment), 2. Bed pad (alarm) applied (New) . Review of the Witness Statement written by NA #2 dated 7/9/19 at 8:00 PM revealed NA #2 was assigned to the resident and the bed pad alarm was sounding intermittently. Review of the facility investigation documentation dated 7/9/19 revealed the pressure pad alarm was not applied correctly and Resident #1 had a .large laceration to R (right) forehead .Newly Implemented interventions: Sent to ER for evaluation + tx (treatment) . Further review of the interdisciplinary team fall investigation revealed in order to reduce reoccurrence the equipment (pressure pad alarm) would be replaced/repaired. Review of the hospital emergency room documentation dated 7/9/19 revealed Resident #1 had a .Laceration: Wound Repair of 8 cm (centimeters) (3.1 in (inch)), subcutaneous (under the skin), laceration to the forehead .Skin closed with 10 .sutures . Telephone interview with NA #2 on 8/12/19 at 5:28 PM and on 8/13/19 at 11:06 AM confirmed she had placed Resident #1 into the bed on 7/9/19 and then left the room to attend to another resident. Further interview revealed .(named ADON) said to get a new one (bed pad alarm) . Telephone interview with RN #1 on 8/13/19 at 9:42 AM revealed .(named NA #7) .said (Resident #1) was on the floor .I saw (named MDS nurse) was in the doorway (of the resident's room) .I said I don't hear the alarm .I asked about the alarm sounding because I didn't hear it. (named NA #2) had put the resident to bed . Observation from 8/6/19 to 9/19/19 at various times during the survey revealed alarms were audible on both units and once activated were continuously audible. Further observation revealed staff responded immediately when the alarm was activated, resident was checked for safety and the alarm was reset by the staff. Interview with the ADON on 8/13/19 at 10:35 AM in the ADON's office revealed a .non-certified technician (NA #7) had come to me and said (RN #1) needed me in (Resident #1's) room. (named MDS nurse) and I .took charge of the scene .(named Resident #1) was sitting on the floor on his buttocks .between the bed and the window. I sent (named RN #1) to get a pressure dressing, and told the non-certified aide to get a washcloth so I could apply pressure .I left him on the floor, made him comfortable, and applied pressure to his forehead .The (bed pad) alarm on the bed was malfunctioning. (named MDS nurse) tested it and sometimes it was working and other times was not working so we replaced the (bed) pad (alarm) . Medical record review of the Physician's Telephone Order dated 7/9/19 revealed .Pressure pad (alarm) on bed @ all times for safety; check for placement + (and) functionality .Tab alarm on bed + chair @ all times for safety; check for placement and functionality .Mats on floor @ all times for safety . Medical record review of the MAR and TAR dated 7/1/19 through 7/31/19 for Resident #1 revealed no documentation of the alarm functionality monitoring every shift to ensure proper functioning. Review of Resident #1's 7/9/19 fall investigation revealed no witness statements from the visitor who alerted NA #7 of the fall, the ADON or the MDS nurse; no documentation of resident's location prior to the fall; how the resident got to the location and no review of the alarm placement and functionality documentation since the 6/3/19 implementation through 7/31/19. Interview with the Administrator, DON, and ADON on 8/13/19 at 1:50 PM in the conference room confirmed the facility failed to monitor the alarm functionality from 6/3/19 through 7/31/19. When they were asked why the 5/1/19 investigation failed to include a statements from CNA #8 and NA #4 and the 7/9/19 investigation failed to include statements from the visitor alerting NA #7 of the fall, the ADON and the MDS nurse, the DON stated .I don't know .we should have . When the DON was asked where Resident #1 was located prior to the 7/9/19 fall and how did the resident get to the location, the DON revealed she .did not ask . When asked if the facility considered the investigation thorough in order to determine the cause of the fall, the Administrator, DON nor the ADON responded. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 5 day MDS dated [DATE] revealed Resident #2 had adequate hearing; had impaired vision and used lenses; and his speech was clear, he could make himself understood and he usually understood others. The resident was cognitively intact with a score of 14 on the BIMS. The resident had evidence of an acute mental status change from baseline and had disorganized thinking present which fluctuated. The resident had exhibited a change in energy level and concentration for 2-6 days of the review period; and exhibited physical behaviors for 1-3 days of the review period. The resident required extensive 1 person assistance for bed mobility, transferring and toileting. The resident required limited 1 person assistance for walking in room and in corridor. The resident was not steady and could only stabilize with staff assistance for moving from seated to standing position, moving on and off the toilet and for surface to surface transferring. The resident was always continent of the bowel and occasionally incontinent of bladder. The resident had fallen 1 month and 2-6 months prior to admission. Review of the Admission Nursing assessment dated [DATE] revealed Resident #2's Fall Risk Evaluation score was 26 indicating he was at high risk for falls. Review of the Admission/Interim Plan of Care (baseline care plan) dated 7/5/19 revealed Resident #2 was identified at risk for falls with a history of falls. The interventions included .PT/OT (Physical Therapy/Occupational Therapy) referral .Instruct resident on safety measures as needed .Requires staff supervision/assistance for safe transfers/ambulation . Review of the Nurse's Notes dated 7/7/19 at 11:00 PM revealed Resident #2 was .alert to person .Confused @ x's (times). Non-compliance (with) safety-RSD (resident) ambulated per self to bathroom this nurse redirected. Assist x 1 (with) ADL's (activities of daily living) + ambulation gait unsteady . Review of the Incident/Accident Report, written by RN #1, dated 7/14/19 at 7:00 AM revealed Resident #2 was heard screaming from the resident's room and was found lying on the floor on the left side complaining of hip and shoulder pain. The resident was assisted to the bed. The resident was sent to the emergency room for a possible fracture. Review of the written statement, by the DON regarding Resident #2's fall revealed on the morning of 7/14/19, around 7:30 AM, RN #1 called the DON to notify the DON Resident #2 had fallen and was sending the resident to the emergency room . RN #1 was in the resident's room doing bed B's accucheck. RN #1 had reported that Resident #2 was in the bathroom without oxygen, unattended, and the RN #1 knew the resident was compromised, due to respiratory status and orthostatic [MEDICAL CONDITION]. Further review revealed RN #1 .went to get a tech (technician), and as I was walking up the ramp it hit me (left resident unattended) and when I went back to (named Resident #2's) room he was in the floor . Review of the handwritten statement, by NA #1 dated 7/16/19 revealed on the morning of 7/14/19 LPN #1 said Resident #2 was on the commode and asked .if I would go check on him . The NA was not aware the resident could get out of bed due to resident's blood pressure dropping so badly when he stood up, let alone walking unassisted. The NA went to the resident's bathroom, asked if the resident needed help, Resident #2 replied with .'Naw, naw' .No, leave me the hell alone.' Then I said 'OK, here's this cord (call light) when you're done pull this so I know you're done and I can help you back to bed, I don't want you to get hurt . Continued review revealed the NA left the resident unattended and about 15 minutes later (named RN #1) was yelling in the hallway the resident was on the floor. The NA entered the resident's room to see the resident sitting on the floor, on the left leg, and the resident was yelling in pain. (named RN #1) was trying to get vital signs but the resident was moving his arms.RN #1 said, 'Let's move him to the bed.' At that time I felt (named RN #1) being my superior I needed to do as she said . At about 7:00 AM (named LPN #2) came on duty and came to help .(named LPN #2) and (named RN #1) grabbed his legs and I hooked my arms under his arm pits and we got him from the floor to his bed . Interview with the Rehabilitation Director on 8/12/19 at 2:25 PM in the conference room, revealed on the last day of therapy provided on 7/12/19 the resident declined and required moderate to maximum assistance for bed mobility, rolling side to side, scooting and supine to sit and minimum assistance with transferring. Interview with LPN #1 on 8/12/19 at 6:53 AM in the common area, confirmed the LPN was assigned to Resident #2 on 7/13/19 on the 11:00 PM - 7:00 AM shift. Further interview revealed the LPN had checked on the resident and found the resident in the bathroom. Further review revealed .the (resident) must have walked there by .himself .I asked (the resident) if .was ready to get back to bed and (the resident) said 'No' . Continued interview revealed the LPN had left the resident unattended in the bathroom .I sent (named NA #1) to see about the resident in the bathroom .Then a nurse (RN #1) was coming down the hall and he was hollering, and she (RN #1) said the resident fell by the bed .I went to the room and said leave him on the floor .he was complaining of hip pain . Telephone interview with NA #1 on 8/12/19 at 8:08 AM confirmed the NA was assigned to Resident #2 on 7/13/19 on the 11:00 PM - 7:00 AM shift. The NA revealed .Prior to that day I never seen him get out of bed and walk .and (named LPN #1) said (named Resident#2) was in the bathroom. I said who took him to bathroom? (named LPN #1) said I guess he took himself . NA #1 told the nurse the NA would check on the resident in the bathroom. The resident told the NA he was not finished and the NA handed the resident the call light with instruction .to use it, hit it before he needed to get up . Further interview revealed the NA left the resident unattended in the bathroom. The NA heard (named RN #1) hollering after the RN found (named Resident #2) on the floor. Further interview revealed the NA .was not aware the resident couldn't walk. I was not aware the resident was a fall risk .his head was at the head of the bed and his feet were at the foot of bed like he was trying to get in the bed. He went from the bathroom to the bed . Continued interview revealed RN #1 and the NA were in the resident's room when LPN #1 came in and .told us to keep the resident on the floor . and then LPN #1 left. Later .(named RN #1) said we needed to get the resident into the bed. Then the 7:00 AM-3:00 PM nurse came in, me, that nurse and RN #1 picked up resident and put into bed Telephone interview with RN #1 on 8/12/19 at 10:59 AM when asked if the RN had been involved with Resident #2 on 7/13/19 on the 11:00 PM - 7:00 AM shift regarding a fall, the RN revealed .I was working downstairs when LPN #1 .needed help. I went upstairs .was doing the accucheck of Resident #2's roommate (in B bed). I looked around Resident #2 not in the bed .went to dining room. (named LPN #1) said (named Resident #2) was in the bathroom and 'we were checking on him for a while now.' I said 'You can't do that' .I heard him screaming .(named NA #1) came into room and was screaming 'I told (resident) not to get off toilet.' .(named LPN #2), came in the room with us. I ran to (named LPN #1) at the nursing station .when I realized (named LPN #2) came with me and left the resident (alone) with NA #1 . Review of the hospital Emergency Department Record with admitted [DATE] revealed Resident #2 .Arrived per ems\NH (nursing home) staff, pt. (patient) stood to try to use restroom and fell . L (left) leg shortened ext (extremity) rotated. Pt reports pain in hip .Disposition: 7/14/19 Preliminary [DIAGNOSES REDACTED]. Interview with the DON and ADON on 9/12/19 at 2:05 PM in the conference room confirmed the facility had a NA assigned to the resident who was not knowledgeable of his care and did not get supervised when providing care to Resident #2. Further interview confirmed 3 staff members had seen Resident #2 unattended in the bathroom at 3 separate times. Further interview confirmed the facility did not have a thorough investigation and failed to determine the root cause of the fall. Medical record review revealed Resident #8 was readmitted to the facility was on 12/7/17 with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan addressing falls for Resident #8 with an updated intervention dated 3/12/19 revealed .tab alarm on resident at all times on bed/chair . Medical record review of the Quarterly MDS dated [DATE] revealed Resident #8 BIMS score was 5, indicating the resident had severe cognitive impairment and had exhibited disorganized thinking which fluctuated. The resident required limited 1 person assistance for transferring and toileting. Further review revealed a bed and chair alarm was used daily. Medical record review of the 7/2019 Physician's Order revealed Resident #8 had a pull tab alarm at all times while in bed and chair for safety. Review of the facility staffing revealed RN #1, NA #1 and NA #7 were assigned to Resident #8's unit on 8/1/19 for the 3:00 PM 0 11:00 PM shift. Medical record review of the Nurse's Notes dated 8/1/19 revealed Resident #8 was witnessed attempting to self transfer without locking brakes and sat on the floor. The resident was assessed and no injury was noted. Review of the facility investigation documentation, written by RN #2, dated 8/1/19 at 6:00 PM revealed Resident #8 self propelled the wheelchair to the bedside at 5:50 PM and the RN witnessed the resident attempting to self transfer from the unlocked wheelchair to the bedside. The resident then .sat/slide to floor . and no apparent injury was noted. Further review of the investigation revealed a pressure pad alarm (although a tab alarm was ordered) was utilized. Further review of the interdisciplinary team fall investigation revealed a tab alarm and pressure pad alarms (although not ordered) were included in the preventative measures used prior to the fall. Further review revealed the facility investigation failed to clarify the use of the (ordered) tab alarm at the time of the fall, failed to address who placed the alarm(s) on the resident, failed to address if the alarm(s) were activated at the time of the fall, failed to interview the noncertified staff on duty and failed to determine the root cause of the fall. Medical record review of the Physician's telephone Order dated 8/4/19 revealed pull tab alarm at all times while in bed and chair, check every shift for placement. Sensory pad alarm at all times in bed and chair, check every shift for placement and functionality. Medical record review of the (MONTH) and (MONTH) 2019 MAR/TAR revealed the alarm(s) was/were not checked for placement and functionality until 8/4/19. Interview with the DON and ADON on 9/11/19 at 4:30 PM in the conference room confirmed Resident #8 had an order of a tab alarm on at all times when in chair or bed at the time of the fall. Further interview revealed at times the facility did not obtain orders for the alarms. Interview confirmed the facility failed to thoroughly investigate the fall, failed to address if the alarm(s) was/were functioning, failed to interview the noncertified staff and failed to determine the root cause of the fall. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE] revealed Resident #9 was moderately impaired cognitively with a score of 9 on the BIMS. Continued review of the MDS revealed Resident #9 required limited 1 person assistance with transfers and ambulation; was occasionally incontinent of bladder; and was always continent of bowel. Further review revealed a chair and bed alarm was used daily. Medical record review revealed no physician orders for an alarm(s) for safety. Review of facility investigation revealed on 4/7/19 at 11:40 PM Resident #9 was heard yelling for help. Upon entering the room LPN #1 and CNA #10 found the resident lying on the floor on the left side and partially on the stomach. The resident stated he was getting up to go to the bathroom. No injuries were noted at that time but Resident #9 did complain of back and side hurting. Later the resident complained of a headache and staff noted a hematoma on the left side of his head near the hair line. Continued review of facility investigation included a written statement from CNA #10 dated 4/7/19 revealed .resident (#9) was put to bed before I came in so the alarm was supposed to be already in place but it wasn't turned on therefore no warning before the resident's fall. The nurse evaluated the resident then we picked the resident up off the floor and sat the resident in the wheelchair with the alarm in place in the wheelchair . Further review of the investigation revealed the section on preventative measures in place before the fall failed to mention the alarms. Medical record review of the Nurse's Notes dated 4/8/19 at 1:15 AM, written by LPN #1, revealed Resident #9 stated he .was still hurting some and a hematoma noted to left side of forehead . The note continued at 3:10 AM with .Resident stated back and hip was not hurting now. Stated head and right ankle hurts . The note continued at 7:15 AM with .(named physician) called and stated to send resident to hosp (hospital) . Interview with the DON and ADON on 9/12/19 at 2:55 PM in the conference room revealed Resident #9 got out of bed and fell . Further interview confirmed the facility failed to obtain an order for [REDACTED]. They confirmed the alarm was not turned on at the time the resident fell . They also confirmed there was an incomplete investigation with no documentation of the presence of bed and chair alarms, no interview from CNA #8 assigned to Resident #9 on 4/7/19 on the 3:00 PM - 11:00 PM regarding the alarm not turned on and no root cause determination. Medical record review revealed Resident #13 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #13 was severely cognitively impaired with a score of 3 on the BIMS. Further review revealed the resident required limited 1 person assistance for transferring and ambulation in the room and required extensive 1 person assistance for toileting. The resident had no prior falls. Further review revealed the chair alarm was used less than daily and the bed alarm was used daily. Medical record review of the 6/2019 and 7/2019 Physician's Orders revealed Resident #13 had a .sensory (pressure) pad alarm while in chair and bed .tab alarm at all times in bed and chair for safety . Medical record review of the Nurse's Notes dated 7/12/19 revealed LPN #2 saw Resident #13 in a wheelchair, outside the resident's room, as the LPN was going to assist another resident. When the LPN finished with the other resident and went past Resident #13's room the LPN saw Resident #13 lying on the left side on the floor in the resident's room. The resident stated she was trying to go to the bathroom when her knees gave out and she denied any pain or discomfort. Review of the Incident/Accident report dated 7/12/19 at 10:45 AM revealed Resident #13 was found on the floor in front of the wheelchair in the resident's room. Review of the facility investigation documentation dated 7/12/19 for Resident #13 revealed no witness statements had been completed. Further review revealed the bed/chair alarm had not been correctly applied. Further review revealed the investigation did not specify if the alarm(s) which were to be used were a pressure pad and/or tab alarm. Further review revealed CNA (#9) was to be educated on the importance of the placement of the alarms. Review of the interdisciplinary team investigation revealed the preventative measures in place before the fall included both a tab and pressure alarm on the bed and chair and the corrective measure to reduce reoccurrence was to replace the pressure pad alarm. Medical record review of the 6/2019 and 7/2019 MAR and TAR revealed the facility failed to address the placement and functionality of the tab and pressure pad alarms. Interview with CNA #9 on 9/1/19 at 8:55 AM on 200 hall confirmed the CNA was assigned to Resident #13 on 7/12/19. The CNA revealed she was working alone that day and doing bed baths and the nurse (LPN #2) was helping dress the resident (#13). Further interview revealed Resident #13 .was bad about taking the tab alarm off back then . The CNA had no recall if the alarms were in place on 7/12/19. The CNA confirmed the CNA did not complete a witness statement regardin",2020-09-01
1355,HARTSVILLE CONVALESCENT CENTER,445256,649 MCMURRY BLVD,HARTSVILLE,TN,37074,2019-09-19,607,D,1,0,2T6811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the facility investigation and interview, the facility staff failed to report an allegation of abuse to facility administration, per policy, for 1 resident (#5) of 13 residents reviewed. The findings include: Review of the undated facility policy, Abuse, Neglect, Misappropriation of Property & (and) Exploitation, revealed .Reporting Abuse .If ABUSE is suspected, of any type, employees are required to immediately notify the charge nurse on their unit where the ABUSE is suspected to have occurred. The charge nurse, whatever shift, is then to notify the social worker or the director of nursing immediately, who will then notify the administrator . 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 30 day Minimum (MDS) data set [DATE] revealed Resident #5 was severely cognitively impaired with a score of 6 on the Brief Interview for Mental Status. Further review revealed the resident's hearing and vision were adequate, required lenses for vision; had clear speech, made self understood, and understood others. Further review revealed the resident exhibited inattention continuously with no fluctuation and exhibited disorganized thinking with fluctuation in the behavior. The resident required extensive 1 person assistance for bathing and limited 1 person assistance for transferring. Review of the Incident/Accident Report dated 6/13/19 revealed the Director of Nursing (DON) was notified of the incident on 6/14/19 at 11:00 AM. Further review revealed Certified Nurse Aide (CNA) #6 reported to Licensed Practical Nurse (LPN)) #4 while Resident #5 was in the shower NA (a noncertified Nurse Aide (NA) is an employee performing direct resident care without completing the certification and competency evaluation) #3 was .splashing water in resident's face during shower .purposely, when (resident) tried to speak . Review of the facility incident investigation dated 6/13/19 revealed the DON and the Assistant Director of Nursing .spoke with (named NA #2) .she said '(named NA #3) was splashing water in the resident's (#5) face.' When asked why she didn't report it to someone, she stated 'I told the nurse (named LPN #3) that she (NA #3) was being rude and ugly to the resident' . Interview with LPN #3 on 8/13/19 at 5:25 PM in the conference room revealed .(named NA #2) came to me on 6/13/19 .told me I needed to talk to (named NA #3) who was rude to (named Resident #5). So I went to (named Resident #5) .and asked if anyone rude to her and she said 'no ma'am' . Further interview revealed .All I was told was rude. Had I had more information I would have told the Social Worker and the Director of Nursing . Interview with the Social Worker, who was also the Abuse Coordinator, on 8/13/19 at 3:25 PM in the Social Worker's office, confirmed LPN #3 failed to report the allegation of abuse immediately to the DON or the Social Worker per facility policy. Further interview revealed .I was made aware of the incident the next day, 6/14/19 .",2020-09-01
1337,RIVER GROVE HEALTH AND REHABILITATION,445253,1520 GROVE ST BOX 190,LOUDON,TN,37774,2017-08-08,225,D,1,0,BX0111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the facility investigation, and interview the facility failed to immediately report an allegation of misappropriation for 1 resident (Resident #1) of 4 resident's reviewed. The findings included: Review of the facility policy Abuse dated 10/20/16 revealed, .abuse .and misappropriation of patient property are strictly prohibited .staff reports any alleged violations .immediately .including to the State survey and certification agency . 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 for Mental Status (BIMS) score of 14, indicating Resident #1 was cognitively intact. Review of the facility's Complaints/Grievances Follow-Up dated 7/11/17 revealed, .family member reported bill activity showed phone was in use and when family called to verify phone use the person answering the phone stated a person by the name of (Certified Nursing Assistant #1) gave phone to her . Further review revealed the form was signed and dated by the Administrator and the Director of Nursing (DON) on 7/12/17. Review of the Incident Reporting System (IRS) log revealed the facility reported the incident to the State agency on 7/21/17 at 4:58 PM, 10 calendar days after being made aware of the incident on 7/11/17. Interview with the DON on 8/7/17 at 12:32 PM, in the conference room, confirmed the facility was made aware of the incident on 7/11/17 and did not report the incident immediately to the State agency but instead, 10 days later on 7/21/17.",2020-09-01
382,SEVIERVILLE HEALTH AND REHABILITATION CENTER,445132,415 CATLETT RD,SEVIERVILLE,TN,37862,2017-06-15,225,D,1,0,25IX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the facility investigation, and interview the facility failed to suspend an employee after an allegation of abuse for 1 resident (#1) of 4 residents reviewed. The findings included: Facility Policy review of the Abuse Prevention Policy and Procedure, revised 8/2016, revealed .report all allegations of abuse immediately to the Director of Nursing and Administrator .all employees are required to immediately notify the administrative or nursing supervisory staff that is on duty .so the resident's needs can be attended to immediately and investigation can be undertaken promptly .the charge nurse .will examine the resident .document findings in the clinical records .immediately initiate the Investigation protocol .any employee suspected of abuse, neglect, or mistreatment must be suspended as soon as the incident is reported pending outcome of the investigation .Do not wait . Medical record review revealed Resident #1 was a [AGE] year-old woman admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Continued review revealed the patient was discharged from the facility on 6/8/17. Medical record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact, required extensive assistance of 2 person with transferring, dressing, toileting, and personal hygiene, required extensive assistance of 1 person with walking in room and locomotion on unit, and supervision with eating. Medical record review of a Nursing Note dated 5/23/17 at 4:53 AM revealed .resident rang out for assistance to the restroom .both CNAs (certified nursing assistant) responded to help .resident was very inappropriate towards CNAs by cussing them out and threatening to get them fired .resident accused one CNA of pushing her in the wheelchair .CNA was only guiding .towards the chair .not the first time resident has cussed out these CNAs . Facility investigation review dated 5/23/17 revealed the incident occurred on 5/23/17 at 4:30 AM and at 6:40 AM Licensed Practical Nurse (LPN) #1 (days shift nurse) received the complaint and notified the Director of Nursing (DON) at 6:55 AM. Further review the DON interviewed the resident at 8:30 AM and revealed .stated .she put her light on at about 5:00 or 5:30 am this morning .two nurses came into the room .told them she had .to the bathroom .they (CNAs) wanted her to use the bedpan .she was supposed to be using the toilet .felt this made them mad .one (CNA) was in front of her .one behind the wheelchair .one behind the wheelchair pushed her down into the wheelchair causing her left leg to hurt .she told them nurse behind her .she was going to get her fired .going to tell her son .he would get a lawyer . Review at 10:00 AM the Social Worker interviewed the resident who stated 2 Registered Nurses (RN) came to her room to get her in her wheelchair and assist her to the bathroom .1 RN that was older with dark hair pushed her by her neck . Interview with LPN #1 on 6/13/17 at 11:53 AM in the conference room revealed .work dayshift .when I came in I got report .she (nightshift nurse) only told me the resident was all the time threatening staff with her attorney's .nothing was said about the resident making an allegation of abuse .the two CNAs on dayshift went to do the resident's blood pressure and the resident told them she had 2 CNAs last night and the older one .was helping her into her wheelchair from the bed .the CNA pushed her .said it hurt her and she felt she had been injured all over again .I reported it . Interview with RN #1 on 6/13/17 at 12:08 PM in the conference room revealed .I was assigned to her (resident) .(CNA #3) and (CNA #4) came out and informed me they were getting patient in wheelchair to go to restroom .(CNA #4) was going to assist her .because she was going to miss the wheelchair .I was new .I didn't know (to call supervisor) .(CNA #4) didn't go in room any more that night .I didn't assess her .I didn't know I was suppose to afterward . Interview with the Nurse Practitioner (NP) on 6/13/17 at 1:25 PM in the conference room revealed .she constantly complained .she did not want to be here .she was assessed and there were no signs of abuse .we did order some x-rays and they were negative . Interview with CNA #1 on 6/13/17 at 1:40 PM in the conference room revealed .me and (CNA #2) .had gone in to do her vital signs .said she had been abused .said .that girl last night .tall one .pushed her in her chair .we went and told (LPN #1) . Interview with CNA #2 on 6/13/17 at 2:50 PM in the conference room revealed .me and (CNA #1) .went in to her room cause her light was on .stated she came here for therapy not to be abused .said the CNA had pushed her down and hurt her leg .she didn't name the person .we told the (LPN #1) . Interview with CNA #3 on 6/14/17 at 6:00 AM in the conference room revealed .we had to help her to her wheelchair .I stood in front of her .(CNA #4) stood behind her .when she was fixing to sit she was going to miss the wheelchair .(CNA #4) put her hands on her hips to help assist her into the wheelchair so she would not miss it and fall .she said (CNA #4) pushed her .she was going to get her fired .we assisted her to the bathroom and back to bed .we told (RN #1) about what happened . Interview with CNA #4 on 6/14/17 at 6:15 AM in the conference room revealed .she was cussing .we got her up on the side of the bed .she got up .she was going to miss the wheelchair .I gently helped ease her over into the wheelchair so she would not fall and hurt herself .said you quit shoving me around .she was going to get someone fired .we assisted her to the restroom and back to bed .we mentioned it to the nurse I didn't take it serious .I finished working out the shift . Interview with the Administrator on 6/14/15 at 7:00 AM in the conference room revealed .we did discipline (RN #1) since she did not report the incident immediately and did not send (CNA #4) home . Interview with the Administrator and the DON on 6/15/17 at 9:25 AM in the Administrator's office confirmed the facility failed to report an allegation of abuse immediately to the DON and the Administrator and failed to suspend CNA #4 pending the investigation results per facility policy.",2020-09-01
1351,HARTSVILLE CONVALESCENT CENTER,445256,649 MCMURRY BLVD,HARTSVILLE,TN,37074,2017-09-12,226,D,1,0,9I4J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the facility investigation, and interview, the facility failed to completely investigate a non-abuse allegation for 1 resident (#1) of 3 resident records reviewed. The findings included: Review of facility policy, Abuse Protection and Response, undated revealed : .Investigating Issues .Any employee .with direct or indirect knowledge of any event that might constitute abuse must report the event promptly .having any knowledge .is required to .report the allegation to the proper authorities .for Tennessee; report allegation facility Administrator or Social Service Director and or .All events will be internally investigated in addition to outside investigations . Further review of the policy revealed .Response .All reports of possible abuse will be immediately assessed .Investigative steps will include, but may not limited to .obtain background information concerning the involved parties ( .name(s) of the allegedly involved and role in the situation .) . obtain background information pertaining too the events surrounding the alleged situation ( .time(s) of day, date(s), location .) .assess for any complicating factors related to the alleged situation; contact appropriate outside authorities based on alleged situation; and analyze facts collected . Medical record review revealed Resident #2 was admitted to the facility on [DATE], readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed he was cognitively intact; had no [MEDICAL CONDITION], moods, [MEDICAL CONDITION] or behaviors; required supervision with transfers, walk-in room, locomotion on and off the unit; and supervision with set-up help for walk-in corridor. Further review of the medical record revealed no [MEDICAL CONDITION] medication ordered and psychiatric services were provided for [MEDICAL CONDITION] and monitoring due to comorbidity diagnoses. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE] revealed Resident #1's short term memory was intact, was moderately impaired with daily decision making skills, required total assistance of 2 + person for transfers and dressing, total dependence of 1 person for locomotion on and off the unit, and the upper and lower extremity on one side was impaired. Resident #1 had adequate hearing, had no ability to speak, and was able to make herself understood and she understood others. Review of the facility investigation and a Nurse's Note dated 3/5/17 at 8:25 PM revealed .CNT (Certified Nurse Technician/Aide) entered room noted male RSD (resident) on top of female (with) his pants down, CNT came to this nurse and made aware of situation. This nurse entered room. Noted male RSD standing beside bed adjusting pants. This nurse ask male RSD to exit room, he did so (without) any behaviors. This nurse proceeded to ask female RSD question (with) CNT present. This nurse asked RSD if male RSD was on top of her and if he touched her @ (at) her vaginal area. Female RSD did not respond to questions, she had flat affect. This nurse assured RSD she was not in trouble and that she didn't do anything wrong. The RSD then shook her head yes to the questions. This nurse then ask(ed) RSD if she was OK (with) male RSD on top of her. This question was asked (with) CNT present. She did not respond to the question. This nurse then ask(ed) her if she was fine (with) male RSD on top of her, she then shook her head yes (with) a smile. This nurse removed covers and noted R (Right) side of brief undone and vaginal area exposed. This nurse did not see bleeding or trauma noted. This nurse proceeded in calling social worker, DON, and Administrator. The Nurse's Note continued .At 9:15 PM .This nurse notified .Nurse Practitioner of situation, she stated, Not to send male RSD out tonight if any questions by facility to call her tomorrow. Will notify next shift of situation . Further review of the facility investigation revealed hourly observations of Resident #2's location was documented from 3/7/17 through 3/31/17. Further review of the investigation revealed the facility failed to identify the Certified Nurse Aide (CNA) witnessing the event, failed to interview or have a statement from CNA #1, failed to interview or have a statement from Resident #1 and #2, and failed to interview or have a statement from any other staff member on duty (other than Licensed Practical Nurse #1). Further review revealed the facility investigation include other resident interviews regarding Resident #2's interaction with them or any observations they may have had involving Resident #2 and other residents. Interview with Resident #1 on 9/11/17 at 8:48 AM and 2:00 PM in her room revealed the resident recalled Resident #2, nodded her head Yes when asked if she had affection for him and was ok with him being on top of her and doing what he did. When asked if the resident was ever afraid while he was on top of her, if he had hurt her, and if he had done anything she did not want him to do, she shook head No to each question. Interview with the Abuse Coordinator, the Social Service Director (SSD), with the Director of Nursing (DON) and Administrator present, on 9/11/17 beginning at 9:30 AM in the conference room revealed the SSD interviewed both residents involved regarding the event and informed both resident's Responsible Parties. Further interview revealed the DON would be responsible to interview nursing staff. The DON then stated the SSD was responsible to interview all staff and parties involved. The SSD and DON confirmed, after reviewing the investigation packet information, the facility failed to have documentation of the interviews with both residents, the CNA witnessing the event, the LPN assessing Resident #1, any other staff on duty, and other residents for information regarding Resident #2 interactions with other residents therefore did not completely investigate the allegation. Interview with the DON on 9/11/17 at 1:45 PM in her office confirmed the facility did not document what the resident did from 3/5/17 after the event to 3/7/17 when they documented hourly the location of Resident #2, therefore the facility failed to have a complete investigation. Further interview revealed the DON recalled telling the staff to monitor Resident #2's location after talking with LPN #1 after the event took place.",2020-09-01
1350,HARTSVILLE CONVALESCENT CENTER,445256,649 MCMURRY BLVD,HARTSVILLE,TN,37074,2017-09-12,225,D,1,0,9I4J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the facility investigation, and interview, the facility failed to report a non-abuse allegation to the State Agency within 24 hours of the event for 1 resident (#1) of 3 resident records reviewed. The findings included: Review of a facility policy, Abuse Protection and Response, undated revealed : .Investigating Issues .Any employee .with direct or indirect knowledge of any event that might constitute abuse must report the event promptly .having any knowledge .is required to .report the allegation to the proper authorities .for Tennessee; report allegation facility Administrator or Social Service Director and or .All events will be internally investigated in addition to outside investigations . Further review of the facility policy revealed .Response .All reports of possible abuse will be immediately assessed .Investigative steps will include, but may not limited to .obtain background information concerning the involved parties ( .name(s) of the allegedly involved and role in the situation .) .obtain background information pertaining too the events surrounding the alleged situation ( .time(s) of day, date(s), location .) .assess for any complicating factors related to the alleged situation; contact appropriate outside authorities based on alleged situation; and analyze facts collected . Medical record review revealed Resident #2 was admitted to the facility on [DATE], readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed he was cognitively intact; had no [MEDICAL CONDITION], moods, [MEDICAL CONDITION] or behaviors; required supervision with transfers, walk-in room, locomotion on and off the unit; and supervision with set-up help for walk-in corridor. Further review of the medical record revealed no [MEDICAL CONDITION] medication ordered and psychiatric services were provided for [MEDICAL CONDITION] and monitoring due to comorbidity diagnoses. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE] revealed Resident #1's short term memory was intact, was moderately impaired with daily decision making skills, required total assistance of 2 + person for transfers and dressing, total dependence of 1 person for locomotion on and off the unit, and the upper and lower extremity on one side was impaired. Resident #1 had adequate hearing, had no ability to speak, and was able to make herself understood and she understood others. Review of the facility investigation and a Nurse's Note dated 3/5/17 at 8:25 PM revealed .CNT (Certified Nurse Technician/Aide) entered room noted male RSD (resident) on top of female (with) his pants down, CNT came to this nurse and made aware of situation. This nurse entered room. Noted male RSD standing beside bed adjusting pants. This nurse ask male RSD to exit room, he did so (without) any behaviors. This nurse proceeded to ask female RSD question (with) CNT present. This nurse asked RSD if male RSD was on top of her and if he touched her @ (at) her vaginal area. Female RSD did not respond to questions, she had flat affect. This nurse assured RSD she was not in trouble and that she didn't do anything wrong. The RSD then shook her head yes to the questions. This nurse then ask RSD if she was OK (with) male RSD on top of her. This question was asked (with) CNT present. She did not respond to the question. This nurse then ask her if she was fine (with) male RSD on top of her, she then shook her head yes (with) a smile. This nurse removed covers and noted R (Right) side of brief undone and vaginal area exposed. This nurse did not see bleeding or trauma noted. This nurse proceeded in calling social worker, DON, and Administrator. The Nurse's Note continued .At 9:15 PM .This nurse notified .Nurse Practitioner of situation, she stated, Not to send male RSD out tonight if any questions by facility to call her tomorrow. Will notify next shift of situation . Interview with Resident #1 on 9/11/17 at 8:48 AM and 2:00 PM in her room revealed the resident recalled Resident #2, nodded her head Yes when asked if she had affection for him and was ok with him being on top of her and doing what he did. When asked if the resident was ever afraid while he was on top of her, if he had hurt her, and if he had done anything she did not want him to do, she shook head No to each question. Interview with the Administrator on 9/11/17 at 9:15 AM in the conference room confirmed the event occurred on 3/5/17 at 8:25 PM and the facility reported the event to the State Agency on 3/7/17. Further interview confirmed the Administrator was unaware of the non-abuse event reporting timeframe and the facility failed to report the allegation within 2 hours of the abuse allegation event to the State Agency.",2020-09-01
1354,HARTSVILLE CONVALESCENT CENTER,445256,649 MCMURRY BLVD,HARTSVILLE,TN,37074,2019-09-19,600,G,1,0,2T6811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the facility investigation, interview and employee record review, the facility failed to ensure 1 resident (#5) of 13 residents reviewed was free from abuse when a noncertified Nurse Aide (a noncertified Nurse Aide (NA) is an employee performing direct resident care without completing the certification and competency evaluation) repeatedly splashed water in the resident's face during a shower resulted in psychosocial Harm. The findings include: Review of the undated facility policy, Abuse, Neglect, Misappropriation of Property & (and) Exploitation, revealed .Definitions: Abuse - the willful infliction of injury .intimidation, pain or mental anguish .Each Resident .has the right to be free from mistreatment .Identification: identify events, such as suspicious bruising .occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation .It is the responsibility of the staff .to prohibit and prevent any Resident from Abuse . 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 30 day Minimum (MDS) data set [DATE] revealed Resident #5 was severely cognitively impaired with a score of 6 on the Brief Interview for Mental Status. Further review revealed the resident's hearing and vision were adequate, required lenses for vision; had clear speech, made self-understood, and understood others. The resident required extensive 1 person assistance for bathing and limited 1 person assistance for transferring. Review of the Incident/Accident Report dated 6/13/19 revealed the Director of Nursing (DON) was notified of the incident on 6/14/19 at 11:00 AM. Further review revealed Certified Nurse Aide (CNA) #6 reported to Licensed Practical Nurse (LPN) #4 that Resident #5 was in the shower and NA #3 was .splashing water in resident's face during shower .purposely, when she tried to speak . Review of the written statements addressing the incident on 6/13/19 involving Resident #5 revealed the following: NA #2's undated written statement revealed .On (MONTH) 13th, 2019 between hours of (10:00) AM-12:00 PM I witnessed a patient being treated in a wrongful manner. I saw (named NA #3) splashing (named Resident #5) in the face every time she would say something .and (named NA #3) would just laugh about it when doing it. (Named Resident #5) would yell for (named NA #3) to stop it and she would splash (resident) again . LPN #3's written statement dated 6/13/19 at 11:00 AM revealed .(named NA #2) came to me said you might (want to) say something to (named NA #3). (Named NA #3) was rude + (and) ugly to (named Resident #5) in the shower. I immediately went to the resident and ask if anybody was rude, ugly or mean to her and she said 'no, they're not' . LPN #4's written statement dated 6/14/19 revealed .This morning a technician (CNA #6) told me that (named NA #3) .gave a resident a shower yesterday and kept spraying the resident in the face with water. She said when the resident would try to talk she (NA #3) would spray her in the face. I let my DON know as soon as I was told . Telephone interview with NA #3 on 8/13/19 at 5:07 PM revealed .(named NA #2) took resident (#5) to the .shower room, with (named CNA #6) and me. We went in and .I told (named NA #2) no way to really clean (named resident) good and she needed a shower anyway .We got her set up for the shower and (named CNA #6) left and never came back .Then (named NA #2) left me alone in the room with the resident and I was trying to get the water warmed up and wet her hair. I soaped .her hair, washed .her .and was still alone .Soap got in her eyes and she said she would report me. I said for what, for getting soap out of her eyes? And she said 'Yes' . Further interview revealed (named NA #2) and (named CNA #6) were not in the room during the shower. Telephone interview with NA #2 on 8/12/19 at 5:28 PM revealed Resident #5 .was in the shower with (named NA #3) and (named CNA #6) and me. (named Resident #5) was talking with (named NA #3) and she splashed water in the resident's face. I told (named NA #3) it was not okay, and I said it again not to do that. Then I left the shower and told (named LPN #3) and nothing got done so I went to the DON and ADON (Assistant Director of Nursing) . Telephone interview with CNA #6 on 8/14/19 at 9:51 AM revealed .6/13/19 was my first day of work there and I was in training with (named CNA #2) .I went into the shower room and (named NA #2) and (named NA #3) were with the resident (#5) and (named NA #3) sprayed water in the resident's face and laughed about it. (Named Resident #5) was saying something and I didn't understand what. It was my first day and I didn't know what to do or who to tell so I left the room . Further interview revealed (named NA #3) and (named NA #2) .were both laughing and I didn't think it was funny. (named NA #2) didn't say anything to (named NA #3) to stop it .she was laughing and I left. (named NA #2) and (named NA #3) were in the shower room when I left . When asked why CNA #6 didn't tell anyone, CNA #6 revealed .I know I told a nurse but I think it was the day after and then she got up and told the DON . Interview with Resident #5 on 8/14/19 at 10:57 AM in the first floor dining room revealed the resident recalled the incident during a shower involving getting her face sprayed with water. Further interview with the resident revealed .I was getting a shower and a tech (technician (NA #3)) was spraying water in my face and I didn't want her to do it . When asked if the resident thought the technician was trying to get soap off of her face or eyes, the resident stated .No, she was just doing it . When asked if there were other staff in the shower room the resident revealed .Yes, a couple, and they were laughing about it . When asked if anyone tried to stop the technician from spraying water in her face, the resident revealed .No .I had to play along and they just laughed. I don't want that to happen again . When asked if the resident remembered the technician's name who was doing the spraying or who was in the shower room at the time, the resident revealed .No, not anymore, but haven't seen her, the one that sprayed me . Interview with the DON on 8/13/19 at 4:18 PM in the conference room confirmed the CNAs and the NAs did not have competency verification. Further interview revealed the facility did not substantiate the incident as abuse because the resident .said she was okay . Employee record review revealed the facility failed to ensure Nurse Aides had abuse registry verification prior to providing direct resident care for 4 employees (#1, #2, #8, #9) of 11 employee records reviewed. Interview with the Administrator, Director of Nursing, Assistant Director of Nursing, and the Business Office Manager on 8/14/19 at 5:05 PM and on 8/15/19 at 4:00 PM in the conference room, when asked if the employees were required to have abuse registry verification prior to having direct resident care, the Administrator confirmed all staff were to have abuse registry verification before any resident contact. The facility is required to submit a Plan of Correction.",2020-09-01
1851,SIGNATURE HEALTH OF PORTLAND REHAB & WELLNESS CENT,445306,215 HIGHLAND CIRCLE DRIVE,PORTLAND,TN,37148,2017-09-21,279,E,1,0,DUCD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the facility investigation, interview, and observation, the facility failed to ensure care plans had been updated after falls for 2 residents (#2, #14) and after resident to resident altercations for 5 residents (#10, #11, #12, #13, #15) of 24 residents reviewed. The findings included: Review of facility policy, Abuse, Neglect, Exploitation and Misappropriation of Property, reviewed 5/22/17 and retired 8/12/17 (due to change in ownership), revealed .Investigation Guidelines .the Facility's interdisciplinary care planning team will initiate or review a care plan for the affected resident or residents to address the resident's condition and measures to be implemented to prevent recurrence, if applicable . Review of facility policy, Falls, reviewed 6/1/15, revealed .The care plan will be reviewed following each fall, quarterly, annually, and with each significant change. Interventions are to be revised as indicated by the assessment .If a fall occurs the following actions will be taken .Update care plan . Review of facility policy, Care Plans-Comprehensive, undated, revealed .care plans are revised as information about the resident and the resident's condition change .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 resident status . 1. Review of Resident #2's Admission Record Face Sheet revealed she had been admitted on [DATE]. She had [DIAGNOSES REDACTED]. Review of her current care plan revealed a problem initiated 8/22/16, .At risk for falls .Interventions .bed in lowest position, side rail(s) as an enabler, and staff to assist with transfers 2 persons . Review of her 11/9/16 Quarterly Minimum Data Set (MDS), revealed .she was totally dependent on the assistance of one staff for turning and repositioning in bed . Review of her Progress Notes and fall investigations revealed Resident #2 had a fall on 11/22/16. A Certified Nursing Aide (CNA) had been assisting the resident with incontinence care. The CNA turned away from the resident and she fell out of bed, landing on her side. Resident #2 sustained lacerations to her forehead and arm. Review of Resident #2's facility investigation for the fall on 11/22/16 revealed a post fall intervention of .2 person for assist in bed mobility . The investigation stated her care plan had been reviewed and revised at that time. Review of her current care plan revealed a problem initiated 8/22/16, .At risk for falls .Interventions . failed to include the two person assistance in bed mobility after the 11/11/16 fall. Interview with the Director of Nursing (DON) in her office, on 9/21/17 at 10:40 AM, revealed the care plan should have been updated to include 2 person assistance with bed mobility, after Resident #2's fall. 2. Review of Resident #14's Admission Record Face Sheet revealed she had been admitted on [DATE]. She had [DIAGNOSES REDACTED]. Review of the facility's Event Reports list revealed Resident #14 had falls on 7/21/17, 8/23/17, and 9/11/17. Review of fall investigation dated 7/21/17 revealed Resident #14 had an unwitnessed fall and had been found on the floor with no injury. New nursing interventions put into place were fall mat at bedside. Medical record review of nursing progress notes revealed Resident #14 had a fall and a behavior incident on 8/16/17. It had not been included on the Event Reports. Review of facility investigation dated 8/16/17 revealed Resident #14 had an unwitnessed fall and was .observed on the floor in room at bedside. Resident had no injuries noted . The facility investigation revealed .(a CNA) went into elders (resident's) room to check on her and when I went to pull the covers back she (resident) pulled a fork out from under her pillow and stabbed me with it. It didn't break skin . Interventions implemented included .allow elder to crawl on the floor and ensure free path ways, remove fork from plate . The Care Plan had been documented as reviewed/revised at that time. Review of fall investigation dated 8/23/17 revealed Resident #14 had an unwitnessed fall and was found .laying in front of couch sitting area . Further review revealed she sustained no injuries and new nursing interventions put into place were fall mats. Review of her current Care Plan revised 9/16/17 revealed a .Problem .at risk for fall related injury. She has a dx (diagnosis) of Dementia and her safety awareness is poor . The facility failed to include fall mats on her Care Plan. Her Care Plan also included a .Problem .active and/or at risk for Behavior Problems. She has a dx of dementia with behavioral problems . The facility failed to include the interventions allowing her to crawl on floor or removing her fork from her plate. Observation on 9/19/17 at 7:35 AM in Resident #14's room revealed she was resting in bed with her eyes closed. There was a fall mat folded up on the floor near the head of the bed. It would not have helped prevent injury in that position if the resident fell out of bed. Interview with the DON and Licensed Practical Nurse (LPN) #9 in the DON's office, on 9/20/17 at 11:45 AM, revealed Resident #14 did not have a history of crawling around on the floor and LPN #9 was not sure why that had been documented in the investigation. They indicated that any interventions listed in the fall investigations should have been on her Care Plan. The DON had not been aware her Care Plan had not included all interventions. 3. Review of facility investigation dated 11/25/16 revealed Resident #10 was involved as the aggressor in a witnessed resident to resident altercation with Resident #13 which occurred on 11/25/16. Medical record review of the Admission MDS dated [DATE], revealed Resident #10 was admitted to the facility on [DATE] with Dementia with Behavioral Disturbances; and had a Brief Interview for Mental Status (BIMS) score, of 8 out of 15, indicating moderate cognitive impairment. Review of facility investigation dated 11/25/16 revealed interventions to be implemented were, .referral to social services, psychiatric services, and the chaplain . for Resident #10 and Resident #13. Resident #10 was also .monitored every 15 minutes for 12 hours and will be kept away from Resident #13 . Medical record review of Resident #10's Behavior Care Plan, dated 5/3/17, revealed his physical and verbally aggressive behaviors were present on admission. No new interventions were noted on Resident #10's Behavior Care Plan, except for every 15-minute monitoring for 12 hours. 4. Review of facility investigation dated 11/28/16 revealed Resident #11 was the aggressor in a witnessed resident to resident altercation with Resident #13 on 11/28/16. Medical record review of the Admission MDS dated [DATE] revealed Resident #11 was admitted to the facility on [DATE] with Dementia with Behavioral Disturbances, Restlessness, and Agitation and [MEDICAL CONDITION]. Further review revealed the resident's BIMS score was 0 out of 15, indicating severe cognitive impairment. Review of facility investigation dated 11/28/16, revealed interventions to be implemented were, .referral to social services, psychiatric services and the chaplain . for Resident #11 and Resident #13. Resident #11 was also .referred to an outside psychiatric facility and currently one on one monitored . Medical record review of the Behavior Care Plan dated 11/17/16 revealed Resident #11 had physical and verbally aggressive behaviors present on admission. No new interventions were noted on Resident #11's Behavior Care Plan, after the incident with Resident #13. 5. Review of facility investigation dated 4/8/17 revealed Resident #12 was the victim in a witnessed resident to resident altercation with Resident #13 on 4/7/17. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #12 was admitted to the facility on [DATE] with Dementia without Behavioral Disturbances, [MEDICAL CONDITION] and [MEDICAL CONDITION], both eyes. Further review revealed the resident's BIMS score was 10 out of 15, indicating moderate cognitive impairment. Review of facility investigation dated 4/8/17, (however, the Progress Notes for Resident #12 and Resident #13 revealed the incident occurred on 4/7/17 at 8:00 PM), revealed interventions to be implemented were, .referral to social services, psychiatric services and the chaplain . for Resident #12 and Resident #13. Medical record review of the Behavior Care Plan dated 12/23/16 revealed Resident #12 had physical and verbally aggressive behaviors present on admission. No new interventions were noted on Resident #12's Behavior Care Plan after the incident with Resident #13. 6. Review of facility investigation dated 4/8/17 revealed Resident #13 was the aggressor in a witnessed resident to resident altercation with Resident #12 on 4/7/17. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #13 was admitted to the facility on [DATE] with Dementia with Behavioral Disturbances, [MEDICAL CONDITION] and history of Alcohol and Opioid abuse. Further review revealed the resident had short and long term memory deficit and severe cognitive impairment. Review of facility investigation dated 4/8/17, (however, the Progress Notes for Resident #12 and Resident #13 reflected the incident occurred on 4/7/17 at 8:00 PM) revealed interventions to be implemented were, .referral to social services, psychiatric services and the chaplain . for Resident #12 and Resident #13. Medical record review of the Behavior Care Plan dated 8/26/16 revealed Resident #13's physical and verbally aggressive behaviors were present on admission. No new interventions were noted on Resident #13's Behavior plan of care after the incident with Resident #12. Review of facility investigation dated 4/18/17 revealed Resident #13 was involved as the aggressor in a witnessed resident to resident altercation with an additional Resident #15 on 4/18/17. Review of facility investigation dated 4/18/17 revealed Resident #13 was .immediately removed from the area and placed on 1:1 (one to one) . No documentation could be found in the record and the facility failed to provide documentation upon request of Resident #13 regarding the one to one supervision. The investigation also stated Resident #13 had a history of [REDACTED].when provoked . Further interventions for Resident #13 to be implemented were .referral to social services, psychiatric services and the chaplain . Additionally, the concern would be carried through the QAPI (Quality Assurance Performance Improvement) committee for resolution. Medical record review of the Behavior Care Plan dated 8/26/16 revealed Resident #13's physical and verbally aggressive behaviors were present on admission. No new interventions were noted on Resident #13's behavior Care Plan after the incident with the additional Resident #15 on 4/18/17. 7. Review of facility investigation dated 4/18/17 revealed Resident #15 was involved as the victim in a witnessed resident to resident altercation with Resident #13 on 4/18/17. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #15 was admitted to the facility on [DATE] with Dementia and Anxiety Disorder. The resident's BIMS score was 6 out of 15, indicating severe cognitive impairment. Review of facility investigation dated 4/18/17, revealed the interventions to be implemented were, .referral to social services, psychiatric services and the chaplain for Resident #15 and Resident #13. Medical record review of the Behavior Care Plan dated 4/24/17 revealed no new interventions were noted on Resident #15's Behavior Care Plan after the incident with Resident #13 on 4/18/17. None of the 5 resident-to-resident incidents, which involved Residents #10, #11, #12, #13 and #15 had any determination, or reasonable explanation, as to the cause of the incident. Additionally, the plan of care for the residents were not revised to include additional interventions beyond referrals to social services, psychiatric services and the chaplain were not explored or evidence the services were provided. Interview with the DON on 9/20/17 at 2:20 PM in the conference room, revealed .attempts to determine a root cause during the investigation, but it's not documented .and the care plans were not updated after the falls . Additionally, the DON could not state how the facility tracked, or monitored, resident-to-resident altercations. She was unable to identify what interventions were implemented to prevent further abuse.",2020-09-01
359,FORT SANDERS SEVIER NURSING HOME,445129,731 MIDDLE CREEK RD,SEVIERVILLE,TN,37862,2017-05-18,225,D,1,0,M21J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the facility investigation, review of employee time punches, and interview the facility failed to report an allegation of abuse to the state agency and failed to suspend an employee after an allegation of abuse for 1 resident (#1) of 3 residents reviewed. The findings included: Review of the facility policy, Abuse-Adult, revised 2/15 revealed .all alleged violations .involving .abuse .are reported immediately or as soon as possible (but not to exceed 24 hours after discovery of the incident) to the administrator (or his/her designated representative) .Any employee suspected or involved in abuse will be sent home immediately and not return to work until the investigation is complete .State survey and certification agency should be notified as soon as possible but not to exceed 24 hours after discovery of the incident . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #1 was discharged to home on 3/28/17. Medical record review of a Minimum (MDS) data set [DATE] revealed Resident #1 had a Brief Interview for Mental Status score (a test for cognitive ability) of 13/15 indicating the resident was cognitively intact for daily decision making skills. Review of the facility investigation dated 3/27/17 revealed Resident #1 alleged Certified Nursing Assistant (CNA) #1 yelled at the resident when he assisted her in the bathroom on 3/25/17 at 2:30 PM. Review of CNA #1's time punches revealed CNA #1 worked 6:18 AM - 7:00 PM on 3/25/17 and 6:16 AM - 7:09 PM on 3/26/17. Telephone interview with Resident #1 on 5/15/17 at 3:47 PM, confirmed the resident reported the incident with CNA #1 to Licensed Practical Nurse (LPN) #1 on 3/25/17 immediately following the incident. Interview with LPN #1 on 5/16/17 at 4:22 PM, in the conference room confirmed Resident #1 reported CNA #1 had yelled at her while assisting the resident in the bathroom. Further interview confirmed CNA #1 continued to work after the alleged incident on 3/25/17 and on 3/26/17. Continued interview confirmed LPN #1 did not report the incident to the Administrator or the Director of Nursing (DON). Interview with the DON on 5/17/17 at 10:43 AM, in the conference room confirmed the DON was not aware of the alleged incident until Resident #1 told her on the morning of 3/27/17 at 8:30 AM. Interview with the Administrator on 5/17/17 at 11:25 AM, in the conference room confirmed he was not notified of the alleged incident which occurred on 3/25/17 until the morning of 3/27/17. Continued interview confirmed the facility failed to suspend CNA #1 pending the investigation results and failed to report the allegation of abuse to the state agency per facility policy.",2020-09-01
1404,SUMMIT VIEW OF ROCKY TOP,445259,204 INDUSTRIAL PARK RD,ROCKY TOP,TN,37769,2020-01-17,656,G,1,0,XWNL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the facility's falls investigation, and interview, the facility failed to implement the care plan for falls interventions for 1 resident (Resident #2) of 4 sampled residents. The facility's failure to implement care planned falls interventions resulted in Resident #2 falling and receiving a [MEDICAL CONDITION] (Harm). The findings include: Review of the facility policy, Care Plans, Comprehensive Person-Centered, dated 12/2016, showed .care plan will.Describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.incorporate identified problem areas.aid in preventing or reducing decline in the resident's functional status and/or functional levels. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility fall's investigation dated 12/29/2019, showed Resident #2 fell in another resident's room and sustained a skin tear to the elbow. Review of Resident #2's Care Plan dated 12/29/2019 showed the fall risk interventions implemented after the fall included .PT/OT (physical therapy/occupational therapy) to eval (evaluate) and treat.fall mats placed on both sides of bed. Medical record review showed no documentation the resident was evaluated by PT/OT after the fall on 12/29/2019. Review of a facility fall's investigation dated 1/2/2020 at 9:30 PM showed .Fall.fell into floor next to bed.bruising to R (right) leg and extreme pain.resident lying in floor on R side next to bed.Recommendations/Interventions to prevent recurrence: fall mats (an intervention to have been implemented after the fall on 12/29/2019). During interview with the Director of Nursing (DON) on 1/14/2020 at 3:46 PM, the DON confirmed fall mats were to be implemented after the resident's fall on 12/29/2019. The DON was unsure if the fall mats were in place at the time of the resident's fall on 1/2/2020. Interview with the Rehab Manager on 1/17/2020 at 12:45 PM revealed Resident #2 had a fall on 12/29/2019 and a therapy did not complete an evaluation after that fall. The Rehab Manager stated a therapy evaluation was not completed until Resident #2 returned from the hospital after the fall on 1/2/2020. Telephone interview with Certified Nursing Assistant (CNA) #2 on 1/21/2020 at 3:10 PM revealed .me and the other CNA walked in the room.he (Resident #2) was on the floor.no floor mats (were in place). Telephone interview with Licensed Practical Nurse (LPN) #1 on 1/21/2020 at 4:05 PM confirmed she took care of Resident #2 on 1/2/2020 and .(Resident #2) was in the floor next to his bed on his right side.no floor mats (were in place). Refer to F-689",2020-09-01
3054,SENATOR BEN ATCHLEY STATE VETERANS' HOME,445484,ONE VETERANS WAY,KNOXVILLE,TN,37931,2018-02-27,602,D,1,0,MQRX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the facility's investigation, and interviews the facility failed to prevent misappropriation of property for 1 resident (#1) of 3 residents reviewed for misappropriation of property. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Medical record review of a Minimum Data Set ((MDS) dated [DATE] for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. Review of the facility policy, Abuse and Neglect of Residents and Misappropriation of Residents' Property, undated, revealed .TSVH (Tennessee State Veterans Home) takes a firm stand on the issues of mistreatment, neglect, or abuse of residents and the misappropriation of resident's property .Residents must not be subjected to abuse by anyone including, but not limited to: facility staff . Review of the facility policy, Abuse, Neglect, and Misappropriation Prevention Policy, undated, revealed .Every precaution will be taken to prevent mistreatment, neglect, and /or abuse of a resident or misappropriation of their property. Residents must not be subjected to abuse, neglect, or misappropriation by anyone .Misappropriation of residents property means the deliberate misplacement, exploitation, or wrongful, temporarily or permanent use of a resident's belongs or money without the resident's consent . Review of the facility investigation revealed on 2/7/18 at approximately 3:00 PM, the Social Service Director (SSD) informed the Administrator that Resident #1 had reported his credit card missing. Further review revealed when the Administrator and SSD went to the resident's room, his wife was present and shared a copy of the Resident's (MONTH) credit card statement. One traceable charge was a utility bill payment. Continue review revealed a report was filed with the (county) Sheriff's Department at 1:19 PM, on 2/8/18. On 2/9/18 at 2:50 PM, the Administrator was contacted by Human Resources and SSD who informed him a Detective had called asking if they knew .(alleged perpetrator's name). The officer was informed the individual was a previous employee of the facility. Interview with the Administrator on 2/26/18 at 8:42 AM, in the private dining room confirmed on 2/7/18, Resident #1 reported he had received his credit card statements which had charges on the card for (MONTH) 30, (YEAR) through (MONTH) 28, (YEAR), that neither he nor his wife had made. Further interview revealed the facility had been contacted on 2/9/18 by the detective investigating the incident inquiring about a previously employed individual who had been terminated on 1/25/18 for an unrelated incident prior to the discovery of the missing credit card. Observation and interview on 2/26/18 at 10:00 AM, with Resident #1 in his room revealed the resident seated in a wheelchair. Interview with Resident #1 confirmed the resident recalled the last time he used his credit card had been in (MONTH) (YEAR). Continued interview revealed the resident and his wife had realized there were charges on the (MONTH) statement that he hadn't made, and they thought the card had probably been lost. Interview with Resident #1's wife on 2/26/18 at 2:04 PM, revealed, the resident kept his wallet with credit cards in the drawer of his bedside table. Continued interview confirmed when she saw the (MONTH) charges on the statement, she knew he had not made them. Someone started using it on (MONTH) 30th (2017). Continued interview revealed on (MONTH) 28, (2018), Resident #1's wife called the credit card company, and they (the credit card company) cancelled the card. Continued interview confirmed the residents' wife believed the card had been missing between 8/10/17 and 11/30/17. Interview on 2/27/18 at 12:10 PM, via telephone with the Detective investigating the incident confirmed the alleged perpetrator was a previous employee of the facility, and the incident timeline corresponded with the alleged perpetrators employment at the facility. Continued interview confirmed the Detective had viewed multiple video tapes of the alleged perpetrator making unauthorized purchases with Resident #1's credit card and charges were pending.",2020-09-01
910,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2018-05-16,656,G,1,1,VPQ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the facility's investigation, observation, and interview, the facility failed to implement the care plan for appropriate use of the mechanical lift for transfers for 1 resident (#18) resulting in Harm, and failed to develop comprehensive care plans for the use of oxygen for 2 residents (#6, #71) of 21 sampled residents. The findings included: Review of the facility policy, Safe Lifting and Movement of Residents, revised (MONTH) (YEAR), revealed, .In order to protect the safety and well-being of .residents .this facility uses appropriate techniques and devices to lift and move residents .Resident safety .will be incorporated into goals and decisions regarding the safe lifting and moving of residents .Nursing staff .shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include .Resident's mobility (degree of dependency) .All equipment design and use will meet or exceed guidelines and regulations concerning resident safety .Safe lifting and movement of residents is part of an overall facility employee health and safety program . Review of the facility policy, Fall Prevention Program, dated (MONTH) 2001, revealed, .It is the policy of this facility to identify residents at risk for falls, develop plans of care that address the risk and implement procedures to assist in preventing falls .Maintain equipment and assistive devices in safe working order . Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #18 was cognitively intact. Further review revealed Resident #18 was totally dependent on 2 or more person physical assist for bed mobility, and transfers, and had impaired mobility in upper and lower extremities. Medical record review of Resident #18's comprehensive care plan dated 2/28/18 revealed, .potential for falls r/t (related to) dependent on staff for transfers via mechanical lift and 4 person assist . Further review revealed, .transfer (Resident #18) via mechanical lift and 4 person assist . Medical record review of the Physician Recapitulation Orders dated 5/1/18 - 5/31/18 revealed, .Mech (mechanical) lift for transfers . Medical record review of the Nurse's Notes dated 5/2/18 at 5:00 AM revealed, .called to room by CNA (Certified Nurse Aide #1). Rsd (resident) in floor .(No) injuries voiced. Rsd (resident) lowered to floor by CNA .assessed .assisted back to bed . Medical record review of the Nurse's Notes dated 5/2/18 at 11:30 AM revealed, .NP (Nurse Practitioner) saw resident r/t (related to) .(increased) pain. New order .(right) ankle xray . Medical record review of the Radiology Interpretation dated 5/2/18, revealed, .Impression: Acute bony avulsion (when a tendon or ligament comes away from the bone often pulling a small piece of bone with it) to the medial malleolus (the round bony prominence on inner side of the ankle joint) . Medical record review of the Physician's Telephone Orders dated 5/2/18 at 4:20 PM revealed, .send to (named hospital) ER (emergency room ) for eval (evaluation) (and) tx (treat) for (right) ankle X-Ray . Medical record review of the Radiology Report of the X-Ray of the Right Ankle - 3 View, performed at the Emergency Department on 5/2/18 revealed, .lucency (technical term for an area that lets X-rays through the tissue and as a result appears darker on the picture) noted through the posterior aspect of the calcaneus (heel bone) on lateral projection raising the possibility of fracture .Impression: Questionable calcaneal (heel bone) fracture . Medical record review of the Emergency Department Physician's Report dated 5/2/18 revealed, .patient is a [AGE] year-old female who presents with right foot and ankle pain. Patient is non-ambulatory, had a fall while being transferred (at) the nursing home. Patient has swelling noted to her foot, diffuse (spread over a wide area) dorsal (upper side) tenderness, and lateral malleolus (bony prominence on the outside of the ankle) tenderness. X-rays today show evidence of definitive acute fracture. Patient will be placed [MEDICATION NAME] in a boot, she is given instructions follow up close with her primary care physician. She will be discharge with strict return precautions for worsening symptoms or other concerns . Medical record review of the Nurse's Notes dated 5/2/18 at 11:15 PM revealed, .returned from ER (emergency room ) .(No) new orders ntd (noted). MD (Medical Doctor) to see Rsd (resident) in 2 days. Rsd (Resident) (with) brace on to wore ( be worn) 6 weeks . Medical record review of the Nurse Practitioner Progress Note dated 5/2/18 revealed, .(right) ankle avulsion fx (fracture) s/p (status [REDACTED].(with) orthoboot . Review of the facility investigation dated 5/2/18 revealed at approximately 5:00 AM on 5/2/18 Certified Nursing Aide (CNA) #1 was transferring Resident #18 with a mechanical lift. Further review revealed during transfer the left rear wheel .locked up . and the lift tilted forward. Continued review revealed CNA #1 was unable to return the lift to an upright position and Resident #18 was lowered to the floor. Further review revealed as the day progressed Resident #18 complained of pain and at that time an X-ray was performed of the resident's right ankle which showed an avulsion fracture. Interview with Resident #18 on 5/14/18 at 12:15 PM, and again at 4:09 PM, in the resident's room, confirmed on the day of the incident (5/2/18) only 1 staff member (CNA #1) assisted with the transfer using the mechanical lift, and since the fall it has been 4 staff members every time. Continued interview revealed prior to the fall, it was usually 1 person. Interview with the Director of Nursing (DON) on 5/14/18 at 3:57 PM, in the DON's office revealed Resident #18's care plan, dated 2/28/18, was accurate, and Resident #18 required assistance of 4 staff for transfers with the mechanical lift. Further interview confirmed at the time of the fall on 5/2/18 the facility failed to follow Resident #18's care plan for transferring the resident using the mechanical lift and assistance of 4 persons. Interview with the Medical Director on 5/15/18 at 9:59 AM, in the conference room, confirmed his expectation was for staff to follow the plan of care while providing care to all residents, and the facility's failure to follow the plan of care while transferring Resident #18 with a mechanical lift resulted in an ankle fracture (actual physical harm.) Interview with CNA #1 via phone on 5/15/18, at 4:40 PM, confirmed she was aware Resident #18 required 4 staff for transfers but stated the rest of the staff was really busy. Continued interview confirmed she knew now not to transfer her alone and received training following the incident. Review of a facility policy, Care Plans, Comprehensive Person - Centered, revised (MONTH) (YEAR), revealed .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented .Describe the services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being . Review of a facility policy, Oxygen Administration, revised (MONTH) 2010, revealed .Review the care plan to assess for any special needs of the resident . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] revealed Resident #6 received oxygen therapy. Medical record review of a Physician's Recapitulation Orders dated 5/1/18 - 5/31/18, revealed .O2 (oxygen) @ (at) 2 lpm (liters per minute) to keep O2 Sats (saturation - amount of oxygen in bloodstream) 90% (percent) or above .Change humidifier bottle every month and PRN (as needed) . Medical record review of Resident #6's care plan dated 11/13/17 revealed no documentation indicating Resident #6 received oxygen. Observation of Resident #6 on 5/15/18 at 12:30 PM, in the resident's room, revealed the resident with oxygen applied via nasal cannula (a device used to deliver oxygen through the nares of the nose). Interview with the MDS Coordinator on 5/16/18 at 1:20 PM in the MDS office confirmed the care plan had not been individualized to address the resident's O2 therapy. Medical record review revealed Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed, a Brief Interview for Mental Status (BIMS) score of 9 indicating the resident's cognition was moderately impaired. Further review revealed the resident received oxygen therapy, and experienced shortness of breath or trouble breathing with exertion. Medical record review of Resident #71's care plan dated 2/7/18 revealed no documentation indicating Resident #71 received oxygen. Medical record review of the Physician's Recapitulation Orders dated 5/1/18 - 5/31/18 revealed .O2 (oxygen) @ 6 lpm VIA (by) NC (nasal cannula) CONT (continuous) .Check O2 sats every shift and PRN (as needed) .Change humidifier every month and PRN . Medical record review of the weekly nurse's note dated 5/4/18 revealed, .O2 .3 L/min . Continued review of the nurse's note dated 5/5/18 revealed .O2 .3L/min .continuous . Multiple observations of Resident #71 on 5/15/18 from 8:50 AM to 1:34 PM, in the resident's room, revealed the resident lying in bed with the O2 concentrator and nasal cannula at the bedside, not in use. Interview with the MDS coordinator on 5/16/18 at 1:29 PM, in the MDS office, confirmed the facility failed to develop a comprehensive care plan for the use of oxygen for Resident #71.",2020-09-01
549,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-01-24,609,D,1,0,BRJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the investigation documentation, and interview, the facility failed to report an allegation of abuse immediately or no later than 2 hours for 3 residents (#4, #8, #9) of 7 residents reviewed for abuse. The findings included: Review of the undated facility policy entitled Abuse, Neglect and Exploitation of Residents revealed .Investigating and Reporting .Once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator as soon as possible .An investigation MUST be directed by the Administrator, designee immediately and no later than twenty-four (24) hours of their knowledge of the alleged incident .The Administrator, Director of Nursing or designee will notify the appropriate state agencies per state regulation .The facility shall report not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury . Review of the facility policy entitled Abuse Reporting revealed .Reporting Guidance Federal Regulation .requires reporting of alleged violations of abuse .immediately to the administrator and to the appropriate state agencies in accordance with state law .CMS (Centers for Medicare & Medicaid Services) has defined 'immediately' as as soon as possible, but not to exceed 24 hours after forming suspicion .The facility must report abuse .within 24 hours after the reasonable cause threshold (suspicion) is concluded. If serious bodily injury has been sustained by a resident, the incident will be reported immediately but not later than 2 hours after forming suspicion . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility investigation documentation involving Resident #4 revealed the staff to resident abuse allegation occurred on 10/21/17 at 6:00 PM and the Administrator was notified on 10/22/17 at 4:00 PM, 22 hours after the occurrence. The State Agency was notified on 10/23/17 at 4:47 PM, 46 3/4 hours after the occurrence. The facility failed to report the abuse allegation to the Administrator and the State Agency immediately or not later than 2 hours. Interview with the Administrator and the Regional Nurse on 1/24/18 at 9:00 AM in the conference room confirmed the facility failed to timely report an allegation of abuse to the Administrator and the State Agency. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Nursing Progress Note dated 11/30/17 at 7:20 PM revealed .Received result of Left shoulder x-ray. Results read, fracture involving distal clavicle with minimal displacement. Message sent to NP (Nurse Practitioner). Call placed to on call for primary physician. On call MD (Medical Doctor) returned call and order received to place a sling to LUE (Left Upper Extremity) and leave in place until further notice . Review of facility investigation documentation revealed the Administrator was not notified on 11/30/17 when the facility received Resident #8's x-ray results. Interview with the Administrator and Director of Nursing (DON) on 1/23/18 at 3:15 PM in the Administrator's office confirmed the Administrator and the State Agency were not notified of Resident #8's injury of unknown origin immediately or within the 2 hour timeframe per the regulatory requirement. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Nursing Progress Note dated 11/6/17 at 6:12 AM for Resident #9 revealed .New order for xray of left humerus and left ulnar radial on 11/6/17 for swelling and discoloration . Medical record review of a Nursing Progress Note dated 11/7/17 at 2:31 AM for Resident #9 revealed .On 11/6 residents x-ray results came back around 930p (PM) showing Acute moderate displaced (L) (Left) humeral neck fracture. No fracture, destructive [MEDICAL CONDITION] or other abnormalities of the (L) forearm. Made DON and night time supervisor aware . Further review revealed at 10:00 PM the on-call physician had been notified and at 10:20 PM the resident's daughter had been notified. Medical record review of an assessment dated [DATE] signed by the Attending Physician revealed Resident #9 had an .acute left humerus fracture without fall. Possibly when rolled to clean her, fracture with underlying [MEDICAL CONDITION] . Review of the facility investigation documentation and the medical record revealed the Administrator had not been notified of the xray results, received by the facility on 11/6/17 at around 9:30 PM, until the morning of 11/7/17, when the incident was reported to the State Agency. Interview of the facility Administrator and DON on 1/23/18 at 3:15 PM in the Administrator's office, confirmed the Administrator and the State Agency were not notified of the injury of unknown origin immediately or within the 2 hour timeframe per the regulatory requirement.",2020-09-01
1849,SIGNATURE HEALTH OF PORTLAND REHAB & WELLNESS CENT,445306,215 HIGHLAND CIRCLE DRIVE,PORTLAND,TN,37148,2017-09-21,241,E,1,0,DUCD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, review of the shower list and bathing report, interview and observation, the facility failed to ensure resident dignity, related to facial grooming, was maintained for 4 residents (#5, #6, #22, #23); and failed to ensure baths were given as scheduled for 6 residents (#3, #4, #5, #6, #22, #23) of 24 sampled residents. The findings included: Review of the facility policy, Skin Assessments and Evaluations At-A-Glance, undated revealed, .On resident shower/bath days, CNAs (Certified Nurse Aides) will complete total body skin observations and document them on the CNA Skin Alert Form . There was no policy regarding when residents should have been shaved available at the time of the survey. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident expired on [DATE]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 required extensive 1 person assistance with hygiene, and was total dependence with 1 person assistance for bathing. Review of the Quarterly MDS dated [DATE] revealed Resident #3 was total dependence with 1 person assistance for hygiene and bathing. Review of the Station 1 Shower List revealed Resident #3 was scheduled on Tuesdays and Fridays for a shower. Review of the ,[DATE] Bathing Report revealed Resident #3 failed to receive a shower on Tuesday, [DATE]; on Friday, [DATE]; and on Tuesday, [DATE] as scheduled. Further review revealed the resident failed to receive any form of bathing on [DATE], [DATE], [DATE], [DATE] and [DATE]. Interview with the Director of Nursing (DON ) on [DATE] at 2:35 PM in the conference room, and on [DATE] at 2:25 PM in the conference room, confirmed Resident #3 was scheduled to receive showers every Tuesday and Friday. Further interview confirmed the facility staff failed to provide a shower as scheduled which failed to maintain the dignity of the resident. 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 required extensive 1 person assistance for hygiene and bathing. Review of the Station 1 Shower List revealed Resident #4 was scheduled on Tuesdays and Fridays for a shower. Review of the ,[DATE] Bathing Report revealed Resident #4 failed to receive a shower on Tuesday, [DATE]; on Friday, [DATE]; and on Tuesday, [DATE] as scheduled. Further review revealed the resident failed to receive any form of bathing on [DATE], [DATE], [DATE], [DATE], and [DATE]. Interview with the DON on [DATE] at 2:25 PM in the conference room confirmed Resident #4 was scheduled to receive showers every Tuesday and Friday. Further interview confirmed the facility staff failed to provide a shower as scheduled which failed to maintain the dignity of the resident. 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 Resident #5 could hear adequately, had clear speech, made self understood and understood others; and required extensive 1 person assistance for hygiene and bathing. Interview with Resident #5 on [DATE] at 10:53 AM in his room revealed he liked to be clean shaven and had not had a shave in ,[DATE] days. Observation on [DATE] at 10:53 AM, 11:25 AM, 12:00 PM, 3:10 PM, and 4:40 PM revealed Resident #5 in various locations in the facility with long facial hair. Observation and interview with Resident #5 on [DATE] at 7:45 AM and 9:20 AM in the dining room revealed he was clean shaven and he said he .wanted a shave 2 times a week at least . Interview with direct care Certified Nurse Aide (CNA) #8, on [DATE] from 8:30 AM to 8:55 AM on the Station 1 unit revealed she was assigned to the resident last Thursday and came back Monday to find .my men on (resident's) hall need a shave . Review of the Station 1 Shower List revealed Resident #5 was to have a shower on Tuesdays and Fridays. Review of the Bathing Report for Resident #5 revealed he received 1 shower in ,[DATE] and all other bathing was a half bath. Interview with the DON on [DATE] at 7:30 AM in her office confirmed Resident #5 received 1 shower the entire month of ,[DATE] and there was no documentation of the resident refusing a shower. Further interview confirmed residents were to be shaved as scheduled, requested or as needed. When asked if the failure to bath and shave a resident as requested, scheduled or as needed was an acceptable practice and promoted the dignity of the resident the DON stated No. Medical record review of Resident #6's Quarterly MDS, dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score 8 out of 15, indicating moderate cognitive impairment. Further review revealed Resident #6 required extensive assistance from one staff to complete personal hygiene, which included shaving. Review of Resident #6's Care Plan, dated [DATE] and updated [DATE], revealed she would be clean, dressed, and groomed. On [DATE] at 11:10 AM, Resident #6 was observed in her bedroom seated in a wheelchair with white hairs visible on her chin. On [DATE] at 8:40 AM, Resident #6 was observed in her bed eating breakfast on her over-bed table and multiple white whiskers, approximately 1/2 inch long, were visible on her chin. In an interview in her room, on [DATE] at 8:40 AM, Resident #6 stated the CNAs shaved her chin, and she wanted the whiskers shaved off. Resident #6 was unable to recall the last time the CNAs had shaved her chin whiskers. Review of Resident #6's Bathing Schedule revealed she should have received a bath or shower every Wednesday and Saturday. Review of Resident #6's Bathing Reports and C.N.[NAME] Skin Care Alert sheets from (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) revealed: December, she should have received a bath or shower 9 times. There were 2 baths or showers documented. January, she should have received a bath or shower 8 times. There were 2 baths or showers documented. August, she should have received a bath or shower 9 times. There were 5 baths or showers documented. September, she should have received 5 baths or showers to-date for the month. There were 2 baths or showers documented. Observations on [DATE] at 8:40 AM during the initial tour revealed Resident #22 had long whiskers, approximately one-quarter inch or longer, on her chin. Review of the Quarterly MDS, dated [DATE], revealed she had a BIMS score of 8, indicating she was moderately cognitively impaired. She was totally dependent and required assistance of one person for personal hygiene like shaving, applying makeup, and brushing teeth. Review of Resident #22's C.N.[NAME] Skin Care Alert sheets, from (MONTH) (YEAR) and to-date in (MONTH) (YEAR), revealed a space labeled Resident Shaved that could be marked yes or no. The most recent date she was documented as being shaved was [DATE]. Review of her bathing schedule revealed she should have received a bath or shower every Monday and Thursday. Review of her Bathing Reports and C.N.[NAME] Skin Care Alert sheets from (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) revealed: December, she should have received a bath or shower 9 times. There were 2 bed baths documented. January, she should have received a bath or shower 9 times. There was 1 bed bath documented. August, she should have received a bath or shower 9 times. There were 3 full baths or showers documented. September, she should have had 5 baths or showers to-date for the month. There were 2 full baths or showers documented. Observations on [DATE] at 8:40 AM during the initial tour revealed Resident #23 had long whiskers, approximately one-quarter inch or longer, on her chin. Review of the Quarterly MDS, dated [DATE], revealed she had a BIMS score of 15, indicating she was cognitively intact. She required extensive assistance of one person for personal hygiene. Review of Resident #23's C.N.[NAME] Skin Care Alert sheets from (MONTH) (YEAR) to-date in (MONTH) (YEAR) revealed the most recent date she was marked as receiving a shave was [DATE]. Review of her bathing schedule revealed she should have received a bath or shower every Tuesday and Friday. Review of the Bathing Reports and C.N.[NAME] Skin Care Alert sheets from (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) revealed: December, she should have received a bath or shower 9 times. There were 4 showers documented. January, she should have received a bath or shower 9 times. There were 2 showers documented. August, she should have received a bath or shower 9 times. There were 5 showers documented. September, she should have received 5 baths or showers to-date for the month. There was 1 shower documented. Interview with CNA #8 on [DATE] at 3:00 PM, at the main nurses' station, revealed residents were usually shaved on their bath or shower days, if needed, and documented on the C.N.[NAME] Skin Care Alert sheets. Those sheets should have been filled out every time a bath or shower was given, or if the resident refused. If staff noticed facial hair they typically shaved it. Interview with the DON on [DATE] at 3:15 PM, in her office, revealed residents should have been shaved as they requested or wanted. Most female residents did not want to have any facial hair. C.N.[NAME] Skin Care Alert sheets should have been filled out every time a resident was given a bath or shower. If the resident refused, refused should have been documented on one of the alert sheets. If Bathing Reports had documented a half type of bathing, that could mean peri care after an incontinence episode or a bed bath. There was no way to tell which it was unless there was a C.N.[NAME] Skin Care Alert sheet with a matching date to the bath report. Review of staff training In-Services from [DATE] revealed .We understand staff issues but do your best to complete showers as much as possible. If families ask about showers don't become defensive, just simply say I haven't gotten to it yet but I will before the day is over. Then try your best to complete that shower .",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
851,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-12-19,607,D,1,0,RPNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, video review, facility investigation review, and interview, the facility staff failed to report an allegation of abuse to the facility administration per policy for 1 resident (#2) of 9 residents reviewed. The findings included: Review of the undated facility policy, Abuse, Neglect and Exploitation of Residents, revealed .Responsibilities .All personnel .if abuse is suspected, personnel will report their observations to their supervisor immediately and without delay .will .report any signs of suspected abuse, neglect and exploitation . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged as a 911 at 5:24 PM to the emergency room following the event. Review of the video dated 9/19/17 from 4:07:45 PM to 4:07:55 PM revealed Certified Nurse Aide (CNA) #1 leaning against the hallway wall when Resident #2 aggressively and with fisted hands attempting to strike the second employee. Further review of the 2 views of the video revealed these were the only 2 employees in the area at the time of the event. Review of the facility investigation included CNA #1's interview on 10/24/17 revealed the CNA was asked why she did not report the event when it occurred the CNA .stated due to all the staff being there that the event was reported . Interview with the Administrator on 12/12/17 at 9:30 AM in the conference room revealed the event which occurred on 9/19/17 was reported on 10/24/17 when the agency CNA #1 involved informed the shift supervisor. The shift supervisor then called the Administrator to report the allegation and the investigation was started. Further interview confirmed the facility staff failed to report the allegation to the facility administration immediately per policy.",2020-09-01
1411,SUMMIT VIEW OF ROCKY TOP,445259,204 INDUSTRIAL PARK RD,ROCKY TOP,TN,37769,2019-02-26,610,D,1,0,96W011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record reviews, and interviews, the facility failed to investigate an allegation of abuse for 1 resident (#2) of 5 residents reviewed for abuse. The findings included: Review of facility policy Abuse Investigation and Reporting, revised date (MONTH) (YEAR), revealed .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source .thoroughly investigated by facility management . Medical record review revealed Resident #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's 14 Day Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6 (severe cognitive impairment). Continued review revealed the resident required extensive assist for bed mobility, dressing, and personal hygiene with 1 person assist. Medical record review revealed Resident #1 was admitted to the facility on 1/4/17 with [DIAGNOSES REDACTED]. Medical record review of Resident #1's annual MDS dated [DATE] revealed a BIMS score of 15 (no cognitive impairment). Continued review revealed the resident required limited assist for transfers, toilet use, and personal hygiene with 1 person assist. Interview with the Social Services Director (SSD) on 2/25/19 at 10:45 AM, in her office, revealed on 1/21/19 Certified Nurse Assistant (CNA) #1 reported she witnessed Resident #1 touched Resident #2 on the breast and on the arm. Continued interview revealed the SSD notified the Administrator of the incident. Further interview revealed Resident #1 had made inappropriate comments directed toward staff in the past. Interview with CNA #1 on 2/25/18 at 11:00 AM, in the conference room, revealed on 1/21/19 she observed Resident #1 touch Resident #2 on her breast and arm. Continued interview revealed she told Resident #2 the behavior was inappropriate and then she separated the residents. Interview with Resident #2 on 2/25/19 at 11:30 AM, in her room, revealed Resident #1 had rubbed her arm and her breast. Further interview revealed .he approached me again in the dining room and I told him hands offs .I just rolled away . Interview with the Administrator and Director of Nursing (DON) on 2/26/19 at 1:15 PM, in the DON's office, confirmed the facility failed to prevent abuse to Resident #2.",2020-09-01
1410,SUMMIT VIEW OF ROCKY TOP,445259,204 INDUSTRIAL PARK RD,ROCKY TOP,TN,37769,2019-02-26,609,D,1,0,96W011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record reviews, and interviews, the facility failed to report an allegation of abuse for 1 resident (#2) and failed to report an injury of unknown origin to the state survey agency for 1 resident (#4) of 5 residents reviewed. The findings included: Review of facility policy Abuse Investigation and Reporting, revised date (MONTH) (YEAR), revealed .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source .shall be promptly reported to local, state and federal agencies . Medical record review revealed Resident #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's 14 Day Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6 (severe cognitive impairment). Continued review revealed the resident required extensive assist for bed mobility, dressing, and personal hygiene with 1 person assist. Interview with the Social Services Director (SSD) on 2/25/19 at 10:45 AM, in her office, revealed on 1/21/19 Certified Nurse Assistant (CNA) #1 reported she witnessed Resident #1 touched Resident #2 on the breast and on the arm. Continued interview revealed the SSD notified the Administrator of the incident. Interview with CNA #1 on 2/25/18 at 11:00 AM, in the conference room, revealed on 1/21/19 she observed Resident #1 touch Resident #2 on her breast and arm. Continued interview revealed she told Resident #2 the behavior was inappropriate and then she separated the residents. Interview with Resident #2 on 2/25/19 at 11:30 AM, in her room, revealed Resident #1 had rubbed her arm and her breast. Interview with the Administrator and Director of Nursing (DON) on 2/26/19 at 1:15 PM, in the DON's office, confirmed the allegation abuse was not reported 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 Resident #4's quarterly MDS dated [DATE] revealed a BIMS score of 15 (cognitively intact). Continued review revealed the resident required extensive assist for bed mobility, transfers, and dressing with 1 person assist. Medical record review of a Nurse Practitioner (NP) assessment dated [DATE] revealed the NP assessed the resident for right knee [MEDICAL CONDITION] and order an x-ray of the right knee and ordered medication for [MEDICAL CONDITION] and inflammation. Medical record review of an x-ray interpretation of the right knee dated 8/22/18 revealed .Impression: Lateral Tibia Plateau (upper part of the shin) Fracture of undetermined age . Medical record review of a Computed [NAME]ography (CT) report dated 8/23/18 revealed .severe osteopenia .lateral tibial plateau fracture .joint effusion .bone infarcts (osteonecrosis) . Interview with the NP on 2/26/19 at 12:20 PM, in the conference room, revealed she assessed Resident #4 for the [MEDICAL CONDITION] and did not see any evidence of trauma to the knee. Interview with the Administrator and Director of Nursing (DON) on 2/26/19 at 1:15 PM, in the DON's office, confirmed the facility failed to report an injury of unknown origin to the state survey agency.",2020-09-01
848,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2018-11-29,610,D,1,0,E9TM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record, and interview the facility failed to do a completed investigation for 1 resident (#24) of 24 residents reviewed for abuse. The finidings include: Review of the facility policy dated 7/2017 Abuse Investigation and Reporting revealed .The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of findings of the investigationb within 5 working days of occcureence of the incident . Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Interview with the Director Of Nursing on 11/27/18 at 12:22 PM in the conference room revealed completed an informal investigation. Further interview confirmed she did not complete a formal interview because the resident retracted her statement.",2020-09-01
847,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2018-11-29,609,D,1,0,E9TM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record, and interview the facility failed to report an investigation for 1 resident ( #24) of 24 residents reviewed to the state agency. The findings include: Review of the facility policy revised 7/2017 Abuse Investigation and Reporting revealed .All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his /her designee, to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility . Review of the facility policy dated 7/2017 Abuse Investigation and Reporting revealed .The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of findings of the investigationb within 5 working days of occcureence of the incident . Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record of the facility investigation dated 10/18/18 revealed there not an investigation completed. Interview with the Administrator on 11/21/18 at 3:52 PM in his office revealed Resident #24 reported an allegation of abuse. Further interview when asked why the allegation was not reported to the state agency the Administrator responded .Resident #24 told us in conversation that nurse was rough with her and then she retracted her statement . Further interview confirmed .we proceeded as an informal investigation .",2020-09-01
1605,CUMBERLAND VILLAGE CARE,445276,136 DAVIS LANE,LAFOLLETTE,TN,37766,2018-08-30,584,D,1,0,O28W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, observation, and interview the facility failed to maintain a clean and homelike environment by eliminating dark brown streaked debris on the bathroom floor and odors in a resident's room, and maintaining a comfortable temperature in 1 (Resident #2) room of 5 resident rooms reviewed. The findings included: Review of the facility policy, Cleaning: Resident/Patient Areas dated 11/1/07, revealed .Cleaning is accomplished using the Seven-Step Cleaning Procedure which includes the following cleaning procedures .Bathroom cleaning .Room inspection-visual inspect room after completing all tasks and correct any issues before leaving the room . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Continued review revealed the resident was assessed with [REDACTED]. Required extensive assisting with personal grooming, total assistance with toileting, and was always incontinent of bowel and bladder. Observation/interview with Resident #2 on 8/28/18 at 10:55 AM, revealed the resident lying in bed. Continued observation revealed the room appeared cool. Observation of the air conditioner unit revealed the temperature was set at 65 degrees Fahrenheit (F). Interview with the resident revealed when asked the resident reported being cold. Continued observation of the resident's bathroom revealed 2 streaks of dark debris bathroom floor and dark debris on the front and seat of the commode. Observation/interview with Licensed Practical Nurse (LPN #4) on 8/28/18 at 11:00 AM, in Resident #2's room, confirmed the air conditioner unit in the room was set at 65 degrees Fahrenheit (F), and the room felt cold. Continued interview confirmed the dark debris on the bathroom floor and commode was feces. Observation of Resident #2, on 8/29/18 at 8:20 AM, revealed the resident in the bed asleep. Continued observation revealed the presence of a strong foul odor. Interview with LPN #4 on 8/29/18 at 8:23 AM, in Resident #2's room confirmed a strong foul urine odor was present in the room Observation of Resident #2 on 8/29/18 at 6:15 PM, in her room, revealed the resident lying in bed. Continued observation revealed a strong foul odor. Interview with Registered Nurse (RN) #2 on 8/29/18 at 6:45 PM, at the secure unit Nurse's Station confirmed the residents room continued to have a strong foul urine odor. Observation/interview with RN #2 on 8/30/18 at 7:30 AM in Resident #2's room confirmed the resident's room, and furnishings including the bedside night stand, privacy curtain, and air conditioner unit continued to have a strong foul odor of urine. Interview with RN #2 on 8/31/18 at 7:55 AM, in Resident #2's room, confirmed a strong foul odor in Resident #2's room. Continued interview confirmed attributing to the odor in the resident's room was the mattress, privacy curtains, heating and air unit, bedside night stand, the floor under the bedside night stand, and the wall and base board behind the bedside night stand. Interview with the Administrator on 8/31/18 at 10:00 AM, in his office confirmed his expectation was odors should be identified and a root cause analysis completed to identify the source of the odor, and the odor be eliminated. Continued interview confirmed the facility failed to follow their policy and eliminate the odor in Resident #2's room, and had failed to provide a clean, comfortable, homelike environment for Resident #2.",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
1600,CUMBERLAND VILLAGE CARE,445276,136 DAVIS LANE,LAFOLLETTE,TN,37766,2018-01-16,558,D,1,0,8DNZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, observation, facility documentation review, and interview, the facility failed to maintain the dignity and well-being for 2 residents (#1 and #4) who had requested showers every other day of 4 alert and oriented residents reviewed. The findings included: Review of the facility's Activities of Daily Living (ADL's) policy, revised 11/28/16 revealed, .1.2 A patient who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . Observation of the South Wing, front hall, on 1/10/18 at 10:00 AM, revealed the area contained rooms 101A through 116B. Observation included residents from the back hall, also the secure unit (with rooms 117A through 134B) of the South Wing being taken to the shower room. Interviews on 1/10/18 from 10:00 AM through 11:15 AM, with 3 alert and oriented female residents (#2, #3, and #4), in their rooms, revealed all 3 residents confirmed they were to receive a shower every other day and had not been showered every other day. Interview with Resident #4 revealed she had been at the facility since (MONTH) of (YEAR), and had been told she would get a shower every other day, and she wanted a shower every other day.most recently I went without a shower for over a week . Interview with Certified Nurse Aide (CNA) #1 on 1/10/18 at 11:10 AM, outside of Resident #4's room, confirmed she usually worked on the South Wing, front hall. Continued interview confirmed residents were to receive a shower every other day and revealed showers had not been done for the last four days .not done because bath team being pulled to replace call-in's . Interview and observation of Resident #1 on 1/10/18 from 11:15 AM through 12:15 PM, in their room, revealed the resident was alert and oriented x 3. Observation revealed a bilateral above the knee [MEDICAL CONDITION] who used a trapeze to get in and out of the bed independently, and frequently lifted self off of the seat of the wheelchair to reposition during the interview. Continued interview revealed the resident had a skin infection and needed to get a shower every other day and spray off the area (the resident indicated the area of skin under the abdominal fold. Continued interview revealed Resident #1 had not always received a shower every other day. Interview with 2 of the 3 bath team CNA's (#2 and #3) for the South Wing on 1/10/18 at 12:20 PM, in the shower room, revealed their routine was to shower the residents on the front section of the South Wing, usually about 20-25 residents one day and the secured hall the next day with the plan to provide a shower for all their residents every other day. Interview confirmed the bath team were the only CNA's providing showers for residents on the South Wing. Review of the facility documentation provided by the CNA's revealed a copy of the South Wing CNA Schedule from 11/13/17 to the present time. Review of the schedules revealed no showers were given on the South Wing as follows: Saturday and Sunday 11/18 - 19/17 and Sunday 11/26/17; Saturday 12/16/16 and Sunday 12/24/17; and Friday 1/5/18 and Sunday 1/7/18. Continued interview with concurrent review of the South Wing schedules confirmed, in addition to the dates marked as no shower days, there were 20 days in the same time period (11/13/17 - 1/9/18) when only 1 CNA remained on the bath team and did showers. Continued interview revealed both the CNA's stated if a resident was not showered an N/A was charted in the resident's handwritten ADL RECORD. Interview continued and confirmed Resident's #1, #4, and others did not always get a bath every other day. Interview with the Administrator on 1/10/18 at 1:00 PM, in the conference room, revealed he was unable to provide information related to the facility's policy for frequency of showers or baths and stated .would need to speak to the Director of Nurses (DON). Interview with the DON on 1/10/18 at 1:15 PM, in the conference room, revealed the DON stated, There isn't a regulation for how often baths or showers have to be given. Interview with the Social Worker and DON on 1/10/18 at 3:45 PM, in the conference room, confirmed the 4 alert and oriented residents (#1, #2, #3, and #4) interviewed on the South Wing were able to voice their preferences for showering or baths. Continued interview confirmed Resident #1 had previously complained to her about not receiving showers every other day. Interview with the DON on 1/10/18 at 4:00 PM, in the conference room, revealed the DON provided the ADL policy and confirmed the families of the facility's residents, residents, and CNA's had an expectation of baths or showers being provided every other day.",2020-09-01
1601,CUMBERLAND VILLAGE CARE,445276,136 DAVIS LANE,LAFOLLETTE,TN,37766,2018-01-16,676,D,1,0,8DNZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, observation, facility documentation review, and interview, the facility failed to provide residents the necessary care and services to ensure residents activities of daily living for baths or showers were maintained for 20 residents (from rooms 101A - 116A) of 22 residents reviewed from 12/19/17 through 12/31/17. The findings included: Review of the facility's Activities of Daily Living (ADL's) policy, revised 11/28/16 revealed, .1.2 A patient who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . Observation of the South Wing, front hall, on 1/10/18 at 10:00 AM, revealed the area contained rooms 101A through 116B. Observation included residents from the back hall, also the secure unit (with rooms 117A through 134B) of the South Wing being taken to the shower room. Interviews on 1/10/18 from 10:00 AM through 11:15 AM, with 3 alert and oriented female residents (#2, #3, and #4), in their rooms, revealed all 3 residents confirmed they were to receive a shower every other day and had not been showered every other day. Interview with Resident #4 revealed she had been at the facility since (MONTH) of (YEAR), and had been told she would get a shower every other day, and she wanted a shower every other day.most recently I went without a shower for over a week . Interview with Certified Nurses Aide (CNA) #1 on 1/10/18 at 11:10 AM, outside of Resident #4's room, confirmed she usually worked on the South Wing, front hall. Continued interview confirmed residents were to receive a shower every other day and revealed showers had not been done for the last four days .not done because bath team being pulled to replace call-in's . Interview and observation of Resident #1 on 1/10/18 from 11:15 AM through 12:15 PM, in their room, revealed the resident was alert and oriented x 3. Observation revealed a bilateral above the knee [MEDICAL CONDITION] who used a trapeze to get in and out of the bed independently, and frequently lifted self off of the seat of the wheelchair to reposition during the interview. Continued interview revealed the resident had a skin infection and needed to get a shower every other day and spray off the area (the resident indicated the area of skin under the abdominal fold. Continued interview revealed Resident #1 had not always received a shower every other day. Continued interview revealed several residents (on the South Wing) had more than a week between showers during (MONTH) (2017). Interview with 2 of the 3 CNA's (#2 and #3) of the bath team for the South Wing on 1/10/18 at 12:20 PM, revealed their routine was to shower the residents on the front section of the South Wing, usually about 20-25 residents one day and the secured hall the next day with the plan to provide a shower for all their residents every other day. Review of facility documentaion provided by the CNA's revealed a copy of the South Wing CNA Schedule from 11/13/17 to the present time. Review of the schedules revealed no showers were given on the South Wing as follows: Saturday and Sunday 11/18-19/17 and Sunday 11/26/17; Saturday 12/16/16 and Sunday 12/24/17; and Friday 1/5/18 and Sunday 1/7/18. Continued interview with concurrent review of the South Wing schedules confirmed, in addition to the dates marked as no shower days, there were 20 days in the same time period (11/13/17 - 1/9/18) when only 1 CNA remained on the bath team and did showers. Continued interview revealed both the CNA's stated if a resident was not showered an N/A was charted in the resident's handwritten ADL RECORD. Interview continued and confirmed Resident's #1, #4, and others did not always get a bath every other day. Review of the ADL RECORD for 22 of the residents residing in rooms 101 A through 115 A for the month of (MONTH) (YEAR) revealed the following 20 residents did not receive a shower as follows: 101 A - No shower for 8 days, 12/23-12/30/17; 101 B - No shower for 5 days, 12/21-12/25/17; 102 A - No shower for 11 days, from 12/21-12/31/17; 102 B - No shower for 3 days, from 12/23-12/25/17 & from 12/29-12/31/17; 103 A - No shower for 5 days, from 12/23-12/27/17; 104 A - No shower for 8 days, 12/24-12/31/17; 104 B - No shower for 7 days, 12/23-12/29/17; 105 B - No shower for 7 days, 12/23-12/29/17; 106 A - No shower for 3 days, from 12/23-12/25/17 & from 12/27-12/29/17; 106 B - No shower for 5 days, from 12/23-12/27/17; 107 A - No shower for 10 days, from 12/22-12/31/17; 107 B - No shower for 5 days, from 12/23-12/27/17; 108 A - No shower for 11 days, from 12/21-12/31/17; 108 B - No shower for 7 days, 12/23-12/29/17; 109 B - No shower for 11 days, from 12/21-12/31/17; 110 B - No shower for 5 days, from 12/23-12/27/17; 111 A - No shower for 5 days, from 12/23-12/27/17; 112 A - No shower for 7 days, 12/23-12/29/17; 112 B - No shower for 5 days, from 12/23-12/27/17; and 115 A - No shower for 11 days, from 12/19-12/29/17. Continued review of the front hall of the South Wing ADL Records for (MONTH) (YEAR) revealed there were 20 residents (102 B, 103 A, 103 B, 104 A, 104 B, 105 B, 106 B, 107 A, 107 B, 108 B, 109 A, 109 B, 110 A, 110 B, 111 A, 111 B, 112 A, 112 B, 113 A, and 116 A) who did not have a shower recorded for 3 consecutive days, 1/6/18 - 1/8/18. Interview with the Administrator on 1/10/18 at 1:00 PM, in the conference room, revealed he was unable to provide information related to the facility's policy for frequency of showers or baths and stated .would need to speak to the Director of Nurses (DON). Interview with the DON on 1/10/18 at 1:15 PM, in the conference room, revealed the DON stated, There isn't a regulation for how often baths or showers have to be given. Interview with the Social Worker and DON on 1/10/18 at 3:45 PM, in the conference room, confirmed the 4 alert and oriented residents (#1, #2, #3, and #4) interviewed on the South Wing were able to voice their preferences for showering or baths. Continued interview confirmed Resident #1 had previously complained to her about not receiving showers every other day. Interview with the DON on 1/10/18 at 4:00 PM, in the conference room, revealed the DON provided the ADL policy and confirmed the families of the facility's residents, residents, and CNA's had an expectation of baths or showers being provided every other day.",2020-09-01
3571,BLEDSOE COUNTY NURSING HOME,4.4e+233,107 WHEELERTOWN AVENUE,PIKEVILLE,TN,37367,2018-11-26,552,D,1,0,UPH511,"**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 honor the resident's right to be fully informed prior to treatment for 1 resident (#1) of 3 residents reviewed for resident rights. The findings included: Review of the facility policy, Resident's Rights Under Federal Law, revised 1/14, revealed .The resident has a right to be fully informed in advance about care and treatment . Medical record review revealed Resident #1 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Review of an Annual Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Continued review revealed verbal behaviors directed toward others occurred 1 to 3 days during the assessment period. Review of a Physicians Order dated 9/29/18 at 8:50 PM, revealed U.D.S. (Urine Drug Screen) Dx. (diagnosis) Altered Mental Status Interview with Resident #1's mother on 11/26/18 at 10:40 AM, via telephone, revealed On 9/29/18 he went out with a friend and stayed all day; they (the facility) did a drug test on him and didn't tell him what they were doing. Some man called me the next day but I don't know who it was. He said what they were doing to .(Resident #1) was wrong, and they had done a drug test on him. Observation/interview with Resident #1 on 11/26/18 at 12:25 PM, in his room, revealed the resident lying in bed watching television, he was awake and alert. Interview at this time revealed I am in my right mind. I've been here over 4 years, and I tell them if something isn't right, so I think they want me to leave . Continued interview revealed when Resident #1 was asked about a drug test being obtained, he responded .(LPN #2) came in and shined a light in my eyes. I asked her to do a urinalysis. I was hurting and thought I might have a UTI (Urinary Tract Infection). I thought that was what they were doing. I had gone out on a leave, and I had been out all day in the hot sun. I drank water but probably not enough, so I was probably dehydrated. Maybe that is why I was out of it. Interview with Licensed Practical Nurse (LPN) #2 on 11/26/18 at 2:20 PM, in the conference room, confirmed on 9/29/18 He (Resident #1) had been out of the building; his brother brought him back, and he had altered mental status when he returned. So I did what I was supposed to, and notified the doctor of his mental status change. I reported his vitals, and his neuro checks were ok, but he was in an altered mental state. He gave me an order for [REDACTED]. I didn't know at that point the doctor would order a drug screen. Interview with CNA #3 on 11/26/18 at 3:05 PM, via telephone, revealed I was in the room when .(CNA #4) got the urine sample; we didn't tell him we were doing a drug test. Interview with CNA #4 on 11/26/18 at 3:30 PM, via telephone, revealed I actually obtained the urine for the drug screen, but I didn't know that was what it was for. He was acting strange so I thought he might have a UTI. I thought that was why I was getting the sample. I didn't tell him we were doing a drug screen, because I didn't know myself. Interview with the Administrator on 11/26/18 at 4:05 PM, in the conference room confirmed if a resident comes in from an outing with altered mental status it is at the physician's discretion whether to order a drug screen or send them to the ER (emergency room ). It would have been my expectation the resident would have been informed the drug test was being obtained. It is his right to be informed. Continued interview confirmed the facility failed to follow their policy and failed to honor Resident #1's right to be informed prior to receiving treatment.",2020-09-01
5052,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2016-05-25,309,J,1,0,TE8F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, record review, and interview, the facility failed to ensure anticoagulant therapy monitoring for 2 residents (#11, #12) of 4 residents reviewed receiving anticoagulant therapy, for a total sample of 15 residents who received laboratory monitoring of the [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) as ordered by the Physician. This failure was cited as past non-compliance which was determined to exist on [DATE] until [DATE]. The findings included: Review of the facility policy, Laboratory Protocol-Diagnostic Testing, revealed To provide uniform procedures for obtaining necessary diagnostic services when ordered by the Attending Physician/NP. Guideline: 1. Provide laboratory, radiological and diagnostic services as necessary and appropriate. 2. Assure that the residents receive laboratory, radiological and diagnostic services as ordered by the Attending Physician/NP. 3. Assure that the results of all diagnostic services are reported to the resident's Attending Physician/NP as necessary. Closed record review revealed Resident #11 was admitted to the facility on [DATE] and expired on [DATE]. Resident #11's anticoagulant treatment was managed by the orthopedic [MEDICATION NAME] service-anticoagulation pharmacist. Review of the hospital discharge information revealed the orthopedic [MEDICATION NAME] service would manage Resident #11's [MEDICATION NAME] therapy until [DATE]. Continued medical record review revealed the normal INR (International Normalized Ratio) range was 1.7 to 2.5. Review of the hospital Interagency Discharge Orders dated [DATE] indicated follow-up Labs: PT ([MEDICATION NAME])/INR twice weekly on every Monday and Thursday. Review of the Physician's Order Sheet dated [DATE] at 12:00 AM revealed [MEDICATION NAME] Sodium 2.5 milligram (mg) tablet one by mouth (po) at hour of sleep (HS) for femur fracture. PT/INR draw every Monday-anticoagulant therapy. Review revealed the facility failed to transcribe the Physician's Orders for PT/INR twice weekly on Mondays and Thursdays for Resident #11. This failure resulted in a delay in anticoagulant therapy monitoring. Review of the first Coagulation [MEDICATION NAME] Time Laboratory Report for Resident #11 dated [DATE] revealed PT 49.30 H (high), INR 5.30 (C) critical. Result was called to the facility at 10:10 PM on [DATE]. Review revealed an untimed order to send resident to the emergency room (ER) on [DATE] and and included and order to hold [MEDICATION NAME] written on [DATE]. Interview with RN D on [DATE] at 10:00 AM revealed there were no prior PT/INR's drawn by the facility for Resident #11. RN D stated the facility identified the situation regarding PT/INR's and [MEDICATION NAME] therapy and had a performance improvement plan (PIP) in place. Review of the PIP for following INR Orders indicated the overall goal was to ensure all PT/INR orders are followed as ordered and not missed. The target end date was (MONTH) 26, (YEAR). Review of the Analysis revealed the admission orders [REDACTED]. Orders were not transcribed correctly. The Nurse Supervisor failed to notice this when checking the Physician's Order Sheet. Record review of the (MONTH) Medication Administration Record [REDACTED]. Review revealed the Nurse initialed the MAR indicated [REDACTED] Interview with the laboratory, revealed no INRs were drawn until (MONTH) 6, (YEAR). Closed record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident expired [DATE]. Medical record review of the Physician's Order Sheet dated [DATE] - [DATE] for Resident #12 revealed [MEDICATION NAME] 60 mg/0.6 milliliter syringe inject 0.6 ml subcutaneous daily for A Fib continue until INR is therapeutic on [MEDICATION NAME], Aspirin 81 mg one by mouth daily, and [MEDICATION NAME] 5 mg one po daily for A Fib. Medical record review of the Physician's Order Sheet dated [DATE] - [DATE] for Resident #12 revealed [MEDICATION NAME] 5 mg one po daily for A Fib, [MEDICATION NAME] 60 mg/0.6 ml syringe inject 0.6 ml subcutaneous daily for A Fib, continue until INR is therapeutic on [MEDICATION NAME], ASA 81 mg one po daily. Medical record review of the Coagulation Report dated [DATE] for Resident #12 revealed [MEDICATION NAME] time 85.10 INR 10.76. Further review of the closed record for Resident #12 revealed no other PT/INR reports. Review of the closed record for Resident #12 revealed no orders for PT/INR until Friday [DATE]. Continued review revealed on [DATE] the PT/INR results were critically high with PT 85.10 and INR 10.76. Vitamin K was ordered on [DATE] after Resident #12's INR results had increased to 12.5. Interview with RN H on [DATE] at 11:56 AM revealed .normally if a resident is admitted into the facility on a blood thinner the nurse asks the doctor if they want to order an INR. Interview with RN D on [DATE] at 10:00 AM revealed the facility identified the situation regarding PT/INR's and [MEDICATION NAME] therapy and had a performance improvement plan (PIP) in place. Interview with RN D on [DATE] at 11:25 AM revealed .normally the nurse that admits the resident calls the doctor and lets them know the resident is on [MEDICATION NAME] and gets an order for [REDACTED]. Interventions: 1. [MEDICATION NAME] nurse to oversee [MEDICATION NAME] residents (new nurse role). 2. Admission/Readmission chart check: All new admissions and readmission charts will be brought to the first daily clinical meeting following admission/readmission. a. One staff member will read the admission orders [REDACTED] b. A second staff member will check those orders against the Physician Order Sheet. c. A third staff member will check the lab books to ensure all the labs are logged to be drawn. d. A fourth staff member will update the white board as needed based on the orders. Conclusion: PIP is ongoing. Interview with Administrative Staff Member Q on [DATE] at 1:55 PM revealed he/she attends all clinical meetings held in the mornings on Monday through Friday. Administrative Staff Member Q stated that attendees of the clinical meeting include: a. chaplain b. quality of life director (activity director) c. behavior health manager d. rehabilitation staff e. maintenance (plant ops) f. director of nursing g. assistant directors of nursing h. medical records i. staff development j. dietitian. Administrative Staff Member Q added the Assistant Director of Nursing's (ADON) read the Physician Orders for their units. A second ADON checks the admission orders [REDACTED]. The Administrative Staff Member Q stated when there is no order and the resident is on [MEDICATION NAME] it would be noted. Continued interview with the Administrative Staff Member Q stated .the White Board was revamped in (MONTH) or (MONTH) of (YEAR). It was revised before [DATE] .the facility's Medical Director prefers to follow residents individually and monitor them closely . Both RN D and Administrative Staff Member Q stated on [DATE] at 1:55 PM .PT/INRs are recorded/tracked on a flow sheet now. Re-education of the white boards has kept everything in check. The Performance Improvement Plan (PIP) is ongoing. For [MEDICATION NAME] the resident's name is put on the White Board. Anything that needs to be followed up on is put on the White Board. In Stand Down meetings staff follow up on those things. Stand down meetings are held Monday through Friday at 3:30 PM . Telephone interview with the Medical Director on [DATE] at 3:50 PM revealed .the decision whether to order PT/INR on residents on anticoagulant therapy varied from person to person. The decision was multifactorial. When notified of a critical INR value normally would immediately write an order for [REDACTED]. The facility implemented a performance improvement plan and is evaluated by the Quality Assurance Quality Improvement Committee process to prevent any further laboratory monitoring errors of this type, for this reason and the above interventions F-309 was cited as a past non-compliance [DATE] through [DATE].",2019-05-01
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
3609,TRINITY HEALTH AND REHABILITATION CENTER,445533,700 WILLIAMS FERRY RD,LENOIR CITY,TN,37771,2019-08-27,600,D,1,0,NN2511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of a facility investigation, medical record review, and interview, the facility failed to prevent abuse for 1 resident (#1) of 5 residents reviewed for abuse. The findings included: Review of the facility policy Abuse Prevention/ Reporting Policy and Procedure Updated 8/5/17 revealed .Every resident has the right to be free from abuse .Residents must not be subjected to abuse by anyone including .other residents .Definitions: 3) sexual abuse: Touching the resident in an intimate manner or allowing another resident to do so .It is non-consensual sexual contact of any type with a resident . Review of a facility investigation dated 8/19/19, not timed, revealed on 8/19/19 at approximately 11:45 AM, Resident #2 was seen with his arm down the blouse of Resident #2 . Continued review revealed the Activity Director witnessed the incident and separated the residents. Further review revealed a physical examination of Resident #1 revealed no injuries and Resident #1 could not recall the incident minutes after it occurred. Continued review revealed Resident #2 recalled the incident and stated .(Resident #1) wanted (Resident #2) to feel (Resident #1's) boobs . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #1had short and long term memory loss and was a total assistance of two or more persons for activities of daily living (ADLs). Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical Record review of Resident #2's Annual MDS dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact). Further review revealed the resident was bedbound and required assistance of one or two persons for ADLs. Interview with the Activity Director (AD) on 8/27/19 at 10:52 AM, in the conference room, confirmed she witnessed Resident #2 with his arm inside Resident#1's blouse while both residents were sitting in the day room. Continued interview revealed the AD immediately separated the two residents and took Resident #2 back to his room. Further interview revealed the AD notified the Director of Nursing (DON) of the incident and an investigation was initiated. Continued interview revealed Resident #1 was not injured and did not remember the incident minutes after it happened. Interview with Nurse Practitioner (NP) #1 on 8/27/19 at 11:15, in the conference room, revealed she interviewed both residents involved in the incident and Resident #1 had no memory of the incident. Interview with the Administrator and DON on 8/27/19 at 3:40 PM, in the conference room, confirmed the facility failed to protect Resident #1 from abuse.",2020-07-01
3613,TRINITY HEALTH AND REHABILITATION CENTER,445533,700 WILLIAMS FERRY RD,LENOIR CITY,TN,37771,2019-09-24,600,D,1,0,5N0L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of a facility investigation, medical record review, and interviews, the facility failed to ensure 1 resident (#2) was free from abuse of 6 residents reviewed for abuse. The findings include: Review of facility policy Abuse, Neglect and Misappropriation or Property, last updated 8/15/17 revealed .Every resident has the right to be free from abuse .Residents must not be subjected to abuse by anyone including .other residents .Abuse is defined as willful infliction of injury .Willful as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Review of a facility investigation dated 9/8/19 revealed on 9/8/19 at approximately 11:45 PM Resident #1 was restless and attempting to get out of bed unassisted so for reasons of safety the facility staff assisted the resident into her wheelchair. Further review revealed the resident then self-propelled herself to the lobby area. Continued review revealed Licensed Practical Nurse (LPN) #1 overheard a loud noise in the lobby, went to investigate, and observed Resident #1 hit Resident #2 on the chest area and then attempt to slap Resident #2. Further review revealed Resident #2 attempted to kick Resident #1 in self-defense, but did not make contact. Continued review revealed the residents were separated and no injuries were noted to either resident. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged to an inpatient psychiatric unit on 9/9/19. Medical record review Resident #1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had short and long term memory problems. Continued review revealed the resident required extensive assistance of one person with activities of daily living (ADLs) and had a history of [REDACTED]. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical Record review of Resident #2's Admission MDS dated [DATE] revealed Resident #2 had short and long term memory problems. Further review revealed the resident was total assist with bed mobility, dressing, toilet use and personal hygiene with the physical assistance of two + persons, was independent with locomotion on and off unit in his wheelchair and was independent with eating. Interview with the Administrator and the DON on 9/24/19 at 3:40 PM, in the Administrator's office, confirmed the facility failed to protect Resident #2 from an altercation with Resident #1. Telephone interview with LPN #1 on 9/24/19 at 5:45 PM revealed she heard a loud argument between Resident #1 and Resident #2 so she went to the lobby to investigate. Further interview confirmed LPN #1 witnessed Resident #1 hit Resident #2 on the chest.",2020-07-01
3614,TRINITY HEALTH AND REHABILITATION CENTER,445533,700 WILLIAMS FERRY RD,LENOIR CITY,TN,37771,2019-09-24,609,D,1,0,5N0L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of a facility investigation, medical record review, and interviews, the facility failed to report an allegation of abuse timely to the Administrator and the State Survey Agency within 2 hours for 1 resident (#2) of 6 residents reviewed for abuse. The findings include: Review of facility policy Abuse, Neglect and Misappropriation or Property, last updated 8/15/17 revealed .Every resident has the right to be free from abuse .Residents must not be subjected to abuse by anyone , including .other residents .Abuse is defined as willful infliction of injury .Willful as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Prevention: 4) staff will be provided with information regarding the process for reporting witnessed abuse, suspected abuse .11) all reports whether from family, residents or staff will be reported immediately to the Administrator and Abuse coordinator and/or DON (Director of Nursing) . Review of a facility investigation dated 9/8/19 revealed on 9/8/19 at approximately 11:45 PM Resident #1 was restless and attempting to get out of bed unassisted so for reasons of safety the facility staff assisted the resident into her wheelchair. Further review revealed the resident then self-propelled herself to the lobby area. Continued review revealed Licensed Practical Nurse (LPN) #1 overheard a loud noise in the lobby, went to investigate, and observed Resident #1 hit Resident #2 on the chest area and then attempt to slap Resident #2. Further review revealed Resident #2 attempted to kick Resident #1 in self-defense, but did not make contact. Continued review revealed the residents were separated and no injuries were noted to either resident. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged to an inpatient psychiatric unit on 9/9/19. Medical record review Resident #1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had short and long term memory problems. Continued review revealed the resident required extensive assistance of one person with activities of daily living (ADLs) and had a history of [REDACTED]. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical Record review of Resident #2's Admission MDS dated [DATE] revealed Resident #2 had short and long term memory problems. Further review revealed the resident was total assist with bed mobility, dressing, toilet use and personal hygiene with the physical assistance of two + persons, was independent with locomotion on and off unit in his wheelchair and was independent with eating. Telephone interview with LPN #1 on 9/24/19 at 5:45 PM revealed she heard a loud argument between Resident #1 and Resident #2, so she went to the lobby to investigate and witnessed Resident #1 hit Resident #2 on the chest and then attempt to slap him. Further interview revealed Resident #2 attempted to kick Resident #1 in self-defense, but did not make contact. Continued interview confirmed LPN #1 did not report the incident to the Director of Nursing, the Administrator, or to the State Survey Agency. Interview with the Administrator on 9/24/19 at 9:40 PM, in the Administrator's office, confirmed the facility failed to report the incident between Resident #1 and Resident #2 to the State Survey Agency within the 2 hours.",2020-07-01
515,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2019-04-24,609,J,1,0,G6YR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of a facility investigation, medical record review, and interviews, the facility failed to report an allegation of neglect to the State Survey Agency timely for 1 of 6 (Resident #1) residents reviewed for neglect. Resident #1 eloped and the incident was not reported to the State Survey Agency within 2 hours. The facility's failure to report neglect timely placed Resident #1 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). F-609 was cited at a scope and severity of J and is Substandard Quality of Care. The Nursing Home Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 4/23/19 at 12:00 PM, in the Family Room. The IJ was effective from 3/18/19 through 3/19/19. The IJ was removed on 3/19/19 when the facility implemented a corrective action plan. Corrective actions were validated by the surveyor on 4/22/19 - 4/24/19. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction for those tags. The findings include: The facility's Abuse Prevention Policy & Procedure, revised 2/26/18 documented, .All allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the state survey agency, adult protective services and to all other agencies as required, per state and federal guidelines .Immediately means as soon as possible, but not later than 2 hours after the allegation is made . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5 day Minimum Data Set ((MDS) dated [DATE] revealed, Resident #1 was moderately cognitively impaired, had poor decision making skills, required cues and supervision, wandering occurred 1-3 days of the assessment period, had an unsteady gait and used a walker when ambulating. Medical record review of Resident #1's Baseline Care Plan, dated 3/12/19, revealed the resident was at risk for elopement as evidenced by wandering and the intervention was ensure staff is aware of resident's wander risk, and exit alarms. Medical record review of Resident #1's nurses' note dated 3/17/19 at 3:13 PM revealed, .Wandering into resident's room and pushing on exit door handles . Review of the facility investigation dated 3/18/19 revealed, on 3/18/19 at approximately 2:00 AM, the facility staff were unable to locate Resident #1 and initiated the protocol for elopement of a resident. Continued review revealed the facility staff searched all rooms in the facility and the outside grounds and notified the Administrator and local police department of the missing resident. At approximately 4:45 AM, Resident #1 was found lying in a creek embankment containing water and transported to the hospital. Based on the United States Weather Service records, the recorded low temperature for the facility area on 3/18/19 was 37 degrees Fahrenheit. Medical record review of an acute care hospital Hospitalist Progress Note dated 3/18/19 at 9:40 AM documented, .Assessment Plan: 1.[MEDICAL CONDITION], 2. UTI (urinary tract infection), 3. Hypothermia secondary to prolonged exposure outside in the cold. Initial temperature 92.2 (Fahrenheit) (normal body temperature 98.6) on arrival resolved with bear (Bair) hugger (warming device) .[MEDICAL CONDITION] (elevated potassium level) .Hematoma (bruising and swelling) around the right eye . Interview with the DON on 3/21/19 at 2:55 PM in the Family Room, the DON stated, .The Administrator reported (the incident to the State) that morning after she (Resident #1) was taken to the ER (emergency room ) . Interview with the Administrator on 4/22/19 at 2:00 AM in the Family Room, the Administrator stated, .I was notified 3:13 (AM) by phone from the night shift RN (Registered Nurse) a resident had eloped .I called the DON to inform her of the elopement . Review of the facility self-report revealed the incident was reported to the state survey agency on the morning of 3/18/19 (at 7:13 AM approximately 5 hrs and 13 minutes after the incident). The facility's corrective action plan included the following: On 3/18/19 the facility did the following: [NAME] A Certified Nursing Assistant (CNA) was stationed by the 200 hall door until all emergency doors and wiring of emergency doors were inspected for proper functioning. B. The Maintenance Director checked the functionality of all 7 exit doors, door code boxes and the alarm systems of the doors. 1. Opened every code box at every exit door and checked the wiring to ensure working properly. 2. Checked every code box battery to ensure they were working properly. Ordered all new batteries as a preventive measure. On 3/19/19 replaced all batteries in the code boxes on all exit doors. C. In the ceiling above the 200 hall exit door, opened the junction box to ensure all wiring was correct, tight, and replaced the discolored wiring. D. The security code to the 200 hall entrance/exit door was changed by the Maintenance Director. E. The Maintenance Director changed the wiring from the 200 hall exit door to the generator due to discoloration of the wires. F. The DON and designee re-assessed all residents in the building to determine any resident at risk for elopement. Results were no new residents identified as an elopement risk or added to the list. [NAME] Conducted in-services with 100% of all staff on wandering residents, elopement, abuse and systemic changes that were implemented to promote resident safety. Staff was required to have the in-service education prior to working their next shift. Changes included: 1. If staff observed changes in a resident's behavior that included wandering and/or exit seeking, the nurse must complete an elopement risk assessment. After completing the risk assessment, if the resident is determined to be at risk of elopement, the resident is to be added to alert charting to be completed by nursing. 2. The CNA is to communicate to nurses any observed changes in a resident's behavior that involved wandering and/or exit seeking. 3. The Elopement Binder was updated to include a current facesheet and picture of each resident at risk of elopement. An Elopement Binder will be kept at the receptionist desk and one at the nurses' station. 4. If any entrance/exit door alarm sounds, a staff member is to go to the door and check outside. Don't assume it was a visitor. H. The Care Plan for Resident #1 was updated to include new interventions for the risk for elopement. I. Completed an elopement scenario drill for each shift. [NAME] DON and designee conducted in-services with nursing staff on procedure process for risk of elopement: 1. If resident is observed with elopement behaviors the following must be done: a. Ensure safety of resident/residents b. Complete Elopement risk assessment c. Notify MD (Doctor of Medicine) and family d. Notify DON and Administrator e. Medical records to update Elopement Binder f. Begin Alert charting. K. The Nursing Home Administrator, DON, Assistant Director of Nursing (ADON), Director of Social Services, Maintenance Director, Regional Director Operational Support and Regional Director Clinical Services Support conducted an ad hoc Quality Assurance Meeting to review the circumstances of the incident and implement an immediate action plan for the investigation of the incident. The surveyors verified the facility's corrective action plan on 4/22/19-4/24/19 as follows: [NAME] Review of the Quality Assurance Performance Improvement meeting, attendance, agenda sheets and minutes confirmed the facility conducted an ad hoc Quality Assurance meeting on 3/18/19, and began review monthly on 4/19/19 to ensure sustainability of the plan of correction. B. Medical record reviews revealed 100% of residents were re-assessed on 3/18/19 using the Nursing Risk Assessment for Elopement Risk with 100% completion. C. Observation of the Resident Monitoring System log and interview with the Maintenance Director on 4/22/19 at 10:50 AM, in the Family Room, confirmed the 7 exit door alarms were checked weekly for functioning alarm sounding. Continued interview confirmed the battery function of the security code boxes was checked monthly. D. Review of the list of residents at risk of elopement confirmed the list was updated and the Elopement Binders were updated to include all residents currently at risk of elopement. E. On 4/23/19 at 2:05 PM, the surveyor attempted to exit through the doorway located at the end of the 200 hall by pushing on the door, setting off the alarm. The facility staff responded immediately. F. Comparison of facility in-service records and sign in/out sheets, for policy reviews and changes beginning 3/18/19 were validated. Interview with the DON on 4/23/19 at 10:15 AM, in the Family Room, confirmed staff education was 100% complete. Continued interview revealed the facility had conducted elopement scenarios with facility staff on 3/18/19 and 3/19/19 and will continue at random. [NAME] Multiple observations and interviews were conducted by the surveyor with residents and employees on both shifts throughout the complaint survey conducted on 3/21/19 - 4/24/19, which confirmed full implementation of the systemic changes to enhance resident/staff safety and the reporting. H. Review of the facility's self-reported incidents to the State Agency and review of the Concern/Comment Log revealed the facility had no other incidents of allegations of neglect and/or elopement since the implementation of the corrective action plan.",2020-09-01
514,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2019-04-24,600,J,1,0,G6YR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of a facility investigation, medical record review, observation, and interview, the facility failed to prevent neglect for 1 of 6 (Resident #1) residents reviewed, which resulted in Resident #1 exiting the facility, was found sitting in a creek containing water and sustained hypothermia (dangerously low body temperature) and a hematoma (swelling and bruising)around her right eye. The facility's failure to prevent neglect placed Resident #1 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). F-600 was cited at a scope and severity of J and is Substandard Quality of Care. The Nursing Home Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 4/23/19 at 12:00 PM, in the Family Room. The IJ was effective from 3/18/19 through 3/19/19. The IJ was removed on 3/19/19 when the facility implemented a corrective action plan. Corrective actions were validated by the surveyor on 4/22/19 - 4/24/19. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction for those tags. The findings include: The Wandering, Unsafe Resident policy, revised (MONTH) 2014 documented, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement .The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 5 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was moderately cognitively impaired, had poor decision making skills, required cues and supervision, was ambulatory with an unsteady gait and used a walker, and wandering occurred 1-3 days of the assessment period. Medical record review of Resident #1's Baseline Care Plan, dated 3/12/19, revealed the resident was at risk for elopement as evidenced by wandering and the intervention was ensure staff is aware of resident's wander risk, and exit alarms. Review of the facility's list of residents at risk for elopement revealed Resident #1 was not included on the list from 3/12/19 - 3/18/19. Medical record review of Resident #1's nurses' note dated 3/17/19 at 3:13 PM documented, .Wandering into resident's room and pushing on exit door handles . Review of the facility investigation dated 3/18/19 revealed, on 3/18/19 at approximately 2:00 AM, the facility staff were unable to locate Resident #1 and initiated the protocol for elopement of a resident. Continued review revealed the facility staff searched all rooms in the facility and the outside grounds and notified the Administrator and local police department of the missing resident. Emergency Management Agency and Search and Rescue Dog (K9) responded. At approximately 4:45 AM, Resident #1 was found sitting in a creek embankment containing water by Emergency Management Services and was transported to the hospital. Based on the United States Weather Service records, the recorded low temperature for the facility area on 3/18/19 was 37 degrees Fahrenheit. Medical record review of an acute care hospital Hospitalist Progress Note dated 3/18/19 at 9:40 AM documented, .Assessment Plan: 1.[MEDICAL CONDITION], 2. UTI (urinary tract infection), 3. Hypothermia secondary to prolonged exposure outside in the cold. Initial temperature 92.2 (Fahrenheit) (normal body temperature 98.6) on arrival resolved with bear (Bair) hugger (warming device) .[MEDICAL CONDITION] (elevated potassium level) . Review of the (Named Hospital) history and physical dated 3/18/19 documented, The ER patient (Resident #1) was found to have [MEDICAL CONDITION](elevated heart rate) hypertension (elevated blood pressure) as well as hypothermia patient started on Bair hugger (warming device) .Vital Sign Ranges Last 24 Hours 92.2 F (Fahrenheit) -98.2 F (normal body temperature 98.6 F) .patient has hematoma around the right eye . The (Named) Police Department (PD) report number documented, .3/18/19 at approximately 0304 (3:04 AM) hours dispatched to a missing person endangered .Nursing staff and officers searched the facility and immediate areas .0331 (3:31 AM) hrs (hours) EMA (Emergency Management Agency) K9 (Search and Rescue dog) notified .0411 (4:11 AM) K9 began track .As we were tracking (Resident #1's) scent, we were notified that (Resident #1) was seen lying in the embankment. Once verified that it was (Resident #1), she was transported by EMS (Emergency Management Services) to (named hospital) . Observations on 3/21/19 and 4/22/19 revealed the facility had 7 entrance/exit doors with keypads that required a code to open or enter/exit: 1 Front Main entrance/exit doorway; 1 Dining Room exit doorway; 1 100 hall end of hall exit doorway; 1 patio entrance/exit doorway; 1 200 hall end of hall exit doorway; 1 300 hall vending machine entrance/exit doorway visible from the nurse's station; 1 300 hall end of hall exit doorway. Observations on 3/21/19 at 2:00 PM behind the facility, revealed the enbankment to be a steep enbankment, with undergrowth of grass and weeds, there was a creek with water in the creek bed. Observations on 4/23/19 at 2:10 PM behind the facility, revealed the enbankment to be a steep enbankment, with undergrowth of grass and weeds, there was a creek with water in the creek bed. There had been a recent rain and the creek was slightly deeper than the observation on 3/21/19. Interview with the DON on 3/21/19 at 3:37 PM, in the Family room, the DON stated, She (Resident #1) was found sitting in the creek, water was to her waist while sitting in the creek. Legs were wet. Top was dry. She was disoriented. The Search and Rescue dog with the policeman found her with help of the fire department. Interview with Certified Nursing Assistant (CNA) #4 on 4/22/19 at 1:34 AM, in the 300 hallway, CNA #4 was asked if she sat in the hallway most nights. CNA #4 stated, Yeah, we all do when we finish rounds . CNA #4 was asked if she heard any door alarms sounding on the shift 7:00 PM - 7:00 AM beginning 3/17/19. CNA #4 stated, No. I didn't. Interview with the Maintenance Director on 4/22/19 at 4:20 PM in the Family Room, the Maintenance Director confirmed the Front Main entrance door code had been posted on the code box beside the door both at the entrance and exit code box .on that day (3/18/19) I immediately came in around 5:30 (AM) and checked all exit doors to verify working properly .I pulled open every code box at the exit doors and checked the wiring to make sure working properly .All batteries were working properly, however I went ahead and ordered all new batteries and .replaced all batteries in every code box .I then went into the ceiling above 200 hall exit door and opened the junction box and made sure all wiring was correct and tight, the wiring was working but it was discolored so I replaced it over the 200 hall exit door .I inserviced all day and night shift staff of the elopement policy and procedure and we did .drill (elopement scenario) for each shift . Interview with Licensed Practical Nurse (LPN) #1 on 4/22/19 at 4:52 PM, in the Family Room, LPN #1 was asked if she heard any door alarms sounding on the shift 7:00 PM - 7:00 AM beginning on 3/17/19. LPN #1 stated, I don't recall any alarms going off. LPN #1 stated, No, I was at the desk. LPN #1 was asked if Resident #1 had been observed walking to or past the nurses' station. LPN #1 stated, No. Interview with Registered Nurse (RN) #1 on 4/22/19 at 5:55 PM, in the Family Room, RN #1 was asked if she heard any door alarms sounding. RN #1 stated, Not that I recall. RN #1 was asked if she watched the 200 hall while CNA #1 was helping on the other hall. RN #1 stated, I watched for call lights. RN #1 was asked if she could see down the hall. RN #1 stated, No, I was at the desk. RN #1 was asked if Resident #1 had been observed walking to or past the nurses' station. RN #1 stated, No. RN #1 confirmed her witness statement. RN #1 stated, .That night (named Resident #1) had been up and down the (200) hallway .At 2:00 AM I peeked in her (Resident #1) room to check on her and she was not in her room .I asked (named CNA #1) did you see her leave her room and she said no .I then told all staff to begin searching in all rooms, bathrooms, closets everywhere as well as outside . Interview with CNA #2 on 4/22/19 at 6:47 PM, in the Family Room, CNA #2 stated, I saw (Named Resident #1) going down the hall, 200 hall .directed her back into her room about 12:15 (AM). I went back to my hall on 300. CNA #2 was asked if she heard any door alarms sounding that night. She stated, No. CNA #2 was asked if Resident #1 had been observed walking to or past the nurses' station. CNA #2 stated, No. Interview with CNA #3 on 4/22/19 at 7:05 PM, in the Family room, CNA #3 stated, I asked (Named CNA #1) to help me with a resident on 100 hall around 1:30 (AM). She came to room [ROOM NUMBER] .She left the room after 15 to 20 minutes . CNA #3 was asked if she heard any door alarms sounding that night. She stated, No. CNA #3 was asked if Resident #1 had been observed walking to or past the nurses' station. CNA #3 stated, No. Telephone interview with CNA #1 on 4/22/19 at 7:20 PM, CNA #1 stated, .I ate my meal between 12 (AM) and 1(AM). Meal was in the breakroom. I heated it up in the breakroom across from the nurses' station. Nobody was particularly watching the room (Resident #1's room). Others were watching for lights (resident call lights) or listening for the lights. I left to help (Named a CNA) for about 10 minutes. I did rounds. She (Resident #1) was by her door. I directed her back in her room. I finished my round, probably 4 people, and 2 rooms. Then went and heated my meal. I had a light going off. I went and answered the lights. Went to the bathroom a couple of times. Her door was shut. CNA #1 was asked who was monitoring the hall, particularly Resident #1's room, while she was off the hall. CNA #1 stated, Not sure. I was in/out rooms. CNA #1 was asked if she heard any door alarms sounding that night. CNA #1 stated, No .CNA #1 was asked if Resident #1 had been observed walking to or past the nurses' station. CNA #1 stated, No .saw her (Resident #1) wander out of her room and down the hall toward the nurses' station or walk in her room . A second telephone interview with CNA #1 on 4/22/19 at 7:30 PM, CNA #1 confirmed her witness statement. She stated, .The last time I saw (named Resident #1) was approximately 12:15 AM. I redirected her back to her room. She said she was going to bed and closed the door .At approximately 2:00 AM the nurse (RN #1) said (named Resident #1) was not in her room, did I know where she was .that is when we started searching the facility and the grounds . Interview with the Administrator on 4/23/19 at 9:25 AM, in the Family Room, the Administrator stated, I could see how going into other people's rooms could lead to exiting. Interview with the DON on 4/23/19 at 10:15 AM, in the Family Room, the DON stated, I looked back at the nurses' notes for the day before (day prior to the elopement) During that day, based on the nurses' notes, she was wandering that day and went to an exit door and exhibited those behaviors .Going to exit doors . The DON was asked what her expectations were for monitoring a resident with behaviors of wandering/at risk for elopement. The DON stated, .I would not expect them to be left alone. Be kept in sight. I would expect a visual . Record review of maintenance records of the Resident Monitoring Systems: Check operation of door monitors and patient wandering system dated 3/6/19 - 4/17/19 revealed, the logs were completed weekly and passed inspection. Review of the Emergency Power Generators logbook dated 3/8/19 - 4/16/19 were completed weekly and passed inspection. The facility's failure to monitor and supervise a cognitively impaired resident resulted in Resident #1 wandering away from the facility during the night and suffering from hypothermia and a hematoma around her right eye. The facility's corrective action plan included the following: On 3/18/19 the facility did the following: [NAME] A Certified Nursing Assistant (CNA) was stationed by the 200 hall door until all emergency doors and wiring of emergency doors were inspected for proper functioning. B. The Maintenance Director checked the functionality of all 7 exit doors, door code boxes and the alarm systems of the doors. 1. Opened every code box at every exit door and checked the wiring to ensure working properly. 2. Checked every code box battery to ensure they were working properly. Ordered all new batteries as a preventive measure. On 3/19/19 replaced all batteries in the code boxes on all exit doors. C. In the ceiling above the 200 hall exit door, opened the junction box to ensure all wiring was correct, tight, and replaced the discolored wiring. D. The security code to the 200 hall entrance/exit door was changed by the Maintenance Director. E. The Maintenance Director changed the wiring from the 200 hall exit door to the generator due to discoloration of the wires. F. The DON and designee re-assessed all residents in the building to determine any resident at risk for elopement. Results were no new residents identified as an elopement risk or added to the list. [NAME] Conducted in-services with 100% of all staff on wandering residents, elopement, abuse and systemic changes that were implemented to promote resident safety. Staff was required to have the in-service education prior to working their next shift. Changes included: 1. If staff observed changes in a resident's behavior that included wandering and/or exit seeking, the nurse must complete an elopement risk assessment. After completing the risk assessment, if the resident is determined to be at risk of elopement, the resident is to be added to alert charting to be completed by nursing. 2. The CNA is to communicate to nurses any observed changes in a resident's behavior that involved wandering and/or exit seeking. 3. The Elopement Binder was updated to include a current facesheet and picture of each resident at risk of elopement. An Elopement Binder will be kept at the receptionist desk and one at the nurses' station. 4. If any entrance/exit door alarm sounds, a staff member is to go to the door and check outside. Don't assume it was a visitor. H. The Care Plan for Resident #1 was updated to include new interventions for the risk for elopement. I. Completed an elopement scenario drill for each shift. [NAME] DON and designee conducted in-services with nursing staff on procedure process for risk of elopement: 1. If resident is observed with elopement behaviors the following must be done: a. Ensure safety of resident/residents b. Complete Elopement risk assessment c. Notify MD (Doctor of Medicine) and family d. Notify DON and Administrator e. Medical records to update Elopement Binder f. Begin Alert charting. K. The Nursing Home Administrator, DON, Assistant Director of Nursing (ADON), Director of Social Services, Maintenance Director, Regional Director Operational Support and Regional Director Clinical Services Support conducted an ad hoc Quality Assurance Meeting to review the circumstances of the incident and implement an immediate action plan for the investigation of the incident. The surveyors verified the facility's corrective action plan on 4/22/19 - 4/24/19 as follows: [NAME] Review of the Quality Assurance Performance Improvement meeting, attendance, agenda sheets and minutes confirmed the facility conducted an ad hoc Quality Assurance meeting on 3/18/19, and began review monthly on 4/19/19 to ensure sustainability of the plan of correction. B. Medical record reviews revealed 100% of residents were re-assessed on 3/18/19 using the Nursing Risk Assessment for Elopement Risk with 100% completion. C. Observation of the Resident Monitoring System log and interview with the Maintenance Director on 4/22/19 at 10:50 AM, in the Family Room, confirmed the 7 exit door alarms were checked weekly for functioning alarm sounding. Continued interview confirmed the battery function of the security code boxes was checked monthly. D. Review of the list of residents at risk of elopement confirmed the list was updated and the Elopement Binders were updated to include all residents currently at risk of elopement. E. On 4/23/19 at 2:05 PM, the surveyor attempted to exit through the doorway located at the end of the 200 hall by pushing on the door, setting off the alarm. The facility staff responded immediately. F. Comparison of facility in-service records and sign in/out sheets, for policy reviews and changes beginning 3/18/19 were validated. Interview with the DON on 4/23/19 at 10:15 AM, in the Family Room, confirmed staff education was 100% complete. Continued interview revealed the facility had conducted elopement scenarios with facility staff on 3/18/19 and 3/19/19 and will continue at random. [NAME] Multiple observations and interviews were conducted by the surveyor with residents and employees on both shifts throughout the complaint survey conducted on 3/21/19 - 4/24/19, which confirmed full implementation of the systemic changes to enhance resident/staff safety and the reporting. H. Review of the facility's self-reported incidents to the State Agency and review of the Concern/Comment Log revealed the facility had no other incidents of allegations of neglect and/or elopement since the implementation of the corrective action plan.",2020-09-01
1607,CUMBERLAND VILLAGE CARE,445276,136 DAVIS LANE,LAFOLLETTE,TN,37766,2018-10-17,600,D,1,0,HU1T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of facility documentation, medical record review, observation, and interview the facility failed to prevent verbal abuse for 1 resident (#1) of 5 residents reviewed for abuse. The findings include: Review of the facility policy, Abuse Prohibition Policy, updated 7/1/18 revealed the facility had a system in place for abuse/neglect prevention consistent with regulatory guidelines and failed to follow the policy for section 5.1 .Anyone who witnesses an incident of suspected abuse .is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately .and 5.1.2 The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation . Review of the facility's investigational interviews for the alleged verbal abuse incident revealed Licensed Practical Nurse (LPN) #1 was witnessed speaking to Resident #1 in a loud, disrespectful voice, and using profanity. Continued review revealed Certified Nurse Aide (CNA) #1 told LPN #1 she shouldn't have spoken to .(Resident #1) like she did. Continued review revealed CNA #2 had been sitting with Resident #1 at the nurse's station when the incident occurred and also witnessed the conversation. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) was 15, indicating the resident cognitively intact with daily decision making and the resident's functional status for bed mobility, transfers, locomotion in room and on and off the unit was independent. Observation and interview with Resident #1 on 10/17/18 at 10:55 AM, in the resident's room revealed on 10/3/18 at around 6:30-6:45 AM during shift change, the resident was going to talk to the shower girl about getting her hair washed before a doctor's appointment later that day. Continued interview with the resident revealed she saw CNA #1 coming down the hallway, and she asked the CNA to push her to the Nurses' station. Continued interview revealed the resident stopped at the Nurses' station next to a vital sign machine and started taking her own blood pressure while waiting on the shower girl. Continued interview confirmed LPN #1 was in the medication room at that time, and when she saw me (Resident #1) at the Nurses' station she came out cussing, about me wanting my meds (medication) too soon. Resident #1 stated she tried to explain to the LPN she was not there for her, but she was waiting on the shower girl to get her hair washed. The resident stated the LPN went back into the medication room and after a short while the LPN came back out and tried to console her (Resident #1) due to her crying and being upset about the conversation. Interview with the Assistant Director of Nursing (ADON) on 10/17/18 at 2:15 PM in the conference room revealed the ADON realized Resident #1 was having some anxiety over the incident and offered to have the facility psychologist come and visit her if she thought she would benefit. Continued interview revealed the resident( #1) told the ADON she didn't want to see their psychologist but could call her psychologist she had been seeing for over [AGE] years if she thought she needed to talk to someone about the incident. The ADON stated Resident #1 was upset for 2-3 days and had returned to her normal state and had no other problems since LPN #1 was terminated. Telephone interview with CNA #1 on 10/17/18 at 2:27 PM revealed the CNA was with Resident #1 when LPN #1 came out of the medication room and started going off on Resident #1, cussing at her, telling her the meds weren't ready, acting really unprofessional, and rude. The CNA told LPN #1 she shouldn't have spoken to Resident #1 like she did. The CNA stated he had another resident he had to go take care of and left the area. Telephone interview with LPN #1 on 10/17/18 at 2:50 PM revealed the LPN didn't know what she had done to Resident #1 to upset her so badly. She stated the resident (#1) was always full of drama and always at the nurses' station to get her meds early. The LPN stated she told the resident her medications were not ready yet and she went off crying. Continued interview revealed LPN #1 had tried to calm her down. The LPN stated the facility called her in the next day and terminated her. Telephone interview with CNA #2 on 10/17/18 at 4:01 PM revealed the CNA was sitting with Resident #1 at the nurses' station while she was waiting on the shower girl when LPN #1 came out of the medication room in a tirade talking all potty mouthed to Resident #1 about being there too early for her meds and Resident #1 told LPN #1 she was only up there to see the shower girl to get her hair done before her doctor's appointment later that day. The CNA stated the resident (#1) was upset and crying. The CNA stated nobody really thought the LPN's actions were abuse at the time, but looking back she could see that it was.",2020-09-01
1608,CUMBERLAND VILLAGE CARE,445276,136 DAVIS LANE,LAFOLLETTE,TN,37766,2018-10-17,609,D,1,0,HU1T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of facility documentation, medical record review, observation, and interview the facility failed to report abuse timely for 1 resident (#1) of 5 residents reviewed for abuse. The findings include: Review of the facility policy Abuse Prohibition Policy, updated 7/1/18 revealed the facility had a system in place for abuse/neglect prevention consistent with regulatory guidelines and failed to follow the policy for section 5.1 .Anyone who witnesses an incident of suspected abuse .is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately .and 5.1.2 The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation . Review of the facility investigation revealed LPN #1 was allowed to work her full shift on 10/3/18 due to staff witnesses not reporting the incident. The Certified Nursing Assistant (CNA) #1 and #2 witnessed the verbal abuse by Licensed Practical Nurse (LPN) #1 and failed to report the abuse per policy. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) was 15, indicating the resident cognitively intact with daily decision making and the resident's functional status for bed mobility, transfers, locomotion in room and on and off the unit was independent. Interview with Resident #1 on 10/17/18 at 10:55 AM, in the resident's room revealed on 10/3/18 at around 6:30-6:45 AM during shift change, the resident was going to talk to the shower girl about getting her hair washed before a doctor's appointment later that day. Continued interview revealed she saw CNA #1 coming down the hall and she asked the CNA to push her to the Nurses' station. Continued interview revealed the resident had stopped at the Nurses' station next to a vital sign machine and started taking her blood pressure while waiting on the shower girl. Continued interview revealed LPN #1 was in the medication room and when she saw Resident #1 the Nurses' station she came out cussing at her about wanting her meds too soon and went on about other personal problems the LPN was having. Resident #1 explained to the LPN she was not there for her, she was waiting on the shower girl to get her hair washed. The resident stated the LPN went back into the medication room and after a short while the LPN came back out and tried to console her, and she went back to her room. Further interview with Resident #1 revealed she was very upset and shaky for 2-3 days after the incident. Interview with the Assistant Director of Nursing (ADON) on 10/17/18 at 2:15 PM in the conference room revealed the ADON realized Resident #1 was having some anxiety over the incident and offered to have the facility psychologist come and visit her if she thought she would benefit. Resident #1 told the ADON she didn't want to see their psychologist but could call her psychologist she had been seeing for over [AGE] years if she thought she needed to talk to someone about the incident. The ADON stated Resident #1 was upset for 2-3 days and had returned to her normal state and had no other problems since LPN #1 was terminated. Interview with LPN #2 on 10/17/18 at 2:30 PM, in the conference room revealed Resident #1 told her about the verbal abuse while they were outside smoking on the morning of 10/4/18. Continued interview revealed LPN #2 told the Social Services Director (SSD) about the incident, and the SSD, LPN #2 and ADON went to the resident's room to speak with her about the incident. Continued interview revealed Resident #1 told them she did not want to talk about the matter at that time and for them to come back around 2:00 PM. Continued interview revealed the ADON and SSD returned to the resident's room around 2:30 the same day, and spoke briefly with the resident about the incident. Telephone interview with CNA #1 on 10/17/18 at 2:27 PM revealed the CNA was with Resident #1 when LPN #1 came out of the medication room and started going off on Resident #1, cussing at her, telling her meds weren't ready, and acting really unprofessional and rude. The CNA told LPN #1 she wasn't there to get medication and told her she shouldn't have spoken to her (Resident #1) like she did. The CNA stated he had another resident he had to go take care of, left the area, and failed to report the incident to his supervisor. Telephone interview with LPN #1 on 10/17/18 at 2:50 PM revealed the LPN didn't know what she had done to Resident #1 to upset her so badly. Continued interview revealed LPN #1 stated the resident (#1) was always full of drama and always at the nurses' station to get her meds early. LPN #1 stated she told her (Resident #1) medications were not ready yet and she went off crying. LPN #1stated the facility called her in the next day and terminated her. Telephone interview with CNA #2 on 10/17/18 at 4:01 PM revealed the CNA was sitting with Resident #1 at the nurses' station while she was waiting on the shower girl when LPN #1 came out of the medication room in a tirade talking all potty mouth to the resident( #1) about being there too early for her meds and the resident (#1) told LPN #1 she was only up there to see the shower girl to get her hair done before her doctor's appointment later that day. The CNA stated the resident( #1) was upset and crying. The CNA stated nobody really thought the LPN's actions were abuse at the time but looking back she could see that is was.",2020-09-01
3883,LAURELBROOK SANITARIUM,4.4e+201,114 CAMPUS DRIVE,DAYTON,TN,37321,2018-04-11,656,G,1,0,FLCH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of facility investigation, medical record review, and interviews, the facility failed to follow the comprehensive care plan for transfers for 1 resident (#1) of 4 residents reviewed for falls of 10 residents sampled. The facility's failure to follow the care plan resulted in a fracture (Harm) to Resident #1. The findings included: Review of facility policy Care Plans-Comprehensive, not dated, revealed .An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .Each resident's comprehensive care plan is designed to .identify the professional services that are responsible for each element of care . Review of facility policy Using the Care Plan, not dated, revealed .CNAs (Certified Nursing Assistant) are responsible for reporting to the Nurse Supervisor/Charge Nurse any change in the resident's condition . Review of facility policy Lifting & Transfer of Residents, not dated, revealed .uses lifts for safety of its residents during transfer. Lifts will be used according to the resident mobility assessment outcome. All resident care staff shall use lifts according to protocol . Review of facility investigation dated 2/13/18 revealed .Resident (Resident #1) c/o (complained of) pain and [MEDICAL CONDITION] to the left knee. X-ray shows 'Acute fracture seen in the distal femur interior to the internal fixation rod.' CNA (CNA #8) interviewed .what happened .statement reads: Monday morning at approximately 4:30 am I was trying to transfer resident (Resident #1) from the bed to the wheelchair by standing and pivoting resident but noticed she didn't bare weight, so I lowered her to the floor .with her left leg off to the side . Medical record review revealed Resident #1 was admitted on [DATE] and readmitted on [DATE] for [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 4 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required total assistance of two or more persons for bed mobility, transfers, dressing, and toilet use. Review of Resident #1's Care Plan dated 10/3/17 revealed .The resident has an ADL self-care performance deficit related to [MEDICAL CONDITION] .requires staff assistance with ADLs daily, incontinence of bowel and bladder, decreased mobility, muscle spasms, [MEDICAL CONDITION]'s disease with spastic movements noted and history of falls .Bed Mobility: the resident requires total staff assistance with re-positioning and turning in bed .Toilet Use: the resident is totally dependent on staff for toileting needs .Transfer: the resident requires 2 assist with Hoyer lift for all transfers . Review of the Visual/Bedside Kardex Report (document used by CNAs that describe the type of care residents require), not dated, revealed .Transferring: Hoyer Lift for transfers (Requires two people) . Interview with Licensed Practical Nurse (LPN) #1 on 4/9/18 at 9:45 AM, at the nurse's station, revealed .She (Resident #1) needs help with all of her ADLs. There is not much she does by herself. She has always been a two-person lift. Sometimes she is able to communicate and say a few words but not much else . Interview with CNA #1 on 4/9/18 at 9:50 AM, at the nurse's station, revealed .She (Resident #1) is total care and needs assistance with everything. She has always been a two-person transfer and she is not able to communicate her needs. She cannot move herself or bear any weight . Interview with CNA #2 on 4/9/18 at 10:05 AM, in the conference room, revealed .I know she (Resident #1) has always been a two-person lift. Now, she has a brace on her leg . Interview with Registered Nurse #1 on 4/9/18 at 10:20 AM, in the MDS Coordinator's office, revealed .She (Resident #1) has always been a two-person transfer and I don't know why a CNA would get her up without using a Hoyer lift. Her care plan even has her as being a two-person Hoyer lift transfer . Interview with the Director of Nursing (DON) on 4/9/18 at 10:35, in the conference room, revealed .The incident happened on the 3rd shift (night shift) .(CNA #8) stated that he was getting her ready to get up and transferred her without using the Hoyer lift. He (CNA #8) said 'I just did something stupid and wasn't thinking and I lowered her to the floor.' .He (CNA #8) did not follow protocol and failed to follow the plan of care where it clearly says she is a Hoyer lift. All the CNAs know who is a one person or two-person transfer from the Kardex and it even says on her Kardex that she (Resident #1) was a Hoyer lift for all transfers . Telephone interview with CNA #3 on 4/9/18 at 12:52 PM revealed .(CNA #8) came into another resident's room where I was at and asked me to help him .He (CNA #8) said he attempted to transfer her by himself and lowered her to the floor . Interview with the Administrator on 4/11/18 at 9:45 AM, in the conference room, revealed .She (Resident #1) was supposed to be a two-person transfer with a lift. He (CNA #8) should have followed the Kardex, which tells all the CNAs who is a one or two-person transfer. I just think he took a short cut and didn't do what he was supposed to do. The bigger issue was that he didn't tell anyone. Anytime there is an incident a nurse is to be involved and notified and he didn't do his job and report this to the nurse . Refer to F-689",2020-02-01
3884,LAURELBROOK SANITARIUM,4.4e+201,114 CAMPUS DRIVE,DAYTON,TN,37321,2018-04-11,689,G,1,0,FLCH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of facility investigation, medical record review, and interviews, the facility failed to use a mechanical lift with 2 person assist during a transfer for 1 resident (#1) of 4 residents reviewed for accidents of 10 residents sampled. The facility's failure to use assistive devices resulted in a fracture (Harm) to Resident #1. The findings included: Review of facility policy Accident and Incident, Including Fall Safety, undated, revealed .The staff member discovering the fall or notified of the fall is to stay at the incident sight and get assistance .Do not move the resident unless the resident is in immediate danger, until the Licensed Nurse has done an evaluation .The Licensed Nurse is to do a total evaluation of mental, physical .The Charge/Licensed Nurse is to give direction & assist with moving the resident . Review of facility policy Accidents/Incidents, undated, revealed .Regardless of how minor an accident or incident may be, it must be reported to the charge nurse on duty .Do not leave the accident victim unattended .Summon the charge nurse on duty to evaluate and determine if the individual is to be moved. Stay with the individual and assist the charge nurse as needed . Review of facility policy Fall Risk Reduction and Management, undated, revealed .Falls are to be reported by anyone observing .The staff member discovering the fall .is to stay at the incident site and get assistance .Do not move the resident, until the Licensed Nurse has done an evaluation .The Licensed Nurse is to do a head to toe assessment before the resident is moved . Review of a facility investigation dated 2/13/18 revealed .Resident (Resident #1) c/o (complained of) pain and [MEDICAL CONDITION] to the left knee. X-ray shows acute fracture seen in the distal femur interior to the internal fixation rod. CNA (Certified Nursing Assistant (CNA #8)) interviewed (about) what happened .statement reads: Monday morning at approximately 4:30 am I was trying to transfer resident (Resident #1) from the bed to the wheelchair by standing and pivoting resident but noticed she didn't bear weight, so I lowered her to the floor .with her left leg off to the side .I and another CNA transferred her by Hoyer (mechanical lift device) into the chair .The nurse was not notified prior to leaving my shift . Further review of a witness statement by CNA #3 revealed .On 2/12/18 around 5am (CNA #8) came and got me to help him. Resident (Resident #1) was lying flat on her back on the floor with her head at the foot of the bed and her feet toward the top of the bed .We got the Hoyer lift and lifted the resident into her chair .I thought (CNA #8) had already told the nurse about the incident . Continued review of a witness statement by CNA #8 revealed .On Monday morning at approximately 4:30 AM .I (CNA #8) was trying to transfer (Resident #1) from the bed to the wheelchair by stand pivoting, but I noticed she didn't bare weight so I lowered her to the floor gently in sitting position with left leg off to the side. Another CNA and I transferred her by Hoyer into the chair .Nurse was not notified prior to leaving shift . Medical record review revealed Resident #1 was admitted on [DATE] and readmitted on [DATE] for [DIAGNOSES REDACTED]. Review of Resident #1's care plan dated 10/3/17 revealed .The resident has an ADL (activities of daily living) self-care performance deficit related to [MEDICAL CONDITION] .requires staff assistance with ADLs daily, incontinence of bowel and bladder, decreased mobility, muscle spasms, [MEDICAL CONDITION]'s disease with spastic movements noted and history of falls .Bed Mobility: the resident requires total staff assistance with re-positioning and turning in bed .Transfer: the resident requires 2 assist with Hoyer lift for all transfers . Review of a quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 4 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required total assistance of two persons for bed mobility, transfers, dressing, and toilet use and had an impairment in range of motion on both sides of her upper and lower extremities. Review of a fall risk assessment dated [DATE] revealed Resident #1 scored 35 (moderate risk 25-44), which indicated she had a moderate risk for falls. Review of a nurse's progress note dated 2/12/18 revealed .Reported that resident's left knee was swollen, looked at it and determined left knee was bigger than right knee. Looked like arthritis. She denied pain at this time . Review of a nurse's progress note dated 2/13/18 revealed .NP (Nurse Practitioner) notified of resident's c/o pain and [MEDICAL CONDITION] to left knee. New orders for X-ray to left knee . Review of Patient Report X-ray Results dated 2/13/18 revealed .There is an acute fracture seen in the distal femur inferior to the internal fixation rod . Review of an Acute Care Hospital History and Physical dated 2/13/18 revealed .Chief complaint: Left Leg pain. History of Present Illness: Reportedly, the patient has had no known fall, but she was complaining of left leg pain to her nurse. The patient is in a wheelchair chronically and uses a mechanical lift to transfer from bed to toilet, etc. The patient was noted to have a left femur fracture . Continued review of the acute care hospital discharge summary dated 2/15/18 revealed .Primary Discharge Diagnosis: [REDACTED]. Restrictions: Left leg: No weight bearing. Range of Motion limits: locked in 30 degrees of flexion at all times in hinged knee brace . Interview with Licensed Practical Nurse on 4/9/18 at 9:45 AM, at the nurse's station, revealed .She (Resident #1) needs help with all of her ADLs. There is not much she does by herself .She has always been a two-person lift. Sometimes she is able to communicate and say a few words but not much else . Interview with CNA #1 on 4/9/18 at 9:50, at the nurse's station, revealed .She (Resident #1) is total care and needs assistance with everything. She has always been a two-person transfer and she is not able to communicate her needs. She cannot move herself or bear any weight .When I came to work at 6:00 AM she (Resident #1) was sitting up in her chair with an ice pack on her knee. I know that the graveyard shift got her up that morning. Now she has a long leg brace in place that she wears all the time now . Interview with CNA #2 on 4/9/18 at 10:05, in the conference room, revealed .When I came to work at 6:00 AM she (Resident #1) was sitting in her chair in her room. I'm not sure who got her up .She (Resident #1) was saying her leg was hurting. I went and got an ice pack. I thought it was arthritis so I went and told the nurse (Registered Nurse (RN) #1) that to me, it just looked like arthritis. I know she (Resident #1) has always been a two-person lift. Now, she has a brace on her leg . Interview with RN #1 on 4/9/18 at 10:20, in the MDS Coordinator office, revealed .I remember someone came and told me her (Resident #1) knee was swollen and when I looked at it, it just looked like arthritis. Later, someone yelled for help and when I went into her (Resident #1) room she was unresponsive. What I think happened was because of the pain in her leg, it made her pass out. When I came in to work that morning, I saw her knee was swollen and to me it didn't look any different from the other leg. It just looked like some arthritis. She (Resident #1) at that time was not complaining of any pain. We have to go by her vital signs since she is not able to voice her needs. She is non-ambulatory and dependent on staff for all her ADLs. Around 9:00 AM, it was reported to me her knee was swollen. That is when I saw her. Then later around 11:00 AM or so I saw she was unresponsive. All her vitals were ok. EMTs (emergency medical technicians) came and X-ray came. She was sent out to the hospital that day on 2/13 (2018) and returned on 2/15 (2018) and we were told she had the fracture. She has always been a two-person transfer and I don't know why a CNA would get her up without using a Hoyer lift. Her care plan even has her as being a two-person Hoyer lift transfer . Interview with the Director of Nursing (DON) on 4/9/18 at 10:35, in the conference room, revealed .The incident happened on the 3rd shift (night shift). (CNA #8) stated that he was getting her ready to get up and transferred her without using the Hoyer lift. He (CNA #8) said, 'I just did something stupid and wasn't thinking and I lowered her to the floor. I did not tell the nurse. I went and got (CNA #3) to help me and we got the Hoyer lift and put her in her chair.' .He (CNA #8) did not follow protocol and failed to notify the night nurse that she (Resident #1) was on the floor .the night nurse (LPN #5) had already left and there was nothing communicated to her from (CNA #8) about being transferred with one person, or that the resident was on the floor . Telephone interview with CNA #3 on 4/9/18 at 12:52 PM revealed .(CNA #8) came into another resident's room where I was at and asked me to help him. When I went into (Resident #1's) room, she was on the floor. He (CNA #8) said he attempted to transfer her by himself and lowered her to the floor. When I saw her, her head was at the foot of the bed and her feet were at the head of the bed. We got a Hoyer lift from the hallway and he rolled her to the side and put the lift pad under her and we used the Hoyer lift to put her in her chair. After that I left the room because I still had other people I was getting up and dressed. I thought he had already told the nurse before we moved her so I assumed the nurse knew she was on the floor . Interview with the Administrator on 4/9/18 at 1:10, in the Administrator's office, revealed .He (CNA #8) did not follow our company policy and he did not report anything to the nurse . Interview with LPN #4 on 4/11/18 at 8:25, in the conference room, revealed .I came into work around 5:30 AM that morning and received report from (LPN #5). Around 6:30 AM (CNA #8) was walking up the hallway and told me that the resident (Resident #1) was complaining of knee pain. I told him that I would let her nurse (RN #1) know. I told (RN #1) that the resident was complaining of leg pain. I did not go and see her at that time because she was not assigned to me that morning . Interview with the Administrator on 4/11/18 at 9:45 AM, in the conference room, revealed .She (Resident #1) was supposed to be a two-person transfer with a lift. He (CNA #8) should have followed the Kardex which tells all the CNAs who is a one or two-person transfer. I just think he took a short cut and didn't do what he was supposed to do. The bigger issue was that he didn't tell anyone. Anytime there is an incident a nurse is to be involved and notified and he didn't do his job and report this to the nurse . Interview with RN #1 on 4/11/18 at 10:50, in the conference room, revealed .From what I recall, someone told me to go look at her (Resident #1) knee and to me, it just looked like arthritis. At that time, I was not very concerned. Later, someone yelled for me to come to her room and at that time her color was very grey and she was non-responsive. I called the doctor and ambulance right away and by the time they came, she was responding . Telephone interview with LPN#5 on 4/11/18 at 12:00 revealed .The CNA (CNA #8) never reported anything to me. He didn't tell me anything that night .I never thought he would have done something like that .She (Resident #1) has always been a two-person mechanical lift .",2020-02-01
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
797,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2018-03-21,835,J,1,0,9RON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of facility records, medical record review and interview, the Administrator failed to provide adequate oversight for 1 resident (#123) discharged during an appeal process of an involuntary discharge of 3 residents reviewed for discharge. The Administrator's failure to ensure a safe and orderly discharge resulted in Resident #123 being discharged to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The findings included: Review of facility policy, Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman .10. At the time of notification, the facility will provide each resident .with the following information: a. The plan for the transfer and adequate relocation of the resident .c. Assurances the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, services and location . Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the facility admission followed an acute care hospital stay due to a Traumatic Subdural Hemorrhage requiring surgery. Further review revealed 2 additional [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, out of a possible 15, indicating the resident was cognitively intact. Review of an Interdisciplinary Progress Note dated 12/21/17 at 9:20 AM revealed .Staff brought to administrator team concern that resident may have been smoking in one of the common areas of the facility this morning. Administrator and this writer met with resident in his room to discuss .Resident denies smoking in common area. Initially he refused to allow administrator to search his room but then consented (and) also submitted a blue lighter that he had on his person .Smoking policy/agreement reviewed with resident (and) he was informed that smoking privileges are now suspended. Resident acknowledged this. Also informed resident that he would be issuing him a 30 day discharge . Continued medical record review revealed no evidence the resident had received education and training on the smoking policy and the consequences of noncompliance, prior to this incident. Review of the facility's Notice of Involuntary Discharge revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the Notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Review of a Nurse's Note dated 1/21/18 revealed, .Q (every) 15 minute checks/Smoking in bathroom! Continued review revealed the record of the every 15 minute checks began at 7:30 AM on 1/21/18 and continued until 6:15 PM on 1/30/18. Review of the Nurse Practitioner's progress note dated 2/9/18 revealed, .I am seeing pt (patient/Resident #123) today to discharge. Pt was caught again smoking in a restricted area. Pt is hostile at assessment. Refuses to give name of PCP (primary care physician) or pharmacy. Has letter of court date continuation and believes he can stay here by law. He allows me to assess him, but tells me 'you cannot discharge me!!' Has general body pain, but denies C/P (chest pain), N&V (nausea and vomiting), chills or fever. SS (social services) to arrange for hotel .meds (medications) will be faxed to a local pharmacy .transfer care to Dr. (formal name) . Interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the Social Services office, confirmed Resident #123 filed an appeal on 1/3/18 for the Involuntary Discharge notice dated 12/21/17. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Commissioner's Designee for the Tennessee Department of Finance and Administration, and the presiding Administrative Law Judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Interview continued and the Interim Administrator stated Resident #123, .broke his contract with me (on 2/9/18) .he smoked unsupervised in the designated outside smoking area .he refused to give me his igniter (clarified lighter or matches) . Interview continued and the Interim Administrator stated the facility had a right to emergently discharge the resident, .he would not give me his igniter .he endangered the safety of the other residents . Continued interview revealed the Interim Administrator clarified the contract with Resident #123 was a verbal agreement between the Interim Administrator and the resident, not a written agreement. Continued interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the Social Services office, revealed the SSD notified the resident's sister by phone on 2/9/18, at 4:00 PM after the resident had been discharged , and gave her his hotel room number. Further interview revealed the sister was not the resident's responsible party and the Interim Administrator stated .he was responsible for himself .we paid for 3 nights .our van took him to the hotel .the hotel provided a phone and complimentary breakfast meal. Further interview confirmed the SSD did not know if Resident #123 had any money, and no other arrangements had been made for Resident #123 to receive meals. Continued interview confirmed the resident's prescribed medications were called to a local pharmacy for delivery to the resident at the hotel. Continued interview confirmed the medications had not been delivered to the resident. Further interview confirmed the SSD and Licensed Practical Nurse (LPN) #4 had taken some of the prescribed medications that remained at the Long Term Care facility to the resident's hotel room on 2/13/18. Further interview confirmed the Choices (part of the state medicaid program) Transition Coordinator had not been contacted on 2/9/18 with information of the resident's impending discharge. Continued interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the Social Services office, confirmed the prior Administrator had not provided documentation of notification to the Long Term Care Ombudsman of the Notice of Involuntary Discharge issued to Resident #123 on 12/21/17. Continued interview confirmed the current Interim Administrator and the SSD had not notified the Ombudsman of the Notice of Involuntary Discharge, the pending appeal, or of the resident's discharge on 2/9/18 to a hotel room. Interview with the Interim Administrator on 3/19/18 at 3:30 PM, in room [ROOM NUMBER], revealed she began working at the facility on 1/29/18. Interview continued and in response to why the documented every 15 minute checks on Resident #123 began on 1/21/18, had ended on 1/30/18, she responded, First I have heard of every 15 minute checks . Interview with the Interim Administrator on 3/20/18 at 11:40 AM, in room [ROOM NUMBER], revealed .He was discharged because he had continued to violate the smoking policy. I don't know if I would have discharged him but he refused to give me the matches or lighter and he refused to give them to either of us (reference to the SSD) .not aware of a plan for him to visit (group homes) the following Thursday (2/15/18). Continued interview revealed the facility's interdisciplinary team, the supervising Administrator for the Interim Administrator, the resident's Medicaid insurance case manager, and the Medical Director had not been consulted prior to the decision to discharge Resident #123 to a hotel room on 2/9/18. Interview continued and the Interim Administrator responded to the question of why the Commissioner's Designee was not informed of the impending discharge, she replied, I am not required to contact them . Refer to F-622 (J), F-623 (J), F-624 (J), F-745 (J), F-837 (J), and F-867 (J).",2020-09-01
2367,SIGNATURE HEALTHCARE OF MONTEAGLE REHAB & WELLNESS,445393,26 SECOND STREET,MONTEAGLE,TN,37356,2018-05-24,600,D,1,1,63GM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of the facility investigation, medical record review, observation, and interview the facility failed to prevent physical and sexual abuse for 2 residents (#84 and #90) of 6 residents reviewed for abuse. The findings included: Review of facility's Abuse, Neglect and Misappropriation of Property Policy reviewed 11/16/17 revealed .It is (the facility's) policy to prevent the occurrence of abuse .Definitions .Abuse is the willful infliction of injury .includes physical abuse .for the purposes of this policy 'willful' means non-accidental, or not reasonably related to the appropriate provision of ordered care and services .means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .This policy also presumes that all abuse, as defined in this policy, causes physical harm, pain or mental anguish to any resident, even if he or she does not understand the incident .Physical abuse includes, but is not limited to, hitting, slapping, pinching, kicking, controlling behavior through corporal punishment, or any similar touching of a resident that does not have an appropriate therapeutic purpose, and that is not reasonable related to the appropriate provision of ordered care and services .Sexual abuse .includes, but is not limited to, any physical contact with a resident's body that is not reasonably related to appropriate provision of ordered care or services .if a Stakeholder observes a resident exhibiting any form of abuse toward another resident, the Stakeholder will intervene immediately to interrupt the incident .move them to an environment where residents'safety can be assured .charge nurse and/or Director of Nursing will ensure that the residents do not have access to one another until the circumstances of the incident can be determined . Medical record review revealed Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #84 was discharged from the facility on 5/11/18 for a psychiatric inpatient stay. Medical record review of Resident #84's Care Plan dated 3/1/18 revealed .Active and/or at risk for Behavior Problems Wanders daily, can become resistive to redirection/care. Aggressive, intrusive wandering, combative .provide non-confrontational enironment (environment) for care . Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #84 was severely cognitively impaired, wandered daily, experienced difficulties concentrating, and rejected care 1 to 3 days a week. Review of the facility investigation dated 4/11/18 revealed at approximately 5:55 AM, Licensed Practical Nurse (LPN) #1 notified the Administrator she observed Certified Nursing Assistant (CNA) #3 shove Resident #84 toward the dining room. Further review revealed CNA #4 observed CNA #3 .pushing (Resident #84) to the other area of the hall . Interview with CNA #4 on 5/22/18 at 6:13 AM, in the secured unit confirmed .(Resident #84) was walking down hall .he had blanket around him .heard him holler out .(CNA #3) was trying to keep (Resident #84) from hitting her .she was trying to redirect him with one hand and pushing him with another . Telephone interview with CNA #4 on 5/23/18 at 5:22 PM, confirmed .(Resident #84) was agitated .she was re-directing him .she put her hand in his back and pushed him toward the dining room .(Resident #84) was off balance when (CNA #3) was pushing him down the hall because a blanket was wrapped around his shoulders . Interview with LPN #1 on 05/23/18 at 5:39 PM, at the West Hall nurse's station confirmed on 4/11/18, at approximately 5:30 AM, she heard CNA #3 and Resident #84 yelling but could not understand what they were saying. Continued interview confirmed at that time she turned the corner and observed CNA #3 shove Resident #84 with both hands toward the dining room telling him to .go on . Further interview confirmed Resident #84 .stumbled . but did not fall. Interview with the Administrator on 5/24/18 at 10:51 AM, in the Administrator's office confirmed .my understanding .got a report that (Resident #84) was going down the hallway .(LPN #1) used the term 'shoved' and (CNA #4) initially said he saw (CNA #3) push (Resident #84) . Continued interview confirmed the facility terminated CNA #3 for failing to follow facility policy, .when someone is resistive to care then you back off . Medical record review revealed Resident #90 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the care plan dated 9/30/17 revealed Resident #90 was at risk for behavior problems of intrusive wandering, pilfering, and disrobes. Medical record review of a quarterly ((MDS) dated [DATE] revealed Resident #90 was severely cognitively impaired and rarely understood. Further review revealed the resident had behaviors of disrobing and wandering. Review of a Behavioral Health Progress note for Resident #90 dated 2/19/18 revealed .R .R .(Resident to Resident) victim- male resident (Resident #27) fondled her .Patient unharmed both physically & psychologically from encounter . Medical record review of the Behavioral Health Progress Note for Resident #90 dated 5/7/18 revealed .Med Mgmt Psych eval (Medication Management Psychiatric Evaluation) .Patient (Resident #90) was in front of male resident (Resident #27) in w/c (wheelchair) and lifted shirt out/upward. Male resident touched bare stomach .Patient alert and walking halls. She is loving & (and) sweet toward residents & staff. Affectionate nature. Always stating I'm a little girl Patient has been reported to walk hallways naked .Plan .D/C (discontinue) [MEDICATION NAME] (medication to treat depression) 10 mg (milligrams) qd (every day) .Begin [MEDICATION NAME] 20 mg qd Depression .Please monitor and prevent contact with male resident since she has ability to walk . Medical record review revealed Resident #27 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Resident #27's care plan dated 2/19/18 revealed a problem of sexual abuse/inappropriateness, with goals and approaches for same. Medical record review of an annual MDS for Resident #27 dated 3/12/18, revealed the resident is severely cognitively impaired, rarely understood, requires extensive assistance for tranfers and requires a w/c for ambulation. Medical record review of a Behavioral Health Progress Note for Resident #27 dated 2/19/18 revealed .Patient fondled a female resident (Resident #90) Friday evening .Hypersexuality . Medical record review of the facility investigation dated 5/5/18 revealed Resident #27 was observed in the day room with his hands rubbing over Resident #90's abdomen and Resident #90 was heard saying stop touching me. The residents were separated and Resident #27 was placed on 1:1 until seen by Psychiatric services. Medical record review of a Behavioral Health Progress Note for Resident #27 dated 5/7/18 revealed .Resident #27 .touched a female resident on bare stomach when she had her shirt pulled out .1:1 coverage. Unable to determine issue. Patient separated from female resident. Patient has R (right) leg amputated & (and) in w/c or bed .Plan .D/C [MEDICATION NAME] (hormone medication) 5 mg qd (every day) .Begin [MEDICATION NAME] 5 mg po BID (twice daily)-hypersexuality .Please keep residents separated . Observations of Resident #90 on 5/21/18-5/24/18 revealed the resident was observed at various times ambulating in the hallway, sitting in the activity room with other residents, resting in bed or sitting on a bench in the hallway with other residents. Observations of Resident #27 on 5/21/18-5/24/18 revealed the resident was observed at various times, sleeping in his bed, or sitting up in his w/c in his room. Interview with CNA #7 on 5/22/18 at 4:30 PM, in the 100 hallway confirmed Resident #27 is very hard of hearing. Continued interview confirmed the resident is a .Casanova . and needs to be monitored when he is around female residents. Interview with LPN #1 on 5/22/18 at 4:35 PM, confirmed Resident #27 is on every 15 minute checks and requires monitoring for inappropriate touching of female residents. Interview with LPN #2 on 5/23/18 at 8:20 AM, at the nurse's station confirmed Resident #90 has a history of disrobing and the resident wanders in other resident rooms and requires frequent redirecting. Interview with CNA #6 on 5/23/18 at 8:45 AM, at the nurse's station confirmed she walked by the East day room on 5/5/18 and saw Resident #27 leaning out of his w/c with his hands on Resident #90's bare abdomen rubbing her skin and Resident #90 was telling Resident #27 to stop. Continued interview confirmed the CNA separated the residents and reported the behavior to the nurse. Interview with the Nurse Practitioner on 5/24/18 at 11:15 AM, by phone confirmed Resident #90 is not alert and oriented, and showed signs of increased depression. Further interview confirmed the resident wanders freely throughout the building. Continued interview confirmed the resident has attention seeking behavior for example kissing and stating I'm a little girl. Further interview confirmed the [MEDICATION NAME] dosage was increased to aid in alleviating depression and behaviors. Interview with the Administrator and Director of Nursing on 5/24/18 at 11:25 AM, in the Administrator's office confirmed the facility failed to protect Resident #90 from sexual abuse.",2020-09-01
912,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2018-05-16,689,G,1,1,VPQ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of the manufacturer's mechanical lift operation manual, medical record review, review of the facility investigation, observation and interview, the facility failed to implement interventions for safe transfers with an assistive device to prevent accidents for 1 resident (Resident #18) of 3 residents reviewed for accidents. The facility's failure resulted in actual physical harm for Resident #18. The findings included: Review of the facility policy, Safe Lifting and Movement of Residents, revised (MONTH) (YEAR), revealed, .In order to protect the safety and well-being of .residents .this facility uses appropriate techniques and devices to lift and move residents .Resident safety .will be incorporated into goals and decisions regarding the safe lifting and moving of residents .Nursing staff .shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include .Resident's mobility (degree of dependency) .All equipment design and use will meet or exceed guidelines and regulations concerning resident safety .Safe lifting and movement of residents is part of an overall facility employee health and safety program . Review of the facility policy, Fall Prevention Program, dated (MONTH) 2001, revealed, .It is the policy of this facility to identify residents at risk for falls, develop plans of care that address the risk and implement procedures to assist in preventing falls .Maintain equipment and assistive devices in safe working order . Review of the manufacturer's mechanical lift operation manual, not dated, revealed, .before each patient transfer, it is important for staff to inspect the (named mechanical lift) to make sure no parts are missing or overly worn and that all parts work correctly .Transport Procedure .the required number of staff members must be present .certain patients or situation require the help of one or more additional staff members .The presence of more than one staff member increases safety .additional staff to hold onto sling handles .prevents the patient from swaying thereby decreasing the possibility of tipping the (named mechanical lift) .transporting patients in a (named mechanical lift) .requires at least two staff members . Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #18 was cognitively intact. Further review revealed Resident #18 was totally dependent on 2 or more person physical assist for bed mobility, and transfers, and had impaired mobility in upper and lower extremities. Medical record review of Resident #18's comprehensive care plan dated 2/28/18 revealed, .potential for falls r/t (related to) dependent on staff for transfers via mechanical lift and 4 person assist . Further review revealed, .transfer (Resident #18) via mechanical lift and 4 person assist . Medical record review of the Physician Recapitulation Orders dated 5/1/18 - 5/31/18 revealed, .Mech (mechanical) lift for transfers . Medical record review of the Nurse's Notes dated 5/2/18 at 5:00 AM revealed, .called to room by CNA (Certified Nurse Aide #1). Rsd (resident) in floor .(No) injuries voiced. Rsd (resident) lowered to floor by CNA .assessed .assisted back to bed . Medical record review of the Nurse's Notes dated 5/2/18 at 11:30 AM revealed, .NP (Nurse Practitioner) saw resident r/t (related to) .(increased) pain. New order .(right) ankle xray . Medical record review of the Radiology Interpretation dated 5/2/18, revealed, .Impression: Acute bony avulsion (when a tendon or ligament comes away from the bone often pulling a small piece of bone with it) to the medial malleolus (the round bony prominence on inner side of the ankle joint) . Medical record review of the Nurse's Notes dated 5/2/18 at 4:20 PM, revealed, .Received X-Ray. Call placed to N.P. (Nurse Practitioner). New order received . Medical record review of the Physician's Telephone Orders dated 5/2/18 at 4:20 PM revealed, .send to (named hospital) ER (emergency room ) for eval (evaluation) (and) tx (treat) for (right) ankle X-Ray . Medical record review of the Radiology Report of the X-Ray of the Right Ankle - 3 View, performed at the Emergency Department on 5/2/18 revealed, .lucency (technical term for an area that lets X-rays through the tissue and as a result appears darker on the picture) noted through the posterior aspect of the calcaneus (heel bone) on lateral projection raising the possibility of fracture .Impression: Questionable calcaneal (heel bone) fracture . Medical record review of the Emergency Department Physician's Report dated 5/2/18 revealed, .patient is a [AGE] year-old female who presents with right foot and ankle pain. Patient is non-ambulatory, had a fall while being transferred (at) the nursing home. Patient has swelling noted to her foot, diffuse (spread over a wide area) dorsal (upper side) tenderness, and lateral malleolus (bony prominence on the outside of the ankle) tenderness. X-rays today show evidence of definitive acute fracture. Patient will be placed [MEDICATION NAME] in a boot, she is given instructions follow up close with her primary care physician. She will be discharge with strict return precautions for worsening symptoms or other concerns . Medical record review of the Nurse's Notes dated 5/2/18 at 11:15 PM revealed, .returned from ER (emergency room ) .(No) new orders ntd (noted). MD (Medical Doctor) to see Rsd (resident) in 2 days. Rsd (Resident) (with) brace on to wore ( be worn) 6 weeks . Medical record review of the Nurse Practitioner Progress Note dated 5/2/18 revealed, .(right) ankle avulsion fx (fracture) s/p (status [REDACTED].(with) orthoboot . Review of the facility investigation dated 5/2/18 revealed at approximately 5:00 AM on 5/2/18 CNA #1 was transferring Resident #18 with a mechanical lift. Further review revealed during transfer the left rear wheel .locked up . and the lift tilted forward. Continued review revealed CNA #1 was unable to return the lift to an upright position and Resident #18 was lowered to the floor. Further review revealed as the day progressed Resident #18 complained of increase pain and at that time an X-ray was performed of the resident's right ankle which showed an avulsion fracture. Interview with Resident #18 on 5/14/18 at 12:15 PM, in the resident's room, confirmed on the day of the incident (5/2/18) only 1 staff member (CNA #1) assisted with the transfer using the mechanical lift. Interview with the Director of Nursing (DON) on 5/14/18 at 3:57 PM, in the DON's office revealed Resident #18's care plan, dated 2/28/18, was accurate, and Resident #18 required assistance of 4 staff for transfers with the mechanical lift. Further interview confirmed at the time of the fall on 5/2/18 the facility failed to follow Resident #18's care plan for transferring the resident using the mechanical lift and assistance of 4 persons. Interview with the Medical Director on 5/15/18 at 9:59 AM, in the conference room, confirmed his expectation was for staff to follow the plan of care while providing care to all residents, and the facility's failure to follow the plan of care while transferring Resident #18 with a mechanical lift resulted in an ankle fracture (actual physical harm.) Interview with CNA #1 via phone on 5/15/18, at 4:40 PM, confirmed she was aware Resident #18 required 4 staff for transfers but stated the rest of the staff was really busy. Continued interview confirmed she knew now not to transfer her alone and received training following the incident. Interview with CNA #1 via phone on 5/16/18 at 7:27 AM, confirmed she had not completed a competency with return demonstration on the proper use of transferring residents with a mechanical lift.",2020-09-01
5367,SUMMIT VIEW OF ROCKY TOP,445259,204 INDUSTRIAL PARK RD,ROCKY TOP,TN,37769,2016-03-22,312,E,1,0,5X0U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of the shower schedule, medical record review, observation and interview, the facility failed to provide timely repositioning and timely incontinence care for 4 residents (#1, #2, #4, #7) with/or at risk for developing pressure ulcers and following incontinent episodes and failed to provide showers and/or bed baths for 18 residents (#1, #2, #3, #4, #6, #7, #8, #9, #12, #13, #14, #15, #17, #21, #23, #25, #27, #28) of 28 residents reviewed for 1 floor of 3 floors in the facility. The findings included: Interview with the Administrator and the Registered Nurse (RN) Supervisor #1 on (MONTH) 8, (YEAR) at 1:00 PM, in the conference room revealed the facility's policy allowed for a bed bath in place of a shower if a shower was not given as scheduled. Continued interview revealed a partial bath included only the perineum, rectal area and the underarms and confirmed a bed bath included the entire body. Interview with the Administrator on [DATE] at 2:30 PM, in the conference room revealed the facility had no policy for the frequency of showers and bed baths. Continued interview revealed the facility followed State regulations which read, XXX[DATE]-.06(n) .Residents shall have baths or showers at least two (2) times each week, or more often if requested by the resident . The facility's incontinence care policy was requested from the Director of Nursing (DON) on [DATE]. The facility's policy entitled Prevention of Pressure Ulcers was received from the DON on [DATE]. Review of the policy for the prevention of Pressure Ulcers revealed, .Interventions and Preventive Measures: Residents with Risk Factors .Place resident on a minimum of q (every) 2 hour check and change program .Change position at least every two hours and more frequently as needed .Check resident for incontinence at least q 2 hours and clean skin when soiled . Review of the facility's East wing shower schedule (Complaint # addressed problems with care not being provided as a result of inadequate staffing for the East wing only) revealed showers were scheduled for residents two times per week and were scheduled Monday through Saturday. Resident #1 was admitted to the facility from another nursing home on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored ,[DATE] on the Brief Interview for Mental Status (BIMS) with moderately impaired decision-making skills, had disorganized thinking and delusions; required extensive of 2 people with bed mobility, hygiene and bathing; and was always incontinent of bowel and bladder. Medical record review of the Braden Scale for Predicting Pressure Sore Risk revealed on [DATE], [DATE], and [DATE], revealed the resident was at high risk for the development of Pressure Ulcers. Medical record review of the current comprehensive care plan revealed the resident was at risk for pressure ulcers and had .open areas on coccyx and right scapula and right heel . Continued review revealed, .Turn and reposition with devices every 2 hours on air mattress .Keep clean and dry . Continued review revealed the resident required physical assistance with bathing. Medical record review of the Wound Care Center's orders dated [DATE] revealed, Turn q (every) 2 hours .Avoid position directing pressure to wound site . Medical record review of a nurse's note dated [DATE] revealed, .Turned every 2 hours . Review of the facility's Wound Report dated [DATE] revealed the resident had a Stage 4 Pressure Ulcer to the coccyx which measured 4.0 cm (centimeters) X (by) 3.5 cm X 0.5 cm. Continued review revealed interventions included, Turn Q 1 hr (hour) Observation and interview with Certified Nursing Assistant (CNA) #1 and #2 on [DATE] at 1:45 AM (night shift), in the resident's room revealed the resident was lying on the bed on her back. Observation revealed the CNAs positioned the resident on the right side. Continued observation revealed a gauze dressing on the sacrum. Interview with CNA #1 and #2 in the resident's room at the time of the observation confirmed the resident had a Pressure Ulcer on the sacrum and the resident required repositioning every two hours. Observation revealed the CNAs positioned the resident on the back and removed the brief. Observation revealed the resident had been incontinent of urine with a strong ammonia odor. Observation with the CNAs revealed the skin on the back and buttocks was intact except for the Pressure Ulcer on the sacrum. Continued interview with the CNAs confirmed the resident was in need of incontinence care and that incontinence care or repositioning off the back had not been provided for the resident since the evening shift (2:00 PM-10:00 PM) went off duty at 10:00 PM (3 hours, forty-five minutes). Review of the shower list revealed the resident was scheduled for showers on Tuesdays and Fridays on day shift. Medical record review of the resident's activities of daily living (ADL) records dated [DATE]-[DATE] and review of the shower lists dated [DATE]-[DATE] revealed Resident #1 did not receive a shower or bed bath from [DATE]-[DATE] (6 days); from [DATE]-[DATE] (7 days); from [DATE]-[DATE] (6 days); and from [DATE]-[DATE] (6 days). Medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the facility's shower lists for the East wing dated [DATE]-[DATE] with the Registered Nurse (RN) Supervisor #1 on [DATE] at 3:15 PM, in the conference room confirmed Resident #1 did not receive a shower or bed bath from [DATE]-[DATE] (6 days); from [DATE]-[DATE] (7 days); from [DATE]-[DATE] (6 days); and from [DATE]-[DATE] (6 days). Resident #2 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored ,[DATE] on the BIMS with severely impaired decision-making skills; had inattention, disorganized thinking and delusions; required extensive assistance of two with bed mobility and transfers; was totally dependent on staff for hygiene and bathing; and was always incontinent of bowel and bladder. Review of the current comprehensive care plan revealed, .requires extensive physical assistance with bathing .incontinent of bowel and bladder at all times .staff provides skin care after all incontinent episodes and prn (as needed) .Shower 2 X (times) per week with bed baths on alternate days. As tolerated by resident .Potential for .episodes secondary to Diabetes type II .Monitor and assure position changes .Needs bedrails to prevent injury from: convulsion and provide mobility .Reposition at regular intervals .Risk for skin breakdown/pressure ulcers due to bowel and bladder incontinence .impaired mobility .provide pericare after each episode of incontinence . Medical record review of the Braden Scale for Predicting Pressure Sore Risk dated [DATE], [DATE], and [DATE], revealed the resident was at moderate risk for the development of Pressure Ulcers. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a bed bath or shower from [DATE]-[DATE] (8 days) and from [DATE]-[DATE] (6 days). Review of the shower list revealed the resident was scheduled for showers on Mondays and Fridays on day shift. Observation and interview with CNA #1 and #2 on [DATE] at 1:30 AM (night shift) in the resident's room revealed the resident lying on the bed on her back. Interview with CNA #1 and CNA #2 at the time of the observation confirmed the resident had an odor and confimed the resident had not received any care including repositioning or incontinence care since the evening shift went off duty at 10:00 PM (3 and 1/2 hours). Observation revealed the CNAs positioned the resident on the right side. Continued observation revealed the resident had no skin breakdown on the buttocks, thighs, hips or back. Further observation revealed the resident had a large incontinent bowel movement. Interview with the CNAs at the time of the observation confirmed the resident had a large, incontinent bowel movement and was in need of incontinence care. Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and the shower lists dated [DATE]-[DATE] with RN Supervisor #1 on [DATE] at 3:00 PM, in the conference room confirmed the resident did not receive a bed bath or shower from [DATE]-[DATE] (8 days) and from [DATE]-[DATE] (6 days). Resident #4 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident had impaired short-term memory and moderate impairment of decision-making skills; required extensive assistance with bed mobility and hygiene; was totally dependent on staff for bathing; and was always incontinent of bowel and bladder. Medical record review of the current comprehensive care plan revealed, .incontinent of bowel and bladder related to Dementia as evidenced by having multiple episodes of incontinence every day .Check resident at regular intervals for incontinence care .hygiene as needed after every incontinent episodes to maintain dignity .Risk for skin breakdown due to bowel/bladder incontinence .Provide peri care at regular intervals .Has bruises or abrasions due to: fragile skin .Turn and reposition at regular intervals . Medical record review of the Braden Scale for Predicting Pressure Sore Risk dated [DATE] revealed the resident was at mild risk for the development of Pressure Ulcers. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a bed bath or shower from [DATE]-[DATE] (7 days); from [DATE]-[DATE] (6 days); from [DATE]-[DATE] (11 days); from [DATE]-[DATE] (10 days); and from [DATE]-[DATE] (6 days). Review of the shower list revealed the resident was scheduled for showers on Mondays and Fridays on the evening shift. Observation on [DATE] at 9:35 AM, in the resident's room revealed the resident lying on the right side on the bed. Observation revealed the gown was open in the back; a brief was in place; and the resident had a strong urine odor. Interview with CNA #3 on [DATE] at 9:50 AM, on the 300 hallway of the East wing confirmed the CNA was assigned to the resident on day shift and had just gotten another resident out of the shower. Continued interview confirmed Resident #4 had received no care including incontinence care or repositioning since the night shift staff left at 6:00 AM (almost 4 hours). Continued interview revealed, They don't want us to do incontinence care until after breakfast. It's usually about this time (9:50 AM) when I get started doing rounds. Interview with the Licensed Practical Nurse (LPN) Supervisor #1 of the East wing on [DATE] at 9:55 AM, at the East wing nurses' station revealed the off going night shift staff made rounds with the oncoming day shift to make sure all residents were dry at the end of the night shift (6:00 AM). Continued interview revealed breakfast trays arrived on the unit at 6:30 AM (30 minutes after day shift began) and confirmed the staff did not have time to do much before trays came out. Continued interview confirmed day shift staff did not do rounds on the residents until after breakfast was over which was usually around 8:15 AM. Observation and interview with CNA #3 on [DATE] at 10:10 AM, in the resident's room revealed the CNA removed the resident's brief. Observation revealed the resident's skin was intact. Interview with the CNA at the time of the observation confirmed the resident had been incontinent of a moderate amount of urine and a small amount of bowel movement; was in need of incontinence care; and had a strong urine odor. Continued interview confirmed the resident was last repositioned and provided incontinence care on night shift (at least 4 hours). Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 10:30 AM, in the conference room confirmed the resident did not receive a bed bath or shower from [DATE]-[DATE] (7 days); from [DATE]-[DATE] (6 days); from [DATE]-[DATE] (11 days); from [DATE]-[DATE] (10 days); and from [DATE]-[DATE] (6 days). Resident #7 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident had short and long-term memory problems and moderately impaired decision-making skills; was totally dependent on staff for all activities of daily living (ADL); and was always incontinent of urine. Medical record review of the Braden Scale for Predicting Pressure Sore Risk dated [DATE] revealed the resident was at moderate risk for the development of Pressure Ulcers. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath from [DATE]-[DATE] (9 days); from [DATE]-[DATE] (6 days); and from [DATE]-[DATE] (13 days). Review of the shower list revealed the resident was scheduled for showers on Wednesdays and Saturdays on day shift. Observation on [DATE] at 8:57 AM, in the resident's room revealed the resident was lying on the bed with the eyes closed and mouth breathing. Observation and interview with CNA #4 on [DATE] from 9:13 AM-9:20 AM, in the resident's room revealed the CNA removed the resident's brief. Observation revealed the resident's skin on the back, buttocks, thighs and hips was intact. Interview with CNA #4 confirmed the resident had been incontinent of urine; confirmed a small amount of dried feces on the bilateral buttocks; and confirmed the resident had an odor in the perineal area. Continued interview revealed the CNA was the only CNA on the 500 hallway; however another CNA was on the way. Continued interview confirmed the resident had not been repositioned or provided incontinence care since the night shift left at 6:00 AM (more than 3 hours). Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 10:30 AM, in the conference room confirmed the resident did not receive a bed bath or shower from [DATE]-[DATE] (9 days); from [DATE]-[DATE] (6 days); and from [DATE]-[DATE] (13 days). Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed the resident expired in the facility on [DATE]. Medical record review of the quarterly MDS dated [DATE] revealed the resident had short and long-term memory problems and severely impaired decision-making skills; was totally dependent on staff for all ADL; and was always incontinent of bowel and bladder. Medical record review of the comprehensive care plan updated [DATE] revealed, .Shower 2 X per week with bed baths on alternate days . Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a bed bath or shower from [DATE]-[DATE] (12 days); from [DATE]-[DATE] (9 days); from [DATE]-[DATE] (11 days); and from [DATE]-[DATE] (14 days). Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with RN Supervisor #1 on [DATE] at 9:20 AM, in the conference room confirmed the resident did not receive a bed bath or shower from [DATE]-[DATE] (12 days); from [DATE]-[DATE] (9 days); from [DATE]-[DATE] (11 days); and from [DATE]-[DATE] (14 days). Resident #6 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored ,[DATE] on the BIMS with no impairment of decision-making skills; was totally dependent on staff for hygiene and bathing; was occasionally incontinent of bowel; and was frequently incontinent of bladder. Review of the current comprehensive care plan revealed, .Shower or Bed bath with limited to extensive assistance by staff . Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath from [DATE]-[DATE] (16 days); from[DATE]-[DATE] (12 days); from [DATE]-[DATE] (7 days); and from [DATE]-[DATE] (11 days). Review of the shower list revealed the resident was scheduled for showers on Thursdays and Saturdays on evening shift. Observation on [DATE] at 1:15 PM revealed the resident lying in bed with the head of the bed elevated. Interview revealed the resident did not receive showers but received bed baths per his requests. Continued interview revealed he had gone several days without a bed bath because the facility does not have enough help. Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 3:40 PM in the conference room confirmed the resident did not receive a bed bath or shower from [DATE]-[DATE] (16 days); [DATE]-[DATE] (12 days); from [DATE]-[DATE] (7 days); and from [DATE]-[DATE] (11 days). Resident #8 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual MDS dated [DATE] revealed the resident had short and long-term memory problems and severely impaired decision-making skills; rejected care; and had physical behaviors directed toward others. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath [DATE]-[DATE] (16 days) and from [DATE]-[DATE] (25 days). Review of the shower list revealed the resident was scheduled for a shower on Monday and Thursday evenings. Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 12:40 PM, in the conference room confirmed the resident did not receive a bed bath or shower from [DATE]-[DATE] (16 days) and from [DATE]-[DATE] (25 days). Resident #9 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored ,[DATE] on the BIMS with severe impairment of decision-making skills; required extensive assistance with hygiene and bathing; was always incontinent of bowel and had an indwelling urinary catheter. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath from [DATE]-[DATE] (8 days); from [DATE]-[DATE] (20 days); and from [DATE]-[DATE] (10 days). Review of the shower list revealed the resident was scheduled for showers on Wednesday and Saturdays on the evening shift. Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 12:30 PM, in the conference room confirmed the resident did not receive a bed bath or shower from [DATE]-[DATE] (8 days); from [DATE]-[DATE] (20 days); and from [DATE]-[DATE] (10 days). Resident #12 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored ,[DATE] on the BIMS with moderately impaired decision-making skills; required extensive assistance with hygiene and bathing; and was continent of bowel and bladder. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath from [DATE]-[DATE] (10 days); from [DATE]-[DATE] (9 days); and from [DATE]-[DATE] (10 days). Review of the shower list revealed the resident was scheduled for showers on Monday and Friday on evening shift. Observation of the resident on [DATE] at 8:55 AM in the resident's room revealed the resident lying on the bed with the eyes closed. Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 12:10 PM in the conference room confirmed the resident did not receive a bed bath or shower from [DATE]-[DATE] (10 days); from [DATE]-[DATE] (9 days); and from [DATE]-[DATE] (10 days). Resident #13 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 30 day MDS dated [DATE] revealed the resident scored ,[DATE] on the BIMS with no impairment of decision-making skills; required extensive assistance with bathing; and was continent of bowel and bladder. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath from [DATE]-[DATE] (13 days); from [DATE]-[DATE] (9 days); from [DATE]-[DATE] (16 days); and from [DATE]-[DATE] (7 days). Review of the shower list revealed the resident was scheduled for showers on Wednesday and Saturday on evening shift. Observation of the resident on [DATE] at 8:43 AM, in the resident's room revealed the resident lying on the bed with the legs hanging over the side of the bed. Interview with the resident revealed she had asked over an hour ago to get up. Interview with CNA #4 on [DATE] at 8:55 AM, on the 300 hallway revealed only 3 CNAs were working the East wing. Continued interview revealed another CNA, who was not scheduled, would be coming in later. Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 12:05 PM, in the conference room confirmed the resident did not receive a shower or bed bath from [DATE]-[DATE] (13 days); from [DATE]-[DATE] (9 days); from [DATE]-[DATE] (16 days); and from [DATE]-[DATE] (7 days). Resident #14 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS revealed the resident scored ,[DATE] on the BIMS with no impairment of decision-making skills. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath from [DATE]-[DATE] (9 days); from [DATE]-[DATE] (10 days); from [DATE]-[DATE] (6 days); and from [DATE]-[DATE] (6 days). Review of the shower list revealed the resident was scheduled for showers on Monday and Thursday on day shift. Observation on [DATE] at 9:40 AM in the resident's room revealed the resident lying on the bed. Interview with the resident revealed he sometimes received a shower every 2 days and sometimes went 5 days without a shower. Continued interview revealed the facility don't have enough help .short staffed . Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 12:00 PM, in the conference room confirmed the resident did not receive a shower or bed bath from [DATE]-[DATE] (9 days); from [DATE]-[DATE] (10 days); from [DATE]-[DATE] (6 days); and from [DATE]-[DATE] (6 days). Resident #15 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored ,[DATE] on the BIMS with moderately impaired cognitive skills and required limited assistance with bathing. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath from [DATE]-[DATE] (12 days) and from [DATE]-[DATE] (10 days). Review of the shower list revealed the resident was scheduled for showers on Monday and Friday on day shift. Observation on [DATE] at 8:37 AM in the resident's room revealed the resident was lying on the bed. Interview with the resident revealed she was scheduled to receive a shower yesterday (Monday) but did not because her knee was swollen. Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 11:55 AM, in the conference room confirmed the resident did not receive a shower or bed bath from [DATE]-[DATE] (12 days) and from [DATE]-[DATE] (10 days). Resident #17 was admitted to the facility from another nursing facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual MDS dated [DATE] revealed the resident scored 15 of 15 on the BIMS with no impairment of cognitive skills. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath from [DATE]-[DATE] (13 days). Review of the shower list revealed the resident was scheduled for showers on Tuesday and Friday on day shift. Observation on [DATE] at 9:05 AM revealed the resident sitting up on the bed. Interview revealed the resident was .scheduled to get a shower 2 times a week. Continued interview revealed the shower chair hurt the resident's back and revealed the facility had tried different things to make the shower more comfortable. Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 11:45 AM, in the conference room confirmed the resident did not receive a shower or bed bath from [DATE]-[DATE] (13 days). Resident #21 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored ,[DATE] on the BIMS with no impairment of cognitive skills; required limited assistance with bathing; and was continent of bowel and bladder. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath from [DATE]-[DATE] (7 days) and from [DATE]-[DATE] (23 days). Review of the shower list revealed the resident was scheduled for showers on Monday and Thursday on day shift. Observation of the resident on [DATE] at 8:50 AM, in the resident's room revealed the resident lying on the bed completely covered with a quilt. Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with RN Supervisor #1 on [DATE] at 11:15 AM, in the conference room confirmed the resident did not receive a shower or bed bath from [DATE]-[DATE] (7 days) and from [DATE]-[DATE] (23 days). Resident #23 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored ,[DATE] with no impairment of cognitive skills; required extensive assistance with bathing; and was frequently incontinent of bowel and bladder. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath from [DATE]-[DATE] (14 days) and from [DATE]-[DATE] (16 days). Review of the shower list revealed the resident was scheduled for showers on Tuesday and Saturday on evening shift. Observation on [DATE] at 9:10 AM in the resident's room revealed the resident lying on the bed. Interview with the resident revealed showers were scheduled two times per week and sometimes the showers were not given because the facility was short on people. Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 10:50 AM, in the conference room confirmed the resident did not receive a shower or bed bath from [DATE]-[DATE] (14 days) and from [DATE]-[DATE] (16 days). Resident #25 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored ,[DATE] on the BIMS with severely impaired cognitive skills; required extensive assistance with hygiene and bathing; and was incontinent of bowel and bladder. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath from [DATE]-[DATE] (11 days); from [DATE]-[DATE] (11 days); and from [DATE]-[DATE] (7 days). Review of the shower list revealed the resident was scheduled for showers on Monday and Thursday on evening shift. Observation of the resident on [DATE] at 8:40 AM in the resident's room revealed the resident lying on the bed with the eyes closed. Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 11:00 AM, in the conference room confirmed the resident did not receive a shower or bed bath from [DATE]-[DATE] (11 days); from [DATE]-[DATE] (11 days); and from [DATE]-[DATE] (7 days). Resident #27 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored ,[DATE] on the BIMS with no impairment of cognitive skills; required extensive assistance with hygiene and bathing; had a urinary catheter; and was frequently incontinent of bowel. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath from [DATE]-[DATE] (12 days); from [DATE]-[DATE] (10 days); from [DATE]-[DATE] (13 days); and from [DATE]-[DATE] (6 days). Review of the shower list revealed the resident was scheduled for showers on Tuesday and Friday on evening shift. Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 12:15 PM in the conference room confirmed the resident did not receive a shower or bed bath from [DATE]-[DATE] (12 days); from [DATE]-[DATE] (10 days); from [DATE]-[DATE] (13 days); and from [DATE]-[DATE] (6 days). Resident #28 w",2019-03-01
5368,SUMMIT VIEW OF ROCKY TOP,445259,204 INDUSTRIAL PARK RD,ROCKY TOP,TN,37769,2016-03-22,353,E,1,0,5X0U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, review of the shower schedule, medical record review, observation, and interview, the facility failed to ensure an adequate number of Certified Nursing Assistants (CNA) were scheduled to provide timely repositioning and incontinence care for 4 residents (#1, #2, #4, #7) with/or at risk for developing pressure ulcers and following incontinent episodes and failed to provide showers and/or bed baths for 18 residents (#1, #2, #3, #4, #6, #7, #8, #9, #12, #13, #14, #15, #17, #21, #23, #25, #27, #28) of 28 residents reviewed on 1 floor of 3 floors in the facility. The findings included: Interview with the Administrator and Registered Nurse (RN) Supervisor #1 on (MONTH) 8, (YEAR) at 1:00 PM, in the conference room revealed the facility's policy allowed for a bed bath in place of a shower if a shower was not given as scheduled. Continued interview revealed a partial bath included only the perineum, rectal area and the underarms and confirmed a bed bath included the entire body. Interview with the Administrator on [DATE] at 2:30 PM, in the conference room revealed the facility had no policy for the frequency of showers and bed baths. Continued interview revealed the facility followed State regulations which read, XXX[DATE]-.06(n) .Residents shall have baths or showers at least two (2) times each week, or more often if requested by the resident . The facility's incontinence care policy was requested from the Director of Nursing (DON) on [DATE]. The facility's policy entitled Prevention of Pressure Ulcers was received from the DON on [DATE]. Review of the policy for the prevention of Pressure Ulcers revealed, .Interventions and Preventive Measures: Residents with Risk Factors .Place resident on a minimum of q (every) 2 hour check and change program .Change position at least every two hours and more frequently as needed .Check resident for incontinence at least q 2 hours and clean skin when soiled . Review of the facility's East wing shower schedule (Complaint # addressed problems with care not being provided as a result of inadequate staffing for the East wing only) revealed showers were scheduled for residents two times per week and were scheduled Monday through Saturday. Resident #1 was admitted to the facility from another nursing home on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored ,[DATE] on the Brief Interview for Mental Status (BIMS) with moderately impaired decision-making skills, had disorganized thinking and delusions; required extensive assistance of 2 people with bed mobility, hygiene and bathing; and was always incontinent of bowel and bladder. Medical record review of the Braden Scale for Predicting Pressure Sore Risk revealed on [DATE], [DATE] and [DATE], revealed the resident was at high risk for the development of Pressure Ulcers. Medical record review of the current comprehensive care plan revealed the resident was at risk for pressure ulcers and had .open areas on coccyx and right scapula and right heel . Continued review revealed, .Turn and reposition with devices every 2 hours on air mattress .Keep clean and dry . Continued review revealed the resident required physical assistance with bathing. Medical record review of the Wound Care Center's orders dated [DATE] revealed, Turn q (every) 2 hours .Avoid position directing pressure to wound site . Medical record review of a nurse's note dated [DATE] revealed, .Turned every 2 hours . Review of the facility's Wound Report dated [DATE] revealed the resident had a Stage 4 Pressure Ulcer to the coccyx which measured 4.0 cm (centimeters) X (by) 3.5 cm X 0.5 cm. Continued review revealed interventions included, Turn Q 1 hr (hour) Observation and interview with Certified Nursing Assistant (CNA) #1 and #2 on [DATE] at 1:45 AM (night shift) in the resident's room revealed the resident was lying on the bed on her back. Observation revealed the CNAs positioned the resident on the right side. Observation revealed a gauze dressing on the sacrum. Interview with CNA #1 and #2 in the resident's room at the time of the observation confirmed the resident had a Pressure Ulcer on the sacrum and the resident required repositioning every two hours. Observation revealed the CNAs positioned the resident on the back and removed the brief. Observation revealed the resident had been incontinent of urine with a strong ammonia odor. Observation with the CNAs revealed the skin on the back and buttocks was intact except for the Pressure Ulcer on the sacrum. Continued interview with the CNAs confirmed the resident was in need of incontinence care and incontinence care or repositioning off the back had not been provided for the resident since the evening shift (2:00 PM-10:00 PM) went off duty at 10:00 PM (3 hours, forty-five minutes). Review of the shower list revealed the resident was scheduled for showers on Tuesdays and Fridays on day shift. Medical record review of the resident's activities of daily living (ADL) records dated [DATE]-[DATE] and review of the shower lists dated [DATE]-[DATE] revealed Resident #1 did not receive a shower or bed bath from [DATE]-[DATE] (6 days); from [DATE]-[DATE] (7 days); from [DATE]-[DATE] (6 days); and from [DATE]-[DATE] (6 days). Medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the facility's shower lists for the East wing dated [DATE]-[DATE] with the Registered Nurse (RN) Supervisor #1 on [DATE] at 3:15 PM, in the conference room confirmed Resident #1 did not receive a shower or bed bath from [DATE]-[DATE] (6 days); from [DATE]-[DATE] (7 days); from [DATE]-[DATE] (6 days); and from [DATE]-[DATE] (6 days). Resident #2 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored ,[DATE] on the BIMS with severely impaired decision-making skills; had inattention, disorganized thinking and delusions; required extensive assistance of two with bed mobility and transfers; was totally dependent on staff for hygiene and bathing; and was always incontinent of bowel and bladder. Review of the current comprehensive care plan revealed, .requires extensive physical assistance with bathing .incontinent of bowel and bladder at all times .staff provides skin care after all incontinent episodes and prn (as needed) .Shower 2 X (times) per week with bed baths on alternate days. As tolerated by resident .Potential for .episodes secondary to Diabetes type II .Monitor and assure position changes .Needs bedrails to prevent injury from: convulsion and provide mobility .Reposition at regular intervals .Risk for skin breakdown/pressure ulcers due to bowel and bladder incontinence .impaired mobility .provide pericare after each episode of incontinence . Medical record review of the Braden Scale for Predicting Pressure Sore Risk dated [DATE], [DATE], and [DATE], revealed the resident was at moderate risk for the development of Pressure Ulcers. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a bed bath or shower from [DATE]-[DATE] (8 days) and from [DATE]-[DATE] (6 days). Review of the shower list revealed the resident was scheduled for showers on Mondays and Fridays on day shift. Observation and interview with CNA #1 and #2 on [DATE] at 1:30 AM (night shift), in the resident's room revealed the resident lying on the bed on her back. Interview with CNA #1 and CNA #2 at the time of the observation confirmed the resident had an odor and confimed the resident had not received any care including repositioning or incontinence care since the evening shift went off duty at 10:00 PM (3 and 1/2 hours). Observation revealed the CNAs positioned the resident on the right side. Observation revealed the resident had no skin breakdown on the buttocks, thighs, hips or back. Observation revealed the resident had a large incontinent bowel movement. Interview with the CNAs at the time of the observation confirmed the resident had a large, incontinent bowel movement and was in need of incontinence care. Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and the shower lists dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 3:00 PM, in the conference room confirmed the resident did not receive a bed bath or shower from [DATE]-[DATE] (8 days) and from [DATE]-[DATE] (6 days). Resident #4 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident had impaired short-term memory and moderate impairment of decision-making skills; required extensive assistance with bed mobility and hygiene; was totally dependent on staff for bathing; and was always incontinent of bowel and bladder. Medical record review of the current comprehensive care plan revealed, .incontinent of bowel and bladder related to Dementia as evidenced by having multiple episodes of incontinence every day .Check resident at regular intervals for incontinence care .hygiene as needed after every incontinent episodes to maintain dignity .Risk for skin breakdown due to bowel/bladder incontinence .Provide peri care at regular intervals .Has bruises or abrasions due to: fragile skin .Turn and reposition at regular intervals . Medical record review of the Braden Scale for Predicting Pressure Sore Risk dated [DATE] revealed the resident was at mild risk for the development of Pressure Ulcers. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a bed bath or shower from [DATE]-[DATE] (7 days); from [DATE]-[DATE] (6 days); from [DATE]-[DATE] (11 days); from [DATE]-[DATE] (10 days); and from [DATE]-[DATE] (6 days). Review of the shower list revealed the resident was scheduled for showers on Mondays and Fridays on the evening shift. Observation on [DATE] at 9:35 AM in the resident's room revealed the resident lying on the right side on the bed. Observation revealed the gown was open in the back; a brief was in place; and the resident had a strong urine odor. Interview with CNA #3 on [DATE] at 9:50 AM, on the 300 hallway of the East wing confirmed the CNA was assigned to the resident on day shift and had just gotten another resident out of the shower. Continued interview confirmed Resident #4 had received no care including incontinence care or repositioning since the night shift staff left at 6:00 AM (almost 4 hours). Continued interview revealed, They don't want us to do incontinence care until after breakfast. It's usually about this time (9:50 AM) when I get started doing rounds. Interview with the Licensed Practical Nurse (LPN) Supervisor #1 on the East wing on [DATE] at 9:55 AM, at the East wing nurses' station revealed the off going night shift staff made rounds with the oncoming day shift to make sure all residents were dry at the end of the night shift (6:00 AM). Continued interview revealed breakfast trays arrived on the unit at 6:30 AM (30 minutes after day shift began) and confirmed the staff did not have time to do much before trays came out. Continued interview confirmed day shift staff did not do rounds on the residents until after breakfast was over which was usually around 8:15 AM. Observation and interview with CNA #3 on [DATE] at 10:10 AM, in the resident's room revealed the CNA removed the resident's brief. Observation revealed the resident's skin was intact. Interview with the CNA at the time of the observation confirmed the resident had been incontinent of a moderate amount of urine and a small amount of bowel movement; was in need of incontinence care; and had a strong urine odor. Continued interview confirmed the resident was last repositioned and provided incontinence care on night shift (at least 4 hours). Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 10:30 AM, in the conference room confirmed the resident did not receive a bed bath or shower from [DATE]-[DATE] (7 days); from [DATE]-[DATE] (6 days); from [DATE]-[DATE] (11 days); from [DATE]-[DATE] (10 days); and from [DATE]-[DATE] (6 days). Resident #7 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident had short and long-term memory problems and moderately impaired decision-making skills; was totally dependent on staff for all activities of daily living (ADL); and was always incontinent of urine. Medical record review of the Braden Scale for Predicting Pressure Sore Risk dated [DATE] revealed the resident was at moderate risk for the development of Pressure Ulcers. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath from [DATE]-[DATE] (9 days); from [DATE]-[DATE] (6 days); and from [DATE]-[DATE] (13 days). Review of the shower list revealed the resident was scheduled for showers on Wednesdays and Saturdays on day shift. Observation on [DATE] at 8:57 AM, in the resident's room revealed the resident was lying on the bed with the eyes closed and mouth breathing. Observation and interview with CNA #4 on [DATE] from 9:13 AM-9:20 AM, in the resident's room revealed the CNA removed the resident's brief. Observation revealed the resident's skin on the back, buttocks, thighs and hips was intact. Interview with CNA #4 confirmed the resident had been incontinent of urine; confirmed a small amount of dried feces on the bilateral buttocks; and confirmed the resident had an odor in the perineal area. Continued interview revealed the CNA was the only CNA on the 500 hallway; however another CNA was on the way. Continued interview confirmed the resident had not been repositioned or provided incontinence care since the night shift left at 6:00 AM (more than 3 hours). Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 10:30 AM, in the conference room confirmed the resident did not receive a bed bath or shower from [DATE]-[DATE] (9 days); from [DATE]-[DATE] (6 days); and from [DATE]-[DATE] (13 days). Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed the resident expired in the facility on [DATE]. Medical record review of the quarterly MDS dated [DATE] revealed the resident had short and long-term memory problems and severely impaired decision-making skills; was totally dependent on staff for all ADL; and was always incontinent of bowel and bladder. Medical record review of the comprehensive care plan updated [DATE] revealed, .Shower 2 X per week with bed baths on alternate days . Medical record review of resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a bed bath or shower from [DATE]-[DATE] (12 days); from [DATE]-[DATE] (9 days); from [DATE]-[DATE] (11 days); and from [DATE]-[DATE] (14 days). Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 9:20 AM, in the conference room confirmed the resident did not receive a bed bath or shower from [DATE]-[DATE] (12 days); from [DATE]-[DATE] (9 days); from [DATE]-[DATE] (11 days); and from [DATE]-[DATE] (14 days). Resident #6 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored ,[DATE] on the BIMS with no impairment of decision-making skills; was totally dependent on staff for hygiene and bathing; was occasionally incontinent of bowel; and was frequently incontinent of bladder. Review of the current comprehensive care plan revealed, .Shower or Bed bath with limited to extensive assistance by staff . Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath from [DATE]-[DATE] (16 days); from [DATE]-[DATE] (12 days); from [DATE]-[DATE] (7 days); and from [DATE]-[DATE] (11 days). Review of the shower list revealed the resident was scheduled for showers on Thursdays and Saturdays on evening shift. Observation on [DATE] at 1:15 PM revealed the resident lying in bed with the head of the bed elevated. Interview revealed the resident did not receive showers but received bed baths per his requests. Continued interview revealed he had gone several days without a bed bath because the facility does not have enough help. Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 3:40 PM, in the conference room confirmed the resident did not receive a bed bath or shower from [DATE]-[DATE] (16 days); [DATE]-[DATE] (12 days); from [DATE]-[DATE] (7 days); and from [DATE]-[DATE] (11 days). Resident #8 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual MDS dated [DATE] revealed the resident had short and long-term memory problems and severely impaired decision-making skills; rejected care; and had physical behaviors directed toward others. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath [DATE]-[DATE] (16 days) and from [DATE]-[DATE] (25 days). Review of the shower list revealed the resident was scheduled for a shower on Monday and Thursday evenings. Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 12:40 PM, in the conference room confirmed the resident did not receive a bed bath or shower from [DATE]-[DATE] (16 days) and from [DATE]-[DATE] (25 days). Resident #9 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored ,[DATE] on the BIMS with severe impairment of decision-making skills; required extensive assistance with hygiene and bathing; was always incontinent of bowel and had an indwelling urinary catheter. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath from [DATE]-[DATE] (8 days); from [DATE]-[DATE] (20 days); and from [DATE]-[DATE] (10 days). Review of the shower list revealed the resident was scheduled for showers on Wednesday and Saturdays on the evening shift. Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 12:30 PM, in the conference room confirmed the resident did not receive a bed bath or shower from [DATE]-[DATE] (8 days); from [DATE]-[DATE] (20 days); and from [DATE]-[DATE] (10 days). Resident #12 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored ,[DATE] on the BIMS with moderately impaired decision-making skills; required extensive assistance with hygiene and bathing; and was continent of bowel and bladder. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath from [DATE]-[DATE] (10 days); from [DATE]-[DATE] (9 days); and from [DATE]-[DATE] (10 days). Review of the shower list revealed the resident was scheduled for showers on Monday and Friday on evening shift. Observation of the resident on [DATE] at 8:55 AM, in the resident's room revealed the resident lying on the bed with the eyes closed. Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 12:10 PM, in the conference room confirmed the resident did not receive a bed bath or shower from [DATE]-[DATE] (10 days); from [DATE]-[DATE] (9 days); and from [DATE]-[DATE] (10 days). Resident #13 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 30 day MDS dated [DATE] revealed the resident scored ,[DATE] on the BIMS with no impairment of decision-making skills; required extensive assistance with bathing; and was continent of bowel and bladder. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath from [DATE]-[DATE] (13 days); from [DATE]-[DATE] (9 days); from [DATE]-[DATE] (16 days); and from [DATE]-[DATE] (7 days). Review of the shower list revealed the resident was scheduled for showers on Wednesday and Saturday on evening shift. Observation of the resident on [DATE] at 8:43 AM, in the resident's room revealed the resident lying on the bed with the legs hanging over the side of the bed. Interview with the resident revealed she had asked over an hour ago to get up. Interview with CNA #4 on [DATE] at 8:55 AM, on the 300 hallway revealed only 3 CNAs were working the East wing. Continued interview revealed another CNA, who was not scheduled, would be coming in later. Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 12:05 PM, in the conference room confirmed the resident did not receive a shower or bed bath from [DATE]-[DATE] (13 days); from [DATE]-[DATE] (9 days); from [DATE]-[DATE] (16 days); and from [DATE]-[DATE] (7 days). Resident #14 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS revealed the resident scored ,[DATE] on the BIMS with no impairment of decision-making skills. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath from [DATE]-[DATE] (9 days); from [DATE]-[DATE] (10 days); from [DATE]-[DATE] (6 days); and from [DATE]-[DATE] (6 days). Review of the shower list revealed the resident was scheduled for showers on Monday and Thursday on day shift. Observation on [DATE] at 9:40 AM in the resident's room revealed the resident lying on the bed. Interview with the resident revealed he sometimes received a shower every 2 days and sometimes went 5 days without a shower. Continued interview revealed the facility don't have enough help .short staffed . Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 12:00 PM, in the conference room confirmed the resident did not receive a shower or bed bath from [DATE]-[DATE] (9 days); from [DATE]-[DATE] (10 days); from [DATE]-[DATE] (6 days); and from [DATE]-[DATE] (6 days). Resident #15 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored ,[DATE] on the BIMS with moderately impaired cognitive skills and required limited assistance with bathing. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath from [DATE]-[DATE] (12 days) and from [DATE]-[DATE] (10 days). Review of the shower list revealed the resident was scheduled for showers on Monday and Friday on day shift. Observation on [DATE] at 8:37 AM in the resident's room revealed the resident was lying on the bed. Interview with the resident revealed she was scheduled to receive a shower yesterday (Monday) but did not because her knee was swollen. Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 11:55 AM, in the conference room confirmed the resident did not receive a shower or bed bath from [DATE]-[DATE] (12 days) and from [DATE]-[DATE] (10 days). Resident #17 was admitted to the facility from another nursing facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual MDS dated [DATE] revealed the resident scored 15 of 15 on the BIMS with no impairment of cognitive skills. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath from [DATE]-[DATE] (13 days). Review of the shower list revealed the resident was scheduled for showers on Tuesday and Friday on day shift. Observation on [DATE] at 9:05 AM revealed the resident sitting up on the bed. Interview revealed the resident was .scheduled to get a shower 2 times a week. Continued interview revealed the shower chair hurt the resident's back and revealed the facility had tried different things to make the shower more comfortable. Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 11:45 AM, in the conference room confirmed the resident did not receive a shower or bed bath from [DATE]-[DATE] (13 days). Resident #21 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored ,[DATE] on the BIMS with no impairment of cognitive skills; required limited assistance with bathing; and was continent of bowel and bladder. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath from [DATE]-[DATE] (7 days) and from [DATE]-[DATE] (23 days). Review of the shower list revealed the resident was scheduled for showers on Monday and Thursday on day shift. Observation of the resident on [DATE] at 8:50 AM in the resident's room revealed the resident lying on the bed completely covered with a quilt. Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 11:15 AM, in the conference room confirmed the resident did not receive a shower or bed bath from [DATE]-[DATE] (7 days) and from [DATE]-[DATE] (23 days). Resident #23 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored ,[DATE] with no impairment of cognitive skills; required extensive assistance with bathing; and was frequently incontinent of bowel and bladder. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath from [DATE]-[DATE] (14 days) and from [DATE]-[DATE] (16 days). Review of the shower list revealed the resident was scheduled for showers on Tuesday and Saturday on evening shift. Observation on [DATE] at 9:10 AM in the resident's room revealed the resident lying on the bed. Interview with the resident revealed showers were scheduled two times per week and sometimes the showers were not given because the facility was short on people. Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 10:50 AM, in the conference room confirmed the resident did not receive a shower or bed bath from [DATE]-[DATE] (14 days) and from [DATE]-[DATE] (16 days). Resident #25 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored ,[DATE] on the BIMS with severely impaired cognitive skills; required extensive assistance with hygiene and bathing; and was incontinent of bowel and bladder. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath from [DATE]-[DATE] (11 days); from [DATE]-[DATE] (11 days); and from [DATE]-[DATE] (7 days). Review of the shower list revealed the resident was scheduled for showers on Monday and Thursday on evening shift. Observation of the resident on [DATE] at 8:40 AM in the resident's room revealed the resident lying on the bed with the eyes closed. Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 11:00 AM, in the conference room confirmed the resident did not receive a shower or bed bath from [DATE]-[DATE] (11 days); from [DATE]-[DATE] (11 days); and from [DATE]-[DATE] (7 days). Resident #27 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored ,[DATE] on the BIMS with no impairment of cognitive skills; required extensive assistance with hygiene and bathing; had a urinary catheter; and was frequently incontinent of bowel. Medical record review of the resident's ADL records dated [DATE]-[DATE] revealed the resident did not receive a shower or bed bath from [DATE]-[DATE] (12 days); from [DATE]-[DATE] (10 days); from [DATE]-[DATE] (13 days); and from [DATE]-[DATE] (6 days). Review of the shower list revealed the resident was scheduled for showers on Tuesday and Friday on evening shift. Interview and medical record review of the resident's ADL records dated [DATE]-[DATE] and review of the shower records dated [DATE]-[DATE] with the RN Supervisor #1 on [DATE] at 12:15 PM, in the conference room confirmed the resident did not receive a shower or bed bath from [DATE]-[DATE] (12 days); from [DATE]-[DATE] (10 days); from [DATE]-[DATE] (13",2019-03-01
3344,LIFE CARE CENTER OF OLD HICKORY VILLAGE,445509,1250 ROBINSON ROAD,OLD HICKORY,TN,37138,2019-12-04,760,D,1,0,CBWN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy, medical record review and interview the facility failed to administer bed time medication for 1 (#1) resident of 3 residents reviewed. The findings include: Review of the facility policy Administration of Medications dated 4/24/19 revealed .All medications administered safely and appropriately per physician order to address residents' [DIAGNOSES REDACTED]. 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 required oxygen therapy. Medical record review of the physician order dated (MONTH) (YEAR) revealed .apixaban (anticoagulant) 2.5 mg (milligrams) tablet PO (by mouth) BID (twice daily) 8 AM and 8 PM .[MEDICATION NAME] (antibiotic) 250 mg PO BID .[MEDICATION NAME] chloride (antimuscarinic) 5 mg tablet PO BID .[MEDICATION NAME] (steroid) 20 mg BID for 3 days . Medical record review of the Medication Administration Record [REDACTED].apixaban (anticoagulant) 2.5 mg (milligrams) tablet PO (by mouth) BID (twice daily) 8 AM and 8 PM .[MEDICATION NAME] (antibiotic) 250 mg PO BID .[MEDICATION NAME] chloride (antimuscarinic) 5 mg tablet PO BID .[MEDICATION NAME] (steroid) 20 mg BID for 3 days . medicationa prescribed at bedtime had not been charted as given. Record review of the medication dispencing machine inventory dated 9/28/19 revealed [MEDICATION NAME], Eliquis, [MEDICATION NAME], Montelukast, [MEDICATION NAME], Polyethylene [MEDICATION NAME], and [MEDICATION NAME] were available for medication administration. Telephone interview with Family Member #1 on 12/2/19 at 10:09 AM revealed on the night of 9/28/18 she was called by Resident #1 to tell her she could not breathe and she had not received any medication. Telephone interview with the Pharmacy Technician on 12/4/19 at 11:15 AM revealed the medication dispensing system had medication the nurses could have administered. Continued interview revealed he expected the nurses to go to the medication dispensing system and get the medications that were available and if they were not there to call pharmacy to get medications stat (immediate) from a local pharmacy. Interview with the Director of Nursing on 12/3/19 at 2:54 PM in her office confirmed if Resident #1 did not receive any medication on 9/28/19, .I do not think it was appropriate . Telephone interview with the Former Administrator on 12/4/19 at 2:15 PM revealed the nurses were trained on how to use the medication dispensing system. Continued interview confirmed he expected the nurses to pass medication timely to the residents.",2020-09-01
2232,NORTHSIDE HEALTH CARE NURSING AND REHABILITATION C,445373,202 EAST MTCS ROAD,MURFREESBORO,TN,37130,2019-11-18,657,D,1,0,RW2O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy, medical record review and interview, the facility failed to revise a care plan for activities of daily living for 1 (#1) of 3 residents reviewed. The findings include: Record review of the facility policy Comprehensive Care Plans revised 11/2019 revealed .The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (minimum data set) assessment . 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 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Continued review revealed Resident #1 required total assistance with one staff member for bathing. Medical record review of the Care Plan dated 3/5/19 revealed Resident #1 was care planned for .self- care deficit r/t (related to) ambulation, bathing bed mobility, dressing, eating, hygiene, locomotion, and transfers, r/t L AKA ( left above the knee amputation), [MEDICAL CONDITION] [MEDICAL CONDITION] (chronic heart failure) .(named resident) is frequently incontinent of bladder . Continued review revealed the Care plan was not revised to reflect a male staff member could provide care but if a female staff member provided care it required 2 females. Record review of the Statement of Inservice Training for Employees dated 8/9/19 revealed .When available only male staff is to care for 309 [NAME] If males staff are not available, two females are to assist 309 A . Interview with the Director of Nursing (DON) on 11/21/19 at 3:33 PM in the conference room revealed when asked if the changes were added to the care plan the DON confirmed .It was not a change of care but a change of assignments. I thought it had been added to the care plan. The MDS Coordinator would have been the person to update the care plan . Interview with the Administrator on 11/18/19 at 4:18 PM in the conference room confirmed the family needed to be called and the care plan updated and set in stone as early as possible.",2020-09-01
607,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,279,D,1,0,DC3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy, medical record review, and interview, the facility failed to develop a comprehensive care plan for 1 resident (#4) of 8 residents reviewed. The findings included: Review of facility policy, Care Plans-Comprehensive, revised 10/2010 revealed .An individualized comprehensive care plan that included measureable objectives .to meet the resident's medical, nursing, mental and psychological needs is developed for each resident Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Care Plan dated 2/13/17 revealed .BEHAVIORS: (Resident #4) displays disruptive behaviors with yelling out at times . Further review revealed there was no goal for the care plan. Interview with the Minimum Data Set (MDS) Coordinator on 5/9/17 at 2:13 PM in her office revealed she did not list a goal for the Behavior Care Plan for Resident #4 because she was unsure at the time of the reason for the yelling and stated she was unsure if it was psych (psychiatric) or pain or something else. Interview with the Director of Nursing on 5/10/17 at 11:00 AM in the MDS office, with the MDS Coordinator present revealed there should have been a goal even if the reason for the behaviors was uncertain. Further interview with the DON confirmed it was inappropriate and the facility had failed to develop a comprehensive care plan for Resident #4.",2020-09-01
610,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2017-05-10,323,D,1,0,DC3711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy, medical record review, facility investigation review, and interview the facility failed to prevent an altercation for 2 residents (#3, #4) of 5 residents reviewed. The findings included: Review of facility policy, Abuse Prevention and Intervention Strategies, dated 11/16 revealed .It is the policy of this facility to protect its residents from abuse .has implemented a program of abuse prevention and intervention strategies .Investigation: The facility will investigate all injuries of unknown origin and all allegations of mistreatment, neglect or abuse. All investigations will be conducted in a timely, thorough and objective manner .Any incidents of substantiated abuse and neglect are reported and analyzed and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State or Federal law . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 had a Brief Interview of Mental Status (BIMS) of 10 indicating the resident was moderately cognitively impaired. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed the BIMS could not be conducted because the resident was rarely/never understood. Further review revealed the resident had trouble concentrating nearly every day and had no behavioral symptoms. Further review revealed the resident had short and long term memory problems and the cognitive skills for daily decision making were severely impaired. Review of the facility investigation included an Occurence Report signed by the DON on 4/11/17 and revealed Resident #3 was slapped by Resident #5 on 4/8/17. Continued review revealed the investigation included a statement from Licensed Practical Nurse (LPN) #1 recounting the event, and skin assessments for Residents #3 and #5 on 4/11/17. Interview with the Administrator and the DON on 5/10/17 at 4:15 PM in the conference room confirmed the facility failed to prevent an altercation between the two residents. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #4 had a BIMS of 7 indicating the resident was severely cognitively impaired. Review of the facility investigation included an Occurrence Report for Resident #4 and Resident #5. Further review revealed Resident #4 was hit by Resident #5 on 4/14/17. Continued review revealed the investigation included a statement recounting the incident, a skin assessment on Resident #4 dated 4/14/17, and the record of ongoing 15 minute checks of Resident #5 dated 4/11/17 to 4/14/17. Interview with the Administrator and DON on 5/10/17 at 4:20 PM in the conference room confirmed the facility failed to prevent an altercation between the two residents.",2020-09-01
3366,NASHVILLE CENTER FOR REHABILITATION AND HEALING LL,445512,832 WEDGEWOOD AVENUE,NASHVILLE,TN,37203,2020-02-20,609,D,1,0,QJU311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy, medical record review, facility investigation, and interviews the facility failed to report facility reported incident # to facility administration and to the State Agency in a timely manner. The findings include: Review of the facility policy Abuse, Neglect, and Exploitation of Residents showed .if abuse is suspected, personnel will report their observations to their supervisor immediately and without delay .the Abuse Prohibition Coordinator will report findings to the regulatory agencies as required . Medical record review showed Resident #7 was admitted [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review showed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] showed Resident #7 scored 7 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #8 scored 00 on the BIMS indicating severe cognitive impairment. Review of the facility investigation dated 2/3/2020 showed a resident to resident altercation occurred 2/1/2020 between Resident #7 and Resident #8. Continued review showed Licensed Practical Nurse #7 observed the altercation on 2/1/2020 and documented the incident on 2/2/2020 at 6:59 AM. Further review showed the incident was reported to the state agency on 2/3/2020 by the Director of Nursing (DON). Interview with the DON on 2/20/2020 at 10:10 AM in the conference room confirmed the incident occurred on 2/1/2020 and was reported to the State Agency 2/3/2020.",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
1546,"LEBANON CENTER FOR REHABILITATION AND HEALING, LLC",445268,731 CASTLE HEIGHTS COURT,LEBANON,TN,37087,2018-04-10,659,G,1,0,P4UJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy, record review and interview, the facility failed to ensure a Certified Nurse Aide (CNA)followed the care plan for one (Resident #4) of eight sampled residents during a transfer with a mechanical lift. CNA #1 transferred Resident #4 using a mechanical lift without requesting the assistance of another staff member and without connecting the sling securely to the lift as instructed in the resident's care plan and Minimum Data Set (MDS) (an assessment tool for long term care). Review of the facility policy titled, Lift & Transfer Program revealed, Two trained persons are required to be present when using the lift. Resident #4 fell from the lift during a transfer and sustained a right leg fractured fibula and fractured cervical (neck) vertebrae at C1. Resulting in HARM. Findings Include: Medical record review revealed Resident #4 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS- An assessment tool used by long-term care facilities) dated 8/6/17 revealed Resident #4 required extensive assistance with all activities of daily living. Continued review of the MDS revealed during the assessment period, transfers occurred only once or twice requiring two-person physical assistance. Continued review of the MDS of Resident #4 revealed a BIMS (Brief Interview for Mental Status, range 0-15) score was 3, indicating the resident had severe cognitive impairment. Review of Resident #4 Care Plan with an initiation date of 4/9/18 revealed (Resident #4) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) immobility .Bed Bound.The nterventions, .Transfer, the resident required Mechanical Lift (full body lift and sling remains under pt (patient) with (2) staff assistance for transfers . Review of the undated MDS Kardex Report for (Name of Facility) indicated for the category, ADL Transfer: Support Two persons total lift. Continued review Accidents-Fall Risk revealed, Falls since admission or prior assessment. Review of facility investigation report for the fall that occurred for Resident #4 dated 11/6/17 at 10:00 AM revealed, Certified Nurse Assistant (CNA #1) Had been transferring (Resident #4) from bed to shower chair via Hoyer lift when one strap came loose from lift and patient (Resident #4) fell to floor, continue reviewed revealed strap not secured correct Further reviewed revealed CNA #1 did not have another staff helping her. During an interview with CNA #1 in the conference room on 4/9/18 at 2:30 PM, confirmed the facility policy was to use two nursing staff whenever a resident was transferred via the Hoyer lift. Continued review with CNA #1 confirmed the sitter was not to assist with the use of the Hoyer lift, since the sitter was not an employee of the facility. During an interview on 4/9/18 at 3:15 PM with CNA #2, and on 4/10/18 at 9:50 AM with CNA #3 in the facility's conference room, both confirmed the facility's policy was to use two nursing staff whenever a resident was transferred using the Hoyer lift. CNA #2 and CNA #3 both stated they were aware Resident #4 required two nursing staff to transfer her from the bed to the chair using the Hoyer lift. Both stated the sitter could not be asked to assist since she was not an employee of the facility and was not certified. Interview with the Director of Nursing (DON) on 4/10/18 at 12:215 PM in the Conference room, the DON confirmed that CNA #1 did not follow Resident #4's care plan as well as the MDS Kardex regarding the use of two staff persons when Resident #4 was transferred from the bed to the shower chair. The DON confirmed the facility policy directs the staff to use two staff persons whenever a resident is transferred per the Hoyer lift. Review of the facility policy Lift & Transfer Program revealed Two trained persons are required to be present when using the lift.",2020-09-01
1547,"LEBANON CENTER FOR REHABILITATION AND HEALING, LLC",445268,731 CASTLE HEIGHTS COURT,LEBANON,TN,37087,2018-04-10,689,G,1,0,P4UJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy, record review and interview, the facility failed to ensure adequate supervision was provided for one of eight sampled residents (Resident #4) during a transfer with a mechanical lift. Review of the undated policy for Lift & Transfer Program indicated, Two trained persons are required to be present when using the lift. Certified Nurse Aide (CNA) #1 transferred Resident #4 using a mechanical Hoyer lift without requesting the assistance of another staff and without connecting the lift's straps securely. Resident #4 fell from the Hoyer lift during a Hoyer lift transfer and sustained a fractured right ankle fibula and a cervical fracture to the C1 vertebrae of the neck resulting in HARM. Findings Include: Review of Resident #4 Admission Record indicated the facility admitted Resident #4 on 10/08/13. [DIAGNOSES REDACTED]. Review Nurses' Notes dated 1/25/18 indicated Resident #4 received Hospice care prior to her death in the facility on 1/25/18. Review of the MDS dated [DATE] revealed Resident #4 requires extensive assistance with all activities of daily living. During the assessment period, transfers occurred only once or twice requiring two-person physical assistance. Resident #4's BIMS score was 3 indicating the resident was severely cognitively impaired. Review of Resident #4 Activities of Daily Living (ADL) care plan and the MDS Kardex revealed Resident #4 required extensive assistance with transfers, with the intervention to transfer the resident per the Mechanical Lift (full body lift and sling remains under pt (patient) with (2) staff assistance for transfers Review of the facility investigation dated 11/06/17 at 10:00 AM revealed, Had been transferring from bed to shower chair via Hoyer lift when one strap came loose from lift and patient fell to floor, strap not secured correctly,CNA#1 did not have another staff helping her . The report indicated CNA#1 was a witness (the nurse aide who operated the Hoyer lift), as well as, there was a sitter for Resident #4 in the room at the time of the transfer. Review of the facility investigation documents revealed the investigation was completed by Licenses Practical Nurse (LPN) #1 and the Director of Nursing (DON). It was also signed by the Administrator and Medical Director. The facility concluded the cause of the accident was strap not secured correctly CNA#1 did not have another staff helping her. Review of the document titled, Physician's Telephone Orders dated 11/6/17 revealed, STAT (immediately) X-Ray: C (cervical)-spine- neck pain, T ([MEDICATION NAME])-spine-back pain, R (right) ankle-[MEDICAL CONDITION]/bruising. Review of Resident #4 Radiology Report Ankle AP right, dated 11/06/17 revealed, There is a fracture involving distal fibula with no displacement. The joint alignment is maintained. There is associated soft tissue swelling. Review of the Radiology Report Cervical Spine dated 11/6/17 indicated, Mild [MEDICAL CONDITION] Changes of the cervical spine. Review of the Radiology Report [MEDICATION NAME] Spine dated 11/6/17 revealed Mild [MEDICAL CONDITION] of the [MEDICATION NAME] spine. Review of the Orthopedic Physician's Progress note dated 11/7/17 documented Please place a pillow or air support on the R (right) ankle, Ice 15 minutes trice a day, Rewrap Ace daily- NO Stretch . Review of the Nurse Practitioner's notes (NP), dated 11/6/17 through 1/9/17, revealed Resident #4 right ankle has some ecchymosis, [MEDICAL CONDITION] and tenderness to palpate. Review of the NP's note dated 11/10/17 indicated enlarged gland right submandibular that was tender. Review of the NP's note dated 11/13/17 indicated, .The patient also presents with ecchymosis. It is located on the face Left temporal region .The symptom is gradual in onset not observed on Friday (November 20, (YEAR)) Review of the Telephone Order, dated 11/13/17 at 14:33 (2:33 PM) indicated, send to Tennova Out Patient for CT of head and neck for [MEDICAL CONDITION] and pain . During an interview with the Director of Nursing (DON) on 4/9/18 at 3:20 PM, the DON stated that after the results of the CT showed the fracture to the cervical spine C1, Resident #4 Orthopedic physician ordered the resident to be sent to the Emergency Department (ED) at St. [NAME]. Review of the ED Report revealed, .History of Present Illness, the patient presents with fall at NH (nursing home) one week ago. Dx (diagnosed ) with right ankle fx (fracture) fx Rx (prescription) without splinting (patient is non-ambulatory). CT head/neck today revealed cervical fracture. Sent by EMS (Emergency Medical Services) from outpatient imaging to ED . Interview with CNA#1 on 3/19/18 at 3:05 PM in the conference room, revealed she had worked at the facility for [AGE] years and had received in-service training on using the mechanical Hoyer lift prior to the incident. CNA#1 stated a sitter stayed with the resident 12 hours a day and we (staff) were just so used to the sitter helping us. Continued interview with CNA#1 revealed, I know now that I should have had another staff person with me. Further interview with CNA#1 revealed when she connected the sling to the lift, she thinks one strap did not go past the disc that secures the strap. Further interview with CNA#1 revealed when moved the resident from the bed, across the bolsters, the resident's bottom hit the bolster. CNA#1 stated the strap came off and the resident slide down my legs head first to the floor. CNA #1 stated that the incident happened so fast. CNA# 1, stated she was sent home after the incident and was later retrained on the Hoyer lift with a return demonstration. CNA#1 stated, I will always have another staff person with me . Interview with DON on 03/19/2018 at 11:00 AM in the conference room revealed she was called to the room after Resident #4 fall from the Hoyer lift. Continued interview revealed the resident did not complain of pain. Resident #4 had a sitter in the room at the time of the incident. CNA#1 used the sitter as her assistant to transfer the resident. Interviews with CNA #2 on 4/7/18 and CNA#3 on 4/10/18 in the facility's conference room, confirmed the facility's policy was to use two nursing staff whenever a resident was transferred via Hoyer lift and they could not ask the sitter for Resident #4 to assist with the use of the Hoyer lift, since she was not an employee of the facility and was not certified. The DON stated one of the straps came loose on the Hoyer lift causing the fall. Interview with the DON revealed the Hoyer lift was checked and there was no malfunction. The DON confirmed the strap was not secured properly resulting in a fall from the lift. The resident later had pain and x-rays were initiated. The DON stated that she immediately started an in-service on transfers with a return demonstration of all staff . During an interview on 4/9/18 at 5:10 PM in the conference room, LPN #6 confirmed that whenever a resident was transferred per the Hoyer lift, there were to be two nursing staff assisting with the transfer. LPN# 6 confirmed the sitter for Resident #4 should not have been asked to assist with the use of the Hoyer lift, since she was not an employee of the facility. Telephone interview on 4/10/18 at 9 AM, LPN# 7 indicated the facility's policy was to use two nursing staff whenever a resident was transferred using the Hoyer lift. LPN #7 also confirmed that nursing staff were not to ask any resident's sitter to assist with the transfer since they were not employees of the facility. LPN#7 confirmed that Resident #4's sitter was not an employee of the facility. During an interview on 4/9/18 at 1:45 PM, the NP in the conference room the NP stated Resident #4 only experienced one fall which was on 11/6/17. The NP stated that an x-ray of the cervical area was performed on 11/6/17, since Resident #4 fell head first to the floor. The NP stated that the 11/6/17 x-ray to the cervical area of the neck came back negative for fracture. The NP stated that on 11/13/17, the CT can pick up fractures that the x-ray cannot detect. The NP confirmed that when the CT results of the cervical fracture to C1, the Orthopedic physician ordered the resident to be transferred to the ED of St. [NAME] Hospital for further evaluation. The NP confirmed that Resident #4 returned with a hard collar to the neck. Telephone interview on 4/10/18 at 10:05 AM, the Orthopedic physician that reviewed Resident #4's x-ray results of the right ankle and the CT results of the cervical spine stated that it was very difficult for the x-ray of the cervical neck to identify the fracture to the C1 vertebra due to the [MEDICAL CONDITION] spondylosis of the spine. The Orthopedic physician indicated that on 11/6/17 the resident did not have any pain in the neck area. However, as the week progressed after the fall, a small displacement, a 3-4-millimeter shift, could have caused the swelling of the neck. The CT scan is the gold standard and it can detect a fracture that the x-ray was unable to detect. A review of CNA#1 personnel file indicated no issues with CNA#1 performance until she was suspended on 11/06/2017. She had documentation regarding the use of the Hoyer lift on 06/19/2017 and again on 11/13/2017. Review of the undated policy for Lift & Transfer Program indicated, Two trained persons are required to be present when using the lift. This Requirement is not met as evidenced by: Based on review of facility policy, record review and interview, the facility's nursing staff failed to accurately document one of one (Resident #4) resident's condition after the resident experienced a fall with a fracture during a transfer from the bed to the shower chair utilizing the Hoyer lift. After the fall, the resident experienced bruising and [MEDICAL CONDITION] of the right ankle, [MEDICAL CONDITION] to the right neck, and bruising of the left face. Resulting in Harm. Findings include: Review of a facility investigation for a fall that occurred for Resident #4 dated 11/6/17 at 10:00 AM revealed, Certified Nursing Assistant (CNA #1) had been transferring (Resident #4) from bed to shower chair via Hoyer lift (a mechanical device used to transfer) when one strap came loose from the lift and patient (Resident#4) fell to floor, strap when the strap was not secured correctly, CNA #1did not have another staff helping her. Review of the Radiology report dated 11/6/17 revealed, Results, there is a fracture involving distal fibula (one of the 2 bones in the lower leg) with no displacement . Review of the Orthopedic Physician's Progress Note dated (MONTH) 7,2017 revealed, Please place a pillow or air support on the R (right) ankle, Ice 15 minutes trice a day, Rewrap Ace daily- no stretch . Review of the Nurse Practitioner's (NP) note dated 11/6/17 indicated, . Resident #4 had a fall this morning out of the Hoyer lift .she has some tenderness in (her) neck and shoulders when repositioned and her right ankle has some ecchymosis (bruising), [MEDICAL CONDITION] and tenderness to palpate. Review of the NP's note dated 11/7/17 revealed, .joint swelling ankle and joint tenderness ankle.",2020-09-01
327,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2017-09-08,280,G,1,0,HIQ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility protocol review, medical record review, review of facility falls investigations, and interview, the facility failed to develop and implement interventions to prevent falls for 5 residents (#7, #3, #4, #5, and #6), of 7 residents reviewed for falls, of 69 residents assessed as at risk for falls. The facility's failure resulted in a fractured ankle (harm) for Resident #7. The findings included: Review of the facility policy, Care Plans - Comprehensive Person-Centered revised 5/2017 revealed .The comprehensive, person-centered care plan will .Incorporate identified problem areas .Reflect currently recognized standards of practice for problem areas and conditions .Identifying problem areas and their causes, and developing interventions .are the endpoint of an interdisciplinary process .Care planning interventions are chosen only after careful data gathering, proper sequencing of events .and relevant clinical decision making .The Interdisciplinary Team must review and update the care plan .When the desired outcome is not met .When the resident has been readmitted to the community from a hospital stay; and at least quarterly . Medical record review revealed Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Safety Event Entries (facility investigation conducted post falls) dated 7/6/17, 7/7/17 (2 of 3 falls on this date), 8/24/17, 9/3/17, and 9/4/17, revealed the resident sustained [REDACTED]. Continued review revealed the resident sustained [REDACTED]. Review of a Safety Event Entry dated 7/7/17 4:06 PM revealed .Resident found on floor beside her bed. 3rd fall this shift .What type of injury(s) was sustained? Fracture (Major) . Medical record review of a nurses note dated 7/7/17 at 4:44 PM revealed .Call received from Dr (physician) .stating .resident has a left tibular (ankle) fx (fracture) . Medical record review of the care plan dated 7/7/17 revealed the care plan was not revised or updated to reflect new interventions to prevent falls after the falls on 7/7/17. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Safety Event Entry dated 7/8/17 revealed the resident sustained [REDACTED]. Medical record review of the care plan dated 9/5/17 revealed the care plan was updated on 9/5/17 to include .Falls .Resident re-education to call for assistance with transfers post fall 7/8/17 .start date 9/5/17 . Continued review revealed the care plan was not updated until 60 days after the fall occured. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Safety Event Entry dated 8/7/17 revealed the resident had an unwitnessed fall in her room on this date. Medical record review of the care plan dated 4/17/17 revealed the care plan was not revised to include a new intervention to prevent falls after the fall on 8/7/17. Medical record review revealed Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a Safety Event Entry dated 8/13/17 revealed the resident had an unwitnessed fall and was sent to the hospital for evaluation. Medical record review of the care plan dated 8/21/17 revealed the care plan had not been revised to include a new fall intervention after the resident's fall on 8/13/17. Medical record review revealed Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of a Safety Event Entry dated 8/18/17 revealed the resident sustained [REDACTED]. Medical record review of the care plan dated 8/23/17 revealed .Falls .at risk for falls r/t (related to) hx (history) of falls with fx (fracture) . Continued review revealed the care plan was not revised to reflect new interventions after returning to the facility from a hospitalization . Interview with the Director of Quality on 9/8/17 at 8:20 AM, in the conference room, confirmed Resident #6 had alarms ordered previously for fall prevention on 6/14/17. Continued interview confirmed the resident was discharged to the hospital on [DATE], and the alarm was discontinued at that time. Further interview confirmed the facility failed to revise the resident's care plan when she returned from the hospital, and the current care plan was not accurate. Continued interview confirmed the care plans for Residents #3, #4, #5, and #7 were not revised to include new interventions to prevent further falls after the post-falls investigations had been completed. The facility's failure resulted in Resident #7 sustaining a fractured ankle (tibula). Refer to F-323",2020-09-01
328,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2017-09-08,323,G,1,0,HIQ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility protocol review, medical record review, review of facility falls investigations, interview, and observation, the facility failed to provide supervision to prevent falls for 5 residents (#7, #3, #4, #5, and #6), of 7 residents reviewed for falls, of 69 residents assessed as at risk for falls. The facility's failure resulted in a fractured ankle (harm) for Resident #7. The findings included: Review of the facility protocol, Falls Clinical Protocol, dated 12/2016 revealed .Treatment/Management .the associate and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of consequences of falling. If underlying causes cannot be readily identified or corrected, associates will try various relevant interventions, based on assessment of the nature or category of falling .Monitoring and follow-up .The community associates will monitor and document the individuals response to interventions intended to reduce falling .If the individual continues to fall, the nursing associate and physician will re-evaluate the situation and .will re-evaluate the continued relevance of current interventions . Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating the resident had severe cognitive impairment. Continued review of the functional status revealed the resident required limited assistance for toileting and dressing and supervision for bed mobility, transfer, ambulation and personal hygiene. Medical record review of a Falls Risk assessment dated [DATE] revealed a score of 8, indicating the resident was at high risk for falls, and .A Score of 5 or greater = (equals) High Risk . Medical record review of a nurses note dated 7/6/17 at 3:39 PM, revealed .Witnessed fall at 1530 (3:30 PM) Resident tripped on the carpet as she was walking toward her room No s/s (signs or symptoms) or c/o (complaints of) pain or discomfort .Walker was being used for assistance . Review of a Safety Event Entry (entries for falls investigations) dated 7/6/17 revealed .Witnessed fall. Resident was using walker for assistance to her room but tripped on the carpet. No injuries noted .Event increased the need for monitoring or evaluation . Continued review revealed no documentation the increased monitoring or evaluation was completed. Continued review revealed no other new interventions were implemented after the fall to prevent future falls. Medical record review of a nurse's note dated 7/7/17 at 8:25 AM revealed .Witnessed fall from standing position with walker to couch then slid off edge to floor .no visible injury . Review of a Safety Event Entry dated 7/7/17 8:36 AM, revealed .Resident attempting to sit on couch from standing position, sat on edge of couch and slid to floor .Location where the event occurred? Reception Area .No Harm .Event increased the need for monitoring or evaluation . Continued review revealed no documentation the increased monitoring or evaluation had been completed, and there were no other new interventions implemented to prevent future falls. Medical record review of a nurse's note dated 7/7/17 at 12:09 PM revealed .Resident having extreme agitation. Found walking down hall with no pants on. Nonsensical word salad (incoherent jumble of words), crying, received order .to administer 1 mg (milligram) lorazepam (anti-anxiety medication, same as Ativan) IM (intramuscular) q 6h PRN (every 6 hours as needed). First dose administered at this time . Medical record review of a nurses note dated 7/7/17 at 1:55 PM, revealed .Resident fell in bathroom. All clothes had been removed and she soiled herself. Gotten up off the floor with a gait belt and assist x 3 (with 3 persons) .Left ankle xray (swollen and painful) .Additional dose of 1 mg Ativan (anti-anxiety medication) IM also given at this time . Medical record review revealed no interventions were implemented after the fall on 7/7/17 to prevent future falls. Medical record review of a nurses note dated 7/7/17 at 3:59 PM, revealed .Resident found on floor by her bed. Third fall this shift .Resident is now in wheelchair at the nurse's station . Review of a Safety Event Entry dated 7/7/17 at 4:06 PM revealed .Resident found on floor beside her bed. 3rd fall this shift. 2nd fall occurred 4 hours prior in the bathroom. Resident was naked and had urinated on herself at that time. Unknown why she fell the third time. She is unable to articulate .What type of injury(s) was sustained? Fracture (Major) . Medical record review of a nurses note dated 7/7/17 at 4:44 PM revealed .Call received from Dr (physician) .stating .resident has a left tibular fx (fracture) .1640 (4:40 PM)- resident transported by EMS (emergency medical services) . Medical record review of a nurses note dated 7/7/17 at 11:59 PM, revealed .Resident arrived back from hospital via EMS .No new orders given. Resident has boot on broken ankle and is now resting in bed . Medical record review revealed no new interventions to prevent further falls had been implemented after the third fall on 7/7/17 at 4:06 PM. Medical record review revealed the resident was hospitalized from [DATE] to 7/13/17, and again on 8/4/17 to 8/24/17. Continued review revealed Resident #7 was readmitted to the facility on [DATE]. Medical record review of a falls risk assessment dated [DATE] revealed a score of 14 (score of 5 or higher indicates High Risk). Review of a Safety Event Entry dated 8/24/17 at 5:08 PM revealed .Witnessed fall. Resident was attempting to transfer without assistance . Medical record review revealed no new interventions were implemented after the fall on 8/24/17 to prevent future falls. Review of a Safety Event Entry dated 9/3/17 at 4:32 PM revealed .Resident attempting to stand from wheelchair, with non-weight bearing status d/t (due to) LLE (left lower extremity) fracture .fell to floor .denies injuries . Continued medical record review revealed no new interventions were implemented after the fall to prevent future falls. Review of a Safety Event Entry dated 9/4/17 at 3:57 PM revealed . Unwitnessed fall. Resident attempted to ambulate/transfer without assistance . Continued medical record review revealed no new interventions were implemented to prevent future falls. Interview with the Quality Director on 9/7/17 at 11:30 AM, in the conference room, confirmed Resident #7 had suffered a fractured ankle as a result of the 2nd fall that occurred on 7/7/17. Continued interview confirmed no new interventions were implemented after the fall to address safety concerns, and Resident #7 continued to have falls on 8/24/17, 9/3/17, and 9/4/17, with no new interventions implemented to prevent falls. Continued interview confirmed the facility failed to adequately assess the safety needs and implement interventions to prevent falls for Resident #7, which resulted in harm to the resident. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident had a BIMS score of 15, indicating the resident was cognitively intact. Continued review revealed the resident required limited assistance of 1 for bed mobility, transfers, and ambulation in the room and hallway. Review of a Safety Event Entry dated 5/18/17 at 12:44 PM, revealed .unwitnessed fall. Resident assisted to her w/c (wheelchair) x 3 staff .No Injury . Medical record review of a Falls assessment dated [DATE] revealed score of 4, indicating the resident was a low risk for falls. Medical record review revealed no new interventions were implemented to prevent future falls after the fall on 5/18/17. Medical record review of an Interdisciplinary Note dated 7/8/17 revealed .Resident was in the sitting position without her 02 (oxygen) when this nurse arrived. Resident had fallen on the floor while attempting to use her potty chair unassisted .small abrasions on the 1st and 2nd toe on the left foot and to the 2nd toe on the right foot . Review of Resident #3's Care Plan revealed, .Resident reeducation to call for assistance with transfers post fall 7/8/17 . Continued review revealed the intervention was implemented on 9/5/17, two months after the resident's fall, and no other new interventions were implemented in a timely manner. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Significant Change MDS dated [DATE] revealed the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing and toilet use and the resident used a wheelchair for mobility. Continued review revealed the resident had a history of [REDACTED]. Review of a Safety Event Entry dated 8/7/17 revealed .Was informed by .Rehab Tech that resident was in (on) the floor .W/C (wheelchair) was on it's side .no injuries noted . Medical record review of a Falls assessment dated [DATE] revealed a score of 8, indicating the resident was a high risk for falls. Medical record review revealed no interventions were implemented after the fall on 8/7/17 to prevent future falls. Observation of Resident #4 on 9/7/17 at 11:30 AM, revealed the resident seated in a wheelchair in the resident's room with her daughter visiting. Attempted interview was unsuccessful as the resident was unable to answer questions. Medical record review revealed Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 14, indicating the resident was cognitively intact. Continued review revealed the resident required extensive assistance of 2 staff for bed mobility and transfers. Medical record review of a Falls Risk assessment dated [DATE] revealed a score of 9, indicating the resident was a high risk for falls. Review of the Safety Event Entry dated 8/13/17 revealed .Writer .heard alarm start sounding and went .to residents room .resident lying on the floor on right side .alert and oriented x 2 (oriented to person and place) stated that she was trying to get up and walk to BR (bathroom) (resident does not walk) .large pumpknot noted to right side of forehead, skin tears x 2 to LUE (left upper extremity), red area around eye .order received to transfer to ED (emergency department) for evaluation and treatments . Medical record review of an Interdisciplinary Note dated 8/13/17 revealed .@ (at) 250 (2:50) pm Resident returned to facility .Large purple/red area noted to right side face . Medical record review revealed no new interventions were implemented after the fall on 8/13/17 to prevent future falls. Medical record review revealed Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of an Admission MDS dated [DATE] revealed the resident had short and long term memory impairment and severe cognitive impairment. Continued review revealed the resident required extensive assistance of 2 staff for bed mobility, transfer, and required extensive assistance of 1 staff for locomotion using a wheelchair or walker. Medical record review of a CT Scan (type of xray) report dated 7/14/17 revealed .There is diffuse bone demineralization . Medical record review of a Falls Risk assessment dated [DATE] revealed a score of 8, indicating the resident was at high risk for falls. Medical record review of an Interdisciplinary Note dated 8/18/17 at 10:50 AM, revealed .Resident noted to be on back .resident was attempting to ambulate from her w/c when her leg buckled and she fell on to the floor . Review of a Safety Event Entry dated 8/18/17 revealed The resident stood up from her w/c, her leg buckled and she fell on to the floor. Her left leg was deformed and she was sent to the ER (emergency room ) . Medical record review of an xray report dated 8/18/17 revealed .displaced fracture of the proximal left femur .Underlying generalized demineralization . Medical record review revealed no new interventions were implemented after the fall on 8/18/17, or after Resident #6 returned to the facility on [DATE], to prevent future falls. Interview with the Director of Quality on 9/8/17 at 8:20 AM, in the conference room, confirmed the facility failed to follow the falls protocol to identify and implement pertinent interventions to prevent future falls for Residents #7, #3, #4, #5, and #6. The facility's failure resulted in a fractured ankle for Resident #7.",2020-09-01
673,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-03-10,684,D,1,0,TO3W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility protocol, medical record review, and interview, the facility failed to ensure physician orders [REDACTED].#5) sampled residents. The findings include: 1. The facility's Clinical Pathways protocol documented, .[MEDICAL CONDITION]: (Chest pain) Begin oxygen 2L (liters) by nasal cannula and notify Provider .Dyspnea: Oxygen 2L by nasal cannula .Heartburn: [MEDICATION NAME] suspension (or house equivalent) 30 cc (cubic centimeters) po (by mouth) . 2. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During interview with Respiratory Therapist (RT) #1 on 2/27/19 at 3:25 PM in the respiratory therapy office, RT #1 stated, .the RT on Sunday night had put O2 on him as precaution . During an interview with RT #2 on 2/28/19 at 11:38 AM in the conference room, RT #2 stated, .went and got a concentrator for O2 . RT #2 was asked why the O2 was administered to the resident. She stated, Because I'm an RT and he rubbed his stomach without description. It's just what I do . RT #2 was asked if Resident #5 had chest pain or shortness of breath. RT #2 stated, No. During a telephone interview with LPN #2 on 2/28/19 at 2:18 PM, LPN #2 stated, .He was in his room, rubbing his stomach, wanted something for stomach. I gave him TUMS . LPN #2 was asked if there was a physician order [REDACTED]. During an interview with the Director of Nursing (DON) ) on 2/28/19 at 2:02 PM in the conference room, the DON was asked if there was an order for [REDACTED]. TUMS is what we have as house stock . During a telephone interview with the Physician on 3/1/19 at 7:33 AM, the Physician was asked if TUMS was included in the facility's standing orders protocol. The Physician stated, There are protocols for them to give [MEDICATION NAME] . The Physician was asked if [MEDICATION NAME] and TUMS were the same drugs. The Physician stated, No. They are different drugs.",2020-09-01
1846,SIGNATURE HEALTH OF PORTLAND REHAB & WELLNESS CENT,445306,215 HIGHLAND CIRCLE DRIVE,PORTLAND,TN,37148,2019-05-21,726,D,1,0,YL5411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility review, medical record review, personel record review, and interview, the facility failed to ensure staff performed duties utilizing appropriate competancey to ensure resident safety for 1 (#3) of 6 residents reviewed. The findings include: Review of the facility policy, Abuse, Neglect and Misappropriation of Property, revised [DATE], revealed .Definitions .Allegation of Abuse Means a report, complaint, grievance, statement, incident, or other facts that a reasonable person would understand to mean abuse .is occurring, has occurred, or plausibly might have occurred .Immediately ALL alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than 2 hours after the allegation is made .Reporting Requirements: Every Stakeholder (employee), contractor and volunteer immediately shall report any allegation of abuse .to the charge nurse on duty . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].On [DATE] Resident #3 had an unplanned discharge for abdominal pain and concern for worsening right hip decubitus ulcer. Resident #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] Resident #3 had an unplanned discharge to the hospital for [DIAGNOSES REDACTED]. Resident #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. Medical record review of the Care Plan for Resident #3 with onset date of [DATE] revealed .Potential for altered comfort level from Pain .has stiffness of joints, hx (history) of fractures, multiple pressure injuries, and dx (diagnoses) chronic pain .Approaches: Monitor and report to nurse and S/S (sign/symptom) of Pain .Report changes in pain location/type, intensity/frequency .Administer Mediation as ordered . Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #3 has adequate hearing and vision; clear speech, made self-understood and understood by others; Brief Interview for Mental Status was ,[DATE], indicting cognition was intact; no acute change in mental status, no [MEDICAL CONDITION], no mood, no [MEDICAL CONDITION]; exhibited little interest/pleasure in doing things, feeling down/depressed/hopeless, and tired/little energy for ,[DATE] days during the review period; required extensive 2 person assistance for bed mobility, and toileting; total 2 person assistance for transfers; extensive 1 person assistance for locomotion on/off unit, dressing, hygiene, and bathing; range of motion was impaired for bilateral lower limbs; had an indwelling catheter and [MEDICAL CONDITION]; experienced pain in past 5 days of the review period, pain had no effect on sleeping or day-today activities, and the pain intensity was 5 out of 10; had unhealed pressure ulcer, 4 stage 4 sites which were present on entry/reentry; and received antidepressant, antibiotic, and opioid medication during last 7 days of review period. Medical record review of Resident #3's (MONTH) (YEAR) Physician Order Sheet, signed by the physician on [DATE], revealed the following pain medications: [REDACTED] .Tylenol Ex-Str (extra strength) 500 MG (milligrams) Tablet ([MEDICATION NAME]) Give 2 Tablet By Mouth 3 Times(s) Daily. DX: (diagnoses) Pain . was initiated on [DATE]. .[MEDICATION NAME] HCL (opioid pain medication) 15 MG Tablet Give 1 tablet by mouth 6 time(s) Daily. Give 1 tablet by mouth every 4 hours scheduled Hold if Sleeping .Dx: Pain . was initiated on [DATE]. .Pain level every shift . was initiated on [DATE]. Medical record review of the Pain Evaluation dated [DATE] revealed the pain from the wound on resident's bottom radiated, was persistent, stabbing characteristic with frequency of frequent; intensity which at best was ,[DATE], averaged ,[DATE] and at worst was ,[DATE]; Pain was made worse when up in chair and wound care; Interventions to relieve pain were repositioning and medication. Medical record review of Resident #3's (MONTH) 2019 Medication Administration Record [REDACTED]. Review of facility investigation documentation by CNA #2 dated [DATE] at 8:40 PM revealed .After smoke break (Resident #3) told me (resident) had a spell earlier that day with .blood pressure while being outside. When I asked .what was wrong (resident) proceeded to tell me that (CNA #1) had been giving (resident) Tylenol at night which (resident) thought may have caused (resident) to have an allergic reaction . Review of the facility investigation documentation by Licensed Practical Nurse (LPN) #1 dated [DATE] revealed .(Resident) approached this nurse + (and) stated that (CNA #1) had been giving (resident) Tylenol w (with) [MEDICATION NAME]. CNA offered elder (resident) meds (medication) when (resident) was upset because she took so long to get (resident) in bed. Elder stated she offered to give (resident) '3, 4, or 5' if (resident) wanted. Elder stated that (resident) took them but felt guilty because (resident) knew it was messing w (resident's) recovery + (resident) was worried that if she was giving them to (resident), she could be giving them to others as well . Review of the facility investigation documentation by CNA #1 dated [DATE] revealed .On (MONTH) 26, 2019 I was asked by one of my Resident if (resident) could have one of my pill to help (resident) to sleep (resident) said .can't sleep + that (resident) gets nothing for sleep. I gave (resident) one of my pills twice . Obervation of Resident #3 on [DATE] at 8:42 AM revealed Resident #3 in the room, flat in a bed with an air mattress, eyes were shut, lights were off, and catheter bag was concealed. Further observation at 12:12 PM revealed the resident seated upright in bed on an air mattress, was using a personal phone, TV was on, and the resident was able too move the upper body. Further observation at 3:55 PM revealed Resident #3 using bilateral upper extremities to propel wheelchair from the secure unit, on the opposite side of the facility, into the Station 2 hallway, with staff present by resident, and headed to the main dining room at a fast pace. Observation on [DATE] at 11:00 AM revealed Resident #3 in the main dining room seated in the wheelchair participating in an activity. Interview with Resident #3 on [DATE] at 12:12 PM in the resident's room revealed when asked if you reported getting medication from a CNA (Certified Nurse Aide) the resident stated .she (CNA #1) put me to bed and asked if I was hurting anywhere, and I said I was hurting on my butt and she said she had medication she could give me. She said it was Tylenol and gave me some on Thursday, Friday, Saturday and Sunday. On Sunday she told me they were her prescription medication .I got to thinking about it and had to tell someone. What if she did that to someone and they died . When asked if the current medication was controlling the pain, the resident stated .used to get [MEDICATION NAME] every 4 hours and was told insurance won't pay for that anymore and now get it every 6 hours and now have break through pain. Get Tylenol at 2:00 PM too . Further interview at 1:00 PM in the resident's room revealed the staff turns and positions the resident .if I want them to . When asked if he refused to be turned the resident stated .Yes, I guess but if I'm not feeling pain so I'm not turned . Telephone interview with CNA #1 on [DATE] at 3:13 PM when how long she had been a CNA, she stated XXX[AGE] years in 15 states and I know I messed up and deserve punishment for what I did . When asked if she would share her side of the story involving Resident #3 she stated .I was taking the smokers out and reached in my pocket to get something and my Tylenol 4 fell out. I said 'Oh no, that's the only one I brought with me' and (Resident #3) saw it fall. (Resident #3) said .used to take those. I told (Resident #3) they weren't the real kind, just generic. One night (Resident #3) pressed call light and asked for me, called me Ms. (NAME REDACTED) Liz. Said .would like one (Tylenol 4) because .couldn't sleep and I said 'No and I said (resident) would get me in trouble.' (Resident) said they didn't give .anything to help .sleep and I said I would think on it and later I gave (resident) one. Another night, I don't remember day or the date, (resident) pressed the call light and asked for me and said (resident) was awake all night and it was about 2:30 AM and could I give (resident) one and I did. I gave (resident) a total of 2 pills on 2 occasions. (Resident) tricked me but I messed up. I refused to give (resident) anymore and I guess (resident) went and told on me . Telephone interview with CNA #2 on [DATE] at 4:42 PM when asked if she had been informed by a resident regarding medications received from other than a nurse, stated .I was taking the smokers out about 8:40 PM .Resident #3 was finishing cigarette and said (CNA #1) gave (resident) her Tylenol 4 and that's why (resident) had a spell outside that day .may have had bad reaction to medication with other medications (resident) takes. (Resident #3) told me because (resident) was worried (CNA #1) may be giving medication to others also. (Resident) said (resident's) back hurting and (CNA #1) said had some Tylenol 4 and that she could give (resident) 2 tablets a night . When asked who CNA #2 reported Resident #3's comments to, the CNA stated .No one, (resident) asked me not to report it, that (resident) would tell nurse (LPN #1) and (resident) did when nurse changed patch . When asked what the gap of time was from the time the resident informed the CNA to the resident reporting it to the nurse, the CNA stated .maybe 2 hours gap between telling me and telling the nurse, I wasn't aware it was abuse, I was written up for it .have been reeducated . Telephone interview with LPN #1 on [DATE] at 5:25 PM when asked if she had been informed of a medication being provided to a resident by a staff member who was not a nurse the LPN stated .(Resident #3) reported to me at about 1:,[DATE]:00 AM, somewhere around there. (Resident #3) at times goes to bed late and gets a dressing change before going to bed and that's when (resident) told me. Resident said that over the weekend, Friday, Saturday, and Sunday, CNA #1 was taking forever to get (resident) in bed, and (resident) not get to bed on time and got upset with the CN[NAME] Said her way to make it up was to offer Tylenol with [MEDICATION NAME]. Said (resident) could have as many as .wanted and (resident) took 2 each night over weekend . When asked if there were any other interactions, the LPN stated .I got another nurse (LPN #3) and asked the resident to tell LPN #3 what was told to me (LPN #1) and (resident) said same to her. The (resident) asked me what I was going to do and I told (resident) I will tell the Administrator. (Resident) reported .knew it was wrong and was in recovery and worried CNA #1 do it to other people, (resident) felt guilty and reported it. Called Administrator about 2:30 AM to report . Interview with the Administrator on [DATE] at 5:45 PM in the administrative office area when asked about a CNA dispensing medication, the Administrator stated .not expect staff that aren't nurses to give medications, not what a CNA does We suspended CNA #1, we called the police and reported (CNA #1) to the Board .",2020-09-01
1489,LAUGHLIN HEALTH CARE CENTER,445264,801 E MCKEE ST,GREENEVILLE,TN,37743,2018-01-10,760,D,1,1,Y2ZQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility's policy, medical record review, hospital record review, personnel record review, and interviews the facility failed to ensure 1 resident (#50) of 21 sampled residents was free of any significant medication errors. The findings included: Review of the facility's policy titled Medication, Preparation and Administration dated (MONTH) 2001 and revised (MONTH) 2014 revealed .The correct medications will be given to the correct resident, within the correct time frame, by the correct route and in the correct dosage . Medical record review revealed Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of nursing progress notes dated 7/28/17 revealed the nursing supervisor was immediately notified Resident #50 was given the medications belonging to the roommate. The nurse who administered the medication was a new hire (3rd day) working with a regular licensed nurse. The physician was immediately notified and due to the medications of [MEDICATION NAME], and Eliquis the physician elected to send the resident to the hospital for evaluation and observation. Review of the emergency department notes dated 7/28/17 revealed Resident #50 arrived in the emergency department at 0922 for being inadvertently given another patient's medications. The resident was mistakenly given: [MEDICATION NAME] 125 mg (milligrams); [MEDICATION NAME] XR 120 mg; [MEDICATION NAME] 25 mg-100 mg 2 tabs; [MEDICATION NAME] 40 mg; Eliquis 25 mg; [MEDICATION NAME] 17 GM (gram); [MEDICATION NAME] 40 mg; Multivitamin; Vitamin C 500 mg; Vitamin D 2000 IU (units); [MEDICATION NAME] 24 mcg (micrograms); and Tylenol 500 mg. Further review revealed the resident returned to the facility the same day while remaining hemodynamically and neurologically stable. Review of the personnel files of the 2 Licensed Practical Nurses (LPN) involved revealed a counseling form dated 7/28/17 for .Meds given to wrong person. 5 rights of Medicine Administration policy reviewed. Cautioned to ask someone to identify the resident if you do not know them . Telephone interview with Licensed Practical Nurse (LPN) #4 on 1/10/18 at 11:40 AM revealed she and the new nurse were at the medication cart in the hallway and the new nurse had pulled the medication for Resident #50's roommate. LPN #4 stated she pointed to the roommate but had turned to talk with another resident coming down the hall. LPN #4 stated when she turned and saw the nurse giving the medication to the wrong resident it was too late the resident had already swallowed the medications. The physician was immediately notified. LPN #4 confirmed she should not have turned and observed the new employee closer. Interview with the Director of Nursing (DON) on 1/10/18 at 12 noon in the DON's office confirmed the seasoned nurse should not have let the new nurse administer medications without proper observation during orientation. The DON confirmed the facility failed to ensure Resident #50 was free of significant medication errors.",2020-09-01
1999,GRACELAND REHABILITATION AND NURSING CARE CENTER,445331,1250 FARROW ROAD,MEMPHIS,TN,38116,2020-02-10,835,J,1,0,U67J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on job description review, medical record review, facility investigation review, and interview, the Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain and maintain the highest practicable well-being of residents. Administration failed to provide oversight and ensure training of staff, ensure staff supervision, ensure a safe environment, complete a thorough investigation of resident elopement, revise the resident's plan of care, and conduct a Quality Assurance and Performance Improvement (QAPI) Committee meeting. Administration's failure to ensure a safe environment placed 1 of 4 sampled residents (Resident #1) in Immediate Jeopardy when the resident, a cognitively impaired resident with known wandering and exit-seeking behaviors, was missing approximately 2 hours and 45 minutes after she was last seen by facility staff. Resident #1 was picked up by a police officer 1.3 miles from the facility. Resident #1 had crossed State Route 175 (Shelby Drive), a heavily traveled 7 lane highway. This resulted in Immediate Jeopardy for Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy for F-835 on 2/9/2020 at 11:38 AM, in the Conference Room. The facility was cited F-600, F-610, F-656, F-657, F-689, F 835, and F-867 at a scope and severity of J. F-600, F-610, and F-689 are Substandard Quality of Care. A partial extended survey was conducted 2/7/2020 through 2/9/2020. The Immediate Jeopardy was effective from 11/1/2019 through 2/9/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 2/10/2020 at 12:30 PM. The Removal Plan was validated onsite by the surveyors on 2/10/2020 through review of assessments and Care Plans, review of updated policies related to residents with active exit-seeking behaviors, newly developed auditing tools, in-service training records, and staff and Administration interviews. The findings include: Review of the facility's undated job description titled, Administrator, showed, .Purpose of Your Job Position .The primary purpose of your position is to direct the day-to-day functions of the Facility in accordance with current federal, state and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. Delegation of Authority .As Administrator you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Committee Functions .Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice .Ensure that all employees, residents, visitors and the general public follow the Facility's established policies and procedures .Assume the administrative authority, responsibility, and accountability of directing the activities and programs of the Facility .Assist the Quality Assurance and Assessment (currently known as the Quality Assurance and Performance Improvement (QAPI)) Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies . Review of the facility's undated job description titled, Director of Nursing Services, showed, .Purpose of Your Job Position .The primary purpose of your position is to plan, organize, develop, and direct the overall operation of our Nursing Services Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility and as may be directed by the Administrator or the Medical director to ensure that the highest degree of quality care is maintained at all times. Delegation of Authority .As Director of Nursing Services you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties .Administrative Functions .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies .Personnel Functions .Ensure that CNAs (Certified Nursing Assistants)/GNAs (Graduate Nursing Assistants), department personnel, residents, and visitors follow the department's established policies and procedures at all times .Review and revise care plans and assessments as necessary, but at least quarterly . Review of the facility's investigation dated 1/16/2020, showed that the facility's video camera footage was viewed by the Administrator and DON to determine how Resident #1 exited the building. The camera footage showed that on 1/16/2020 at 1:48 PM, Resident #1 got up from her wheelchair and walked into a resident room. At 1:50 PM, Resident #1 was seen exiting a window in room [ROOM NUMBER] and walking towards the back of the building. The surveyor viewed this video camera footage. During an interview on 2/7/2020 at 4:00 PM, the Administrator stated that her duties and responsibilities included ensuring the facility staff, residents, and anyone visiting the facility was safe. During an interview on 2/7/2020 at 6:20 PM, the Administrator stated that the facility was waiting until the State Survey Agency completed an investigation of the facility reported allegation of neglect related to Resident #1's elopement before calling an ad hoc meeting (a meeting to obtain information as the need arises). The Administrator also confirmed that the facility's QAPI Committee should have met as soon as possible after the elopement. During a telephone interview with the Medical Director on 2/9/2020 at 8:55 AM, the Medical Director confirmed she had not been informed that Resident #1 had eloped from the facility on 1/16/2020 for 1 or 2 days after the incident. Administration failed to ensure staff did not neglect their duties related to the supervision of a resident with a known history of wandering and exit-seeking behaviors. Refer to F-600 and F-689. Administration failed to ensure a thorough investigation was completed of a resident elopement from the facility. Refer to F-610. Administration failed to ensure the development and revision of Resident #1's Care Plan for elopement risk. Refer to F-656 and F-657. Administration failed to ensure a QAPI Committee meeting was held to identity, investigate, analyze, implement, and evaluate the need for corrective actions or performance improvement activities related to a resident's elopement from the facility. Refer to F-867. The surveyors verified the Removal Plan by: 1. Administration will ensure all incidents of elopement/exit seeking are thoroughly investigated to rule out staff neglect of a resident by including written statements from all parties involved. The surveyors interviewed Administration about thorough investigations related to elopement/exit seeking behaviors. 2. Administration will ensure the safety of all residents by using the newly developed Management Elopement/Exit-Seeking/Wanderers Audit Form. Administrator/Designee will have daily meetings with the DON and Assistant Director of Nursing (ADON) regarding updates on high risk elopement seeking residents. In the event of a weekend occurrence, the Administrator/Designee and DON and/or ADON will be in constant communication with staff. The surveyors reviewed the Audit form and interviewed staff responsible for performing the audits. 3. Administration has currently put measures in place to ensure staff accountability for resident care and safety by implementing an Elopement/Exit-Seeking Procedure and has educated/inserviced all staff. The consistency of procedures will be monitored by Administration weekly times four weeks and monthly ongoing. A new Management Elopement/Exit-Seeking/Wanderers Audit Form has been developed to ensure compliance is met and maintained. The surveyors reviewed inservice records, the audit form, and interviewed Administration and staff on all shifts. 4. Administration measurements will provide a method of monitoring all allegations of abuse and neglect to ensure thoroughness and completeness by having daily staff meetings with management. The staff meetings will address all elopement/exit-seeking behaviors and address preventive measures to redirect resident. Meetings will be held Monday-Friday. The surveyors interviewed the Administrative staff. 5. Management's systemic method of checks and balances now consists of a contracted compliance consulting company that will provide assessment of present operations inclusive of policies and procedures, documentation, communication, quality improvement and performance review, accident and incident investigation, abuse reporting and investigation, compliance and regulatory practices. The surveyors interviewed Administration. 6. Management has hired an additional Registered Nurse with clinical responsibilities of reviewing policy and procedures, review of corrective actions and performance of clinical staff in order to identify, investigate and analyze elopement/exit seeking residents' documentation and provide feedback and necessary resources to address and maintain compliance. All findings are to be reported to the QAPI Committee meeting monthly. The surveyors interviewed Administration. Noncompliance of F-835 continues at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.",2020-09-01
2540,MILLINGTON HEALTHCARE CENTER,445425,5081 EASLEY AVENUE,MILLINGTON,TN,38053,2019-01-27,835,J,1,0,Q97T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on job description review, policy review, Invacare Reliant 450 manufacturer recommendation, hospital medical record review, medical record review, observation and interview, Administration failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of the residents when they failed to ensure a safe environment free of accident hazards, failed to ensure staff implemented care plan interventions, failed to ensure acceptable standards of practice were followed, and failed to ensure the facility maintained an effective Quality Assurance program that identified and addressed concerns for 2 of 7 (Resident #1 and #2) sampled residents that had accidents resulting in actual harm and Immediate Jeopardy. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 1/27/19 at 9:00 AM in the conference room. The facility was cited an Immediate Jeopardy at F835-[NAME] The Immediate Jeopardy is ongoing. An extended survey was conducted on 1/26/19 and 1/27/19. The findings include: 1. Review of the Administrator job description documented, .Administrative Functions .Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility .Interpret the facility's policies and procedures to employees, residents, family members, visitors, government agencies .Ensure that all employees, residents, visitors, and the general public follow the facility's established policies and procedures .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies .Review and check competence of work force and make necessary adjustments/corrections as required or that may become necessary .Ensure that all facility personnel, residents, visitors .follow established safety regulations .Monitor to determine the effectiveness of the facility's risk management program . Review of the Director of Nursing job description documented, .Administrative Functions .Develop, implement, and maintain an ongoing quality assurance program for the nursing service department .Assist the Quality Assessment & (and) Assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies .Make daily rounds of the nursing service department to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards .Assist the Safety Officer in developing safety standards for the nursing service department .Ensure that the department's policy and procedure manuals identify safety precautions and equipment to use when performing tasks that could result in bodily injury .Monitor nursing service personnel to ensure that they are following established safety regulations in the use of equipment and supplies .Ensure that all personnel operate nursing service equipment in a safe manner .Ensure that all personnel involved in providing care to the resident are aware of the resident's care plan .that nursing personnel refer to the resident's care plan .determine if the care plan is being followed 2. Review of the Coordination of Transportation policy dated (MONTH) (YEAR) documented, .The facility will assist in making appointments and safe transport arrangements for the resident .The facility will consider all clinical, physical, mental and financial conditions related to the transportation arrangements . Review of the facility Care Plan Policy with a revised date of 12/12/17 documented, .Each resident will have a plan of care to identify problems, needs, and strengths that will identify how the facility staff will provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Review of the facility Fall Prevention Protocol policy dated 9/21/17 documented, .All residents/patients that had a score of > (greater than 10 was at high risk for falls) 10 on a fall screen will have a care plan to minimize injury . Review of the Invacare Reliant 450 Lift (mechanical assistive transfer device) manufacturer recommendation (undated) documented, .Invacare recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures . Review of facility Lift Management Program policy dated (MONTH) (YEAR) documented, .Our Lift Management Program is designed to meet the following goals: .To protect .residents from injury .Each co-worker is expected to support this program 100% (percent) .This procedure is always done with 2 people . 3. Administration failed to ensure the care plan intervention of supervision was implemented for Resident #1, who was assessed as cognitively impaired and had a history of [REDACTED].#1 was injured when he was unsupervised by facility staff and fell during transportation to a dental appointment. He sustained lacerations and a fractured nose which resulted in Immediate Jeopardy. Administration failed to ensure the care plan intervention of mechanical (assistive transfer device) lift transfers by 2 staff members for Resident #2 was followed. Resident #2 was transferred via mechanical lift by 1 staff member and was found with a discoloration on the cheek on 11/7/18. On 12/12/18 Resident #2 developed significant bruising, swelling, swallowing difficulties and was diagnosed with [REDACTED]. Refer F656. 4. Administration failed to ensure staff followed acceptable standards of practice for safe transport to outside appointments which resulted in Immediate Jeopardy to Resident #1 when he fell forward out of a wheelchair onto the parking lot while being transported by an outside transport company, unsupervised by facility staff. Administration failed to ensure staff followed acceptable standards of practice for safe mechanical lift transfers which resulted in Immediate Jeopardy to Resident #2 when she was found to have a discoloration on her cheek on 11/7/18. On 12/12/18 Resident #2 developed swelling, bruising, swallowing difficulties, and a fractured mandible (jaw) after 1 staff member transferred her via mechanical lift without assistance of another staff member. Refer to F658. 5. Administration failed to ensure a safe accident hazard free environment for Resident #1 who fell during an unsupervised transport and sustained lacerations and a fractured nose resulting in Immediate Jeopardy. Administration failed to ensure a safe and accident hazard free environment for Resident #2 who was found with a discoloration on her cheek on 11/7/18 and on 12/12/18 developed swelling, bruising, swallowing difficulties and a fractured mandible after being transferred via mechanical lift by 1 staff member which resulted in Immediate Jeopardy. Refer to F689. 6. Administration failed to ensure the facility had an effective Quality Assurance program that thoroughly investigated, identified and addressed concerns with safe transportation for the residents. The Administrator failed to assure the transport staff were trained for safe transport of residents. The Administrator stated he .left word with (Named transport service) to request their drivers be in-serviced on safety transport and .obtain a copy of the in-service . Interview with the Administrator on 1/15/19 at 10:20 AM in the conference room, the Administrator was asked to provide a transportation policy and the contract with the transportation company. The Administrator stated, We do not have a transportation policy, staff just get them up and ready and the transport company picks them up .I have no contract copy but we do have a contract with them . Interview with the DON on 1/15/19 at 1:10 PM in the conference room, the DON was asked how resident safety was ensured during transportation out of the building and she stated, We do not do a safety assessment for transportation. Interview with the Administrator on 1/26/19 at 10:15 AM in the conference room, the Administrator stated, .I have made multiple requests for (Named Transportation Company) contract and staff inservices and have received no response, don't have them . Interview with the Administrator on 1/26/19 at 3:10 PM in the conference room, the Administrator was asked if the pressure cushion cover Resident #1 had in the wheelchair had been considered in the root cause for Resident #1 sliding out of the wheelchair and the Administrator stated, I looked at the cushion, he was sitting on it. The Administrator was asked if lack of staff supervision had been considered during the root cause of Resident #1's fall during transport and he stated, .the nurses monitor transport exits . Refer to F865-J",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
2833,AHC VANCO,445460,813 S DICKERSON RD,GOODLETTSVILLE,TN,37072,2018-05-09,689,D,1,0,CD7L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on manufacturers recommendations, medical record review, review of facility investigation, and interview the facility failed to properly tansfer and prevent the occurence of an accident for 1 resident (Resident #2) of 3 residents reviewed for falls/accidents of 8 residents reviewed. Review of the Hoyer Lift (a device used to transfer a person)manufacturer's recommendations revealed .Operating Instructions for Hoyer Lift .Caution .Have someone assist you when attempting to transfer a patient . Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Further review revealed Resident #2 had a history of [REDACTED]. Medical record review of a Quarterly Minimum (MDS) data set [DATE] documented Resident #2 had a Brief Interview for Mental Status score of 4 which indicted she was severely cognitively impaired. Further review rvealed Resident #2 required the extensive assistance of 2 persons with transfer, and extensive assistance of 1 person with hygiene, dressing and bathing. Medical record review of Resident #2's care plan included she was at risk for falls related to weakness and an intervention of .Remind (Resident #2) to call for assistance before moving from bed-to-chair and from chair-to-bed. Hoyer (brand name of a mechanical lift) lift with 2-3 to be used .Use Mech (mechanical) lift x 2 to 3 assist for transfers (hoyer) . Medical record review of a Doctor's Progress Note dated 1/19/18 documented Resident #2 had .[MEDICAL CONDITION], osteopenia, multiple fractures mostly of lower extremities but also spinal .at very high risk of further pathological fractures due to her underlying [MEDICAL CONDITION] I anticipate further fractures as her [MEDICAL CONDITION] is her greatest risk factor for on-going fractures Review of a facility investigation involving Resident #2 revealed on 12/20/17 Resident #2 was placed in a mechanical lift sling by CNA #1 and CNA #2 while Resident #2 was in her bed. CNA #2 left the room and CNA #2 proceeded to transfer Resident #2 into a wheelchair. During the transfer Resident #2 leaned to the left from the sling and began to fall out of the sling. CNA #2 grabbed the Resident's right leg and lowered her to the floor with the resident landing on her left side. Resident #2 initially denied pain. The Nurse Practitioner (APN) examined Resident #2 who complained of pain in her left leg with passive range of motion. Further review revealed a Mobile x-ray was performed at the facility with .Results: There is a fracture involving distal femur and superior patella with increased displacement. The remainder of the femur is intact. Conclusion: Non acute distal left femur fracture as described. The findings are worse than 10/23/17. Continued review revealed Resident #2 was sent to a hospital for evaluation. An x-ray performed 12/20/17 at the hospital revealed .Acute [MEDICAL CONDITION] left femoral condyle with intercondylar extension of the fracture .marked osseous demineralization . Further revew revealed Resident #2 was admitted to the hospital and an orthopedic consult was ordered. Continued review revealed on 12/21/17 the Orthopedic Surgeon's consultation documented .Reviewed femur and tibia films from the emergency department. She (Resident #2) had an intraarticular distal femoral fracture on the left .medial femoral condyle .There is some white callus last calcification and adjacent to this suggested that this may be subacute .this may represent subacute injury . The x-rays also revealed numerous old fractures and severe [MEDICAL CONDITION]. Further review revealed the age of the fracture was undetermined. Continued review of the facility ivestigation revealed statements obtained during the facility incident investigation: 1. CNA #2 documented that she and CNA #3 put Resident #2 in a mechanical lift sling when she was lying in bed.we attached the sling properly to lift and then (CNA #3) left room. I began to put resident in w/c (wheelchair) but before resident was over w/c she fell from sling .I asked resident if she was hurting and she said I am ok 2. CNA #3 documented .Resident was laying on sling in bed properly attached to hoyer lift. Then I left room to assist another Pt (patient/resident). (CNA #2) came for assistance when arriving in room Pt was in floor . 3. Registered Nurse #1 documented she examined Resident #2 .Resident denied pain to RLE (right lower extremity) with passive ROM (range of motion). Resident c/o (complained of) mod (moderate) pain LLE (left lower extremity) with passive ROM . Continued review of the facility investigation revealed the facility identified the root cause of the occurrence was slid out of sling on Hoyer and the intervention put in place was Re-educate staff on proper usage of Hoyer. Interview with Registered Nurse (RN) #1, who was the interim Director of Nursing when the incident occurred, and the Assistant Director of Nursing (ADON) on 5/8/18 at 3:15 PM in the ADON's office revealed when asked about the incident involving Resident #2, the ADON stated CNA #2 and CNA #3 were asked to reenact what was done on the day of the incident. The CNAs had place Resident #2 in bed after a shower and removed the wet sling from underneath the resident. CNA #3 left the room. CNA #2 dressed the resident and then left the room to get CNA #3. They placed a dry sling under Resident #2, attached the upper sling to the lift, crossed the lower part of the sling between the resident's legs and attached to the lift. CNA #3 left the room while the resident was still laying on the bed. CNA #3 then proceeded to transfer Resident #2 using the mechanical lift without assistance. In the process of the transfer the resident slid from the sling and landed on the floor. Continued interview revealed CNA #3 should not have attempted to transfer Resident #2 without assistance. Phone interview with CNA #2 on 5/9/18 at 10:00 AM revealed she had showered Resident #2 and returned her to bed. CNA #3 assisted her with putting a sling under Resident #2 to prepare her to be transferred into a w/c. Continued interview revealed CNA #2 and CNA #3 correctly hooked the sling to the lift then CNA #3 left the room. Further interview revealed CNA #2 proceeded to use the mechanical lift to transfer the resident into a w/c, but in the process Resident #2 leaned to her left and began to slide out of the sling. She stated she grabbed the resident's leg to brake her fall and Resident #2 landed on the floor, kind of on her left side. Continued interview revealed when asked if she typically transferred residents using the mechanical lift by herself she stated she did not.",2020-09-01
4649,HUNTINGDON HEALTH & REHAB CENTER,445210,635 HIGH STREET,HUNTINGDON,TN,38344,2016-08-05,278,D,1,0,Z4P511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview the facility failed to accurately code the Minimum Data Set (MDS) for medications for 1 of 3 (Resident #1) sampled residents. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED] a. .[MEDICATION NAME] .1 TABLET BY MOUTH TWICE DAILY . (antibiotic) was documented given as ordered. b. [MEDICATION NAME] 7.5 MG CAPSULE .1 CAPSULE BY MOUTH AT BEDTIME AS NEEDED . (hypnotic) was documented given as ordered. c. No Antianxiety medication was documented given. The Significant Change MDS dated [DATE] Section N0410 documented the following medications were administered during the 7 day look back period for Resident #1: a. Section F-0 days Antibiotic. b. Section D- 0 days Hypnotic c. Section B-7 days Antianxiety In an interview in the MDS office on 8/2/16 at 2:30 PM, the MDS Coordinator was asked if Section N0410 B antianxiety should be coded 7 days. The MDS Coordinator stated, No, it should not The MDS Coordinator was asked if a Hypnotic should be coded. The MDS stated, Yes, under the D section should be coded 7 days The MDS Coordinator was asked if the antibiotic should be coded 0. The MDS Coordinator stated, No, it should not The MDS Coordinator stated, Section B, D and F are coded incorrectly .",2019-08-01
5506,CONCORDIA NURSING AND REHABILITATION -LOUDON,445253,1520 GROVE ST BOX 190,LOUDON,TN,37774,2016-02-04,309,D,1,0,XSZC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview the facility failed to address the Registered Dietician's recommendation for 1 resident (2) of 4 [MEDICAL TREATMENT] residents reviewed for nutrition. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the initial Minimum (MDS) data set [DATE] revealed the resident scored 3/15 (severely cognitive impairment) on the Brief Interview for Mental Status. Further review revealed the resident required extensive assistance for transfer, dressing, and hygiene/bathing and supervision and set up for feeding. Medical record review of a nutrition service progress note revealed on 8/5/15 the Registered Dietitian (RD) evaluated the resident with the resident eating Medical record review of the physician's orders [REDACTED]. Interview with Registered Nurse (RN) #1 on 2/4/16, at 12:40 PM, in the Family Room, revealed when the (RD) made a recommendation she usually writes an order on the order form and gives it to nursing. RN #1 confirmed she did not receive an order for [REDACTED]. Interview with the RD on 2/4/16, at 12:50 PM, in the Family Room revealed when she made a recommendation she usually wrote an order and gave it to nursing at the nurses' station. When asked if nursing was not at the nurses' station what did she do with the order, she stated she would lie it down on the table for nursing. Further when asked if she followed up on next visit if her recommendation had been addressed with the physician, the RD stated No, not usually. Interview with the Executive Director on 2/4/16, at 1:35 PM, in the Family Room confirmed no documentation could be found that an order had been written or the Physician had been notified of the RD's recommendation for the Boost Plus for Resident #2.",2019-02-01
1778,CONCORDIA NURSING AND REHABILITATION-NORTHHAVEN,445297,3300 BROADWAY NE,KNOXVILLE,TN,37917,2017-09-13,250,D,1,1,238J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview the facility failed to arrange physician ordered home health services for 1 resident (#95) of 35 residents reviewed. The findings included: Resident #95 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Comprehensive physician's orders [REDACTED].Discharge 4/19/17 home with home health .6. Home health nursing for wound care, physical therapy and occupational therapy to eval (evaluation) & (and) tx (treat) as indicated . Interview with the Social Services Director on 9/13/17 at 2:30 PM, in the conference room confirmed the Social Services Director called a referral to the pharmacy only and did not call a home health agency to arrange for home health services. Telephone interview with the Pharmacist at the pharmacy contacted by the Social Services Director on 4/18/17 at 3:00 PM, confirmed the pharmacy provided prescriptions and Durable Medical Equipment only and did not provide home health services.",2020-09-01
3896,LAURELBROOK SANITARIUM,4.4e+201,114 CAMPUS DRIVE,DAYTON,TN,37321,2019-08-20,842,D,1,1,I18S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview the facility failed to ensure a Physician order [REDACTED].#31 and #40) of 17 residents reviewed for POST forms. The findings include: Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a POST form undated had been prepared and signed by the Assistant Director of Nursing (ADON). Further review revealed the POST form had not been signed or dated by the Physician. Interview with the ADON on 8/19/19 at 2:00 PM, in the conference room, revealed she had completed the Post form for Resident #31. Further interview revealed she had talked with the son and he wanted to make a change to the form. Continued interview revealed the change had been made on 6/12/19 and a new form was to be filled out completely. Further interview revealed she is not sure why the Physician had not signed the POST form. Interview with the ADON 8/20/19 at 7:30 AM, in the nursing office, confirmed the facility failed to ensure Resident #31's POST form had been signed and dated by the Physician. Medical record review revealed Resident #40 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a POST form dated 1/20/16 had not been signed by Resident #40 or Resident #40's health care representative. Interview with the ADON on 8/20/19 at 10:35 AM, in the conference room, confirmed the POST form for Resident #40 had not been signed by the resident or the resident representative. Continued interview confirmed the facility failed to complete Resident #40's POST form.",2020-02-01
4028,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2016-12-04,514,D,1,1,Q5LC11,"**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 completely and accurately documented related to [MEDICAL TREATMENT], medication, supplements, and snack administration for 3 of 30 (Resident #21, 77 and 123) sampled residents of the 52 residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #21 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. The resident was dialyzing 3 days a week. Review of the physician's orders [REDACTED]. The physician's orders [REDACTED]. In an interview with the Director of Nursing (DON) on 12/1/16 at 10:25 AM, in the Conference Room, the DON verified there was not a (MONTH) order for the resident's [MEDICAL TREATMENT]. The DON verified the (MONTH) physician's orders [REDACTED]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Interview with the DON on 12/1/16 at 10:33 AM, in the Conference Room, the DON was asked if the fluid restrictions should have been documented. The DON stated, Yes. Review of the (MONTH) (YEAR) physician orders [REDACTED]. There was no documentation the [MEDICATION NAME] was was administered as ordered on [DATE], 11/5/16, 11/8/16, 11/13/16, 11/14/16, 11/25/16, 11/28/16 and 11/29/16. There was no documentation the [MEDICATION NAME] was administered as ordered on [DATE], 11/19/16, 11/20/16, 11/22/16, 11/23/16, 11/24/16, 11/25/16, and 11/29/16. There was no documentation that [MEDICATION NAME] was administered as ordered on [DATE]. Interview with the DON on 12/1/16 at 10:31 AM, in the Conference Room, the DON confirmed the [MEDICATION NAME], and [MEDICATION NAME] were not documented as administered. The DON was asked if the medication should have been signed out. The DON stated, Yes . 2. Medical record review revealed Resident #77 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A care plan updated 4/29/16 revealed, .Potential for skin breakdown .Offer supplemental nutrition to resident as ordered . The (MONTH) (YEAR) physician orders [REDACTED].MED PASS 2.0 4oz (ounces) TID (three times daily) . The order also revealed to offer the resident a night time snack, document the percentage of snack consumed and A if the resident accepted the snack and R if refused. The November, (YEAR) MAR indicated [REDACTED]. There was no documentation the resident's night time snack was documented as ordered from 11/6/16 to 11/16/16. In an interview with the DON on 12/4/16 at 5:46 PM, in the Conference Room, the DON confirmed the MAR indicated [REDACTED]. 3. Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 6/1/16 physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED] The medpass was not documented as given on 6/13/16, 6/14/16, and 6/16/16. The multivitamin was not documented as given on 6/16/16. The [MEDICATION NAME] was not documented as given on 6/20/16. Review of a telephone physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED] The medpass was not documented as given on 7/29/16. The liquid protein was not documented as being administered the month of (MONTH) (YEAR). The [MEDICATION NAME] was not documented as given on 7/1/16, 7/23/16 and 7/24/16. The bedtime snack was not documented as given on 7/5/16, 7/23/16, and 7/24/16. Review of the (MONTH) (YEAR) MAR indicated [REDACTED] The medpass was not documented as given on 8/15/16. The liquid protein was not documented as being administered as ordered on [DATE], 8/12/16, 8/13/16, 8/15/16, 8/17/16, 8/18/16, 8/19/16, 8/21/16, 8/23/16, 8/29/16, and 8/31/16. The multivitamin was not documented as given on 8/28/16 and 8/31/16. The [MEDICATION NAME] was not documented as given on 8/11/16, 8/12/16, 8/15/16, 8/17/16, 8/18/16, 8/19/16, 8/21/16, and 8/23/16. Review of the (MONTH) (YEAR) MAR indicated [REDACTED] The medpass was not documented as given on 9/8/16, 9/12/16, and 9/27/16. The liquid protein was not documented as being administered as ordered on [DATE], 9/16/16, 9/23/16, 9/25/16, 9/26/16 and 9/30/16. The multivitamin was not documented as given on 9/12/16. The bedtime snack was not documented as given on 9/30/16. The (MONTH) (YEAR) MAR indicated [REDACTED] The medpass was not documented as given on 10/8/16, 10/9/16, 10/10/16, 10/29/16 and 10/30/16. The liquid protein was not documented as being administered as ordered on [DATE], 10/17/16, 10/17/16, 10/28/16, 10/29/16, 10/30/16 and 10/31/16. The multivitamin was not documented as given on 10/10/16, 10/29/16, 10/30/16, and 10/31/16. The (MONTH) (YEAR) MAR indicated [REDACTED] The medpass was not documented as given as ordered on [DATE], 11/8/16, 11/11/16, 11/14/16, 11/19/16, 11/24/16, 11/25/16 and 11/27/16. The liquid protein was not documented as given as ordered on [DATE], 11/14/16, 11/19/16, 11/24/16, 11/25/16 and 11/28/16. The multivitamin was not documented as given on 11/24/16 and 11/25/16. The bedtime snack was not documented as being given for (MONTH) (YEAR). Interview with the Director of Nursing (DON) on 12/2/16 at 3:15 PM, in the Conference Room, the DON was asked if she expected the nursing staff to follow physician's orders [REDACTED].Yes .",2019-11-01
1459,AHC CUMBERLAND,445262,4343 ASHLAND CITY HIGHWAY,NASHVILLE,TN,37218,2018-04-25,658,D,1,1,6M2M11,**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 in the care of 1 (Resident #75) of 7 residents reviewed. Findings include: Medical record review revealed Resident #75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's Orders dated 6/11/16 revealed an order for [REDACTED]. Notify Physician of temperature above 102 degrees or if temperature continues more than 24 hours. Further review of Physician's Orders dated 6/11/16 revealed an order for [REDACTED]. Medical record review of the Nurse's Notes dated 12/25/17 revealed Resident #75 had a temperature of 102.1 degrees. Continued review of Nurse's Notes revealed no documentation of [MEDICATION NAME] administered for the temperature above 100 degrees as per Physician's Orders. Medical record review of the Medication Administration Record [REDACTED]. Interview with the Director of Nursing on 4/25/18 at 10:00 AM in the Administrator's office confirmed no [MEDICATION NAME] was documented as administered to Resident #75 on 12/25/17 either on the MAR indicated [REDACTED]. Continued interview confirmed [MEDICATION NAME] should have been administered to Resident #75 when she had a temperature of 102.1 degrees.,2020-09-01
3104,MCKENDREE VILLAGE,445491,4347 LEBANON ROAD,HERMITAGE,TN,37076,2018-01-19,658,D,1,0,7CQJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview the facility failed to follow the Physician's Order for 1 resident (#1) of 3 residents reviewed. The findings include: Medical record review revealed the resident (#1) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's Order revealed [MEDICATION NAME] (pain medication) ER tab 15mg, 1 capsule by mouth every 12 hours. Medical record review of the Controlled Drug Receipt/Record/Disposition Form dated 11/7/17 revealed [MEDICATION NAME] (pain medication) tablet 5mg (milligram) ER, take 3 tablets by mouth (15mg) every 12 hours. Medical record review of the Controlled Drug Receipt/Record/Disposition Form revealed only one-5mg [MEDICATION NAME] tablet was given on 11/7/17 at 9:00 PM. Medical record review of the Controlled Drug Receipt/Record/Disposition Form revealed only one-5mg [MEDICATION NAME] tablet was given on 11/8/17 at 10:30 AM. Interview on 1/19/18 with the Director of Nursing (DON) at 7:56 AM in the conference room revealed the nurse should have administered three-5mg [MEDICATION NAME] tablets to equal 15mg on 11/7/17 and 11/8/17 instead of one-5mg [MEDICATION NAME]. Continued interview revealed the DON confirmed the facility failed to follow the Physician's Order.",2020-09-01
4997,HOLSTON HEALTH & REHABILITATION CENTER,445344,3916 BOYDS BRIDGE PIKE,KNOXVILLE,TN,37914,2016-06-09,157,D,1,0,B01V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview the facility failed to notify the Family or Physician for changes for 1 (#3) resident of 5 residents reviewed. The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of a Nurse's Note dated 2/28/16 revealed .large purple bruise noted on L (left) leg posterior to patellar on popliteal, resident denies pain at this time when asked what happened resident responded 'I don't know what could have caused that' supervisor notified. Will cont (continue) to monitor . Interview with RN #1 (Registered Nurse) on 6/8/16 at 4:00 PM by telephone confirmed the bruise noted on the left leg was reported to RN #1. Continued interview confirmed did not notify the family or the Physician. Medical record review of a Nurse's Note dated 3/3/16 revealed .resident has bruising noted on L upper arm . Interview with LPN #1 (Licensed Practical Nurse) (nurse who documented note on 3/3/16) on 6/7/16 at 1:00 PM, at the nursing station confirmed the bruise was light purple, approximately the size of an apple, and reported the bruise to the DON (Director of Nursing). Interview with the DON (Director of Nursing) on 6/7/16 at 2:15 PM, in the private dining room, confirmed the family was not notified of the bruise to the left upper arm noted on 3/3/16 until the next day on 3/4/16. Medical record review of a Weekly Skin assessment dated [DATE] revealed .CNA (Certified Nursing Assistant) asked writer to assess buttock .L buttock with shearing 1x1 triangular shape .denies pain to area .area cleansed [MEDICATION NAME] skin prep padded drsg (dressing) applied . Medical record review of a Weekly Skin assessment dated [DATE] revealed .L buttock shearing resolved barrier cream applied . Medical record review of a Weekly Skin assessment dated [DATE] revealed . buttock (with) open area odd shape .barrier cream applied . Interview with LPN #2 on 6/7/16 at 1:40 PM in the private dining room, confirmed the family had not been notified of the shearing to L buttock with a treatment change on 9/16/15 or the open area noted on12/4/15 on the buttock.",2019-06-01
3308,NEWPORT HEALTH AND REHABILITATION CENTER,445504,135 GENERATION DRIVE,NEWPORT,TN,37821,2017-05-24,157,D,1,1,8GYB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview the facility failed to notify the Power of Attorney (POA) of discharge from the facility of 1 resident (#162) of 27 residents reviewed. The findings included: Medical record review revealed Resident #162 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Record (face sheet) revealed the POA was the resident's case worker. Medical record review of Minimum Data Set (MDS) discharge records dated 11/23/17 and 1/17/17 revealed resident was discharged to the hospital on [DATE] and 1/17/17. Medical record review revealed no documentation of notification of Resident #162's POA of the discharges from the facility. Interview with the Social Worker (SW) on 5/23/17 at 12:10 PM, in the SW's office confirmed the facility failed to notify the POA of the discharges from the facility on 11/23/16 and 1/17/17.",2020-09-01
4071,BOULEVARD TERRACE REHABILITATION AND NURSING HOME,445235,1530 MIDDLE TENNESSEE BLVD,MURFREESBORO,TN,37130,2016-11-08,157,E,1,0,W7SN11,"**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 11 missed doses of an intravenous antibiotic for 1 resident (#1) of 7 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the (MONTH) and (MONTH) (YEAR) Medication Administration Records revealed Resident #1 missed doses of [MEDICATION NAME] 1000 mg, an intravenous (IV) antibiotic, ordered every 12 hours, on 9/21/16 at 9:00 PM, 9/24/16 at 12:00 PM, [MEDICATION NAME] 1000 mg IV, ordered every 8 hours, 9/26/16 at 8:00 AM, [MEDICATION NAME] 1000 mg IV orderd every 8 hours, 9/27/16 at 9:00 PM, [MEDICATION NAME] 1000 mg IV ordered three times a day, 9/28/16 at 3:00 PM, [MEDICATION NAME] 1000 mg IV ordered three times a day, 9/30/16 at 3:00 PM, [MEDICATION NAME] 1000 mg IV ordered three times a day, 10/3/16 at 9:00 AM, [MEDICATION NAME] 1000 mg IV ordered three times a day, 10/10/16 at 3:00 PM, [MEDICATION NAME] 1000 mg IV ordered three times a day, 10/11/16 at 8:00 AM [MEDICATION NAME] 1000 mg IV ordered three times a day, 10/12/16 at 4:00 PM [MEDICATION NAME] 1000 mg IV ordered three times a day, and 10/18/16 at 9:00 AM [MEDICATION NAME] 1000 mg IV ordered twice a day. Further review revealed no documentation of the physician being notified of the missed doses. Interview with the Medical Director on 11/7/16 at 2:45 PM per telephone, confirmed he and his nurse practitioner, were unaware of the number of [MEDICATION NAME] doses Resident #1 missed during his course of treatment. Interview with RN Unit Manager, on 11/7/16 at 3:10 PM in the conference room, confirmed her expectation for a missed dose of an IV antibiotic is to chart it appropriately and notify the physician immediately. Interview with the Administrator and Director of Nursing on 11/7/16 at 4:00 PM in the conference room, confirmed the facility failed to notify the physician of Resident #1's 11 missed doses of IV antibiotics.",2019-11-01
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
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
4677,GREENHILLS HEALTH AND REHABILITATION CENTER,445267,3939 HILLSBORO CIRCLE,NASHVILLE,TN,37215,2016-08-11,272,D,1,0,NRXS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview the facility failed to provide 1 (Resident #3) resident of 4 resident's reviewed an accurate and complete assessment of the resident's medical status. The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission assessment dated [DATE] revealed the resident had short and long-term memory loss, and had difficulty being understood by others. He had a Gastrointestinal Tube (GT) in his abdomen for feedings and medication administration, and he was totally dependent on staff for all Activities of Daily Living (ADL's). Medical record review of an Admission Nursing assessment dated [DATE] revealed no assessment or documentation for an incision or staples present for Resident #3. Medical record review of a Nursing Daily Skilled Charting note dated 4/16/16 revealed lung sounds were not assessed or documented; Cardiac and circulation were not assessed or documented; Feeding tube assessment was left unanswered; Mood and behavior were not assessed and not documented; Skin was not assessed, and no documentation of an incision or staples was present for Resident #3. Medical record review of a Nursing Daily Skilled Charting note dated 4/17/16 at 4:04 PM revealed Licensed Practical Nurse (LPN) #1 documented the resident had a barrel chest. Continued review revealed no documentation of lung sounds, respiratory rate, or oxygen saturation. cough Hob (head of bed) elevated at 45 degrees. was documented below the assessment area that said Describe locations and details for Left Lung Sounds. Continued review revealed the presence of a GT was left blank. The skin assessment was left blank. A nurses note documented, .staples intact to abd (abdomen) . Further review revealed the Skilled and Additional Services section was left blank. Interview with the Director of Nursing (DON) on 8/10/16 at 2:30 PM in the Conference Room when shown the nursing admission assessment and daily skilled charting assessments for Resident #3 stated,They are not complete and they don't paint a clear picture of what happened to the resident. Continued interview revealed the DON stated, They need more education on documentation and assessment. The DON confirmed the facility failed to provide accurate and complete admission and daily assessments of Resident #3's medical status.",2019-08-01
2642,MT JULIET HEALTH CARE CENTER,445439,2650 NORTH MT JULIET ROAD,MOUNT JULIET,TN,37122,2019-02-07,684,D,1,0,8DHV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview the facility failed to provide care in accordance with a resident's needs and professional standards of practice for a bowel program for 1 (Resident #10) of 5 residents reviewed. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data ((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 2 people for transfers and toileting; was dependent on 1 person for dressing and bathing; required extensive assistance of 1 person for grooming; required intermittent urinary catheterization; and was always incontinent of bowel. Interview with Resident #1 on 2/5/19 at 10:45 AM in her room revealed she has problems with her bowel program. Continued interview revealed she last had a bowel movement on Tuesday (1/29/19). When she requested the bowel program on Friday (2/1/19) she was told they were too busy. When she asked on Saturday (2/2/29) she waited until 1:00 PM before anyone came to help her. She stated the nurse had long pointed nails and Resident #1 did not want her doing the stimulation. The nurse said she had never done it before and did not seem particularly interested in doing it. Finally someone came to assist her but she still had to wait until afternoon. Interview with the Administrator and Director of Nursing (DON) on 2/6/19 at 12:10 PM in the conference room revealed Resident #1 was used to having her personal caregiver who met her every need as soon as she asked for something. Further interview revealed they have had many care plan meetings to explain to her there are many other residents who also need care so she may have to wait a bit before her needs are met. Continued interview revealed the Administrator and DON confirmed the needs of Resident #1 were not met last weekend with the issues of her bowel program.",2020-09-01
1439,BRIARCLIFF HEALTH CARE CENTER,445260,100 ELMHURST DR,OAK RIDGE,TN,37830,2018-02-14,684,D,1,1,RWU011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview the facility failed to provide services by a Specialty Physician for 1 resident (#23) out of 3 residents reviewed. The findings included: Resident #23 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Interview with Resident #23 on 2/12/18 at 10:37 AM, in his room, confirmed he had an appointment with a specialist. Further interview confirmed the facility had not transported the resident to his appointment. Medical record review of a physician's orders [REDACTED].Refer to spine neurologist for back pain . Interview with the Social Worker on 2/13/18 at 3:50 PM, in her office, confirmed the Nurse who signed the physician's orders [REDACTED]. Continued interview confirmed the facility failed to schedule the appointment. Interview with the Director of Nursing on 2/14/18 at 9:35 AM, in her office, confirmed the facility failed to make an appointment with the Neurologist for Resident #23.",2020-09-01
3734,ALLENBROOKE NURSING AND REHABILITATION CENTER,445485,3933 ALLENBROOKE COVE,MEMPHIS,TN,38118,2017-03-02,315,D,1,0,CJSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview the facility failed to provide timely care and services for 1 of 1 (Resident #13) sampled residents reviewed for Urinary Tract Infection [MEDICAL CONDITION]. The findings included: Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Repeat UA (urinalysis) with C & S (culture and sensitivity) . The lab report of the C&S collected on 10/23/16 and reported on 10/25/16 documented, .THE FOLLOWING TEST (S) WERE REQUESTED AND NOT PERFORMED DUE TO THE REASON LISTED BELOW .UA C& .S SPECIMEN WAS RECEIVED WITHOUT A 2ND PATIENT IDENTIFIE (identifier) . A physician's orders [REDACTED].REPEAT UA WITH C&S FOR P/U (pick up) IN THE AM . The C&S lab results collected on 10/27/16 at 7:37 and reported 10/29/16 at 1:42 documented, > (greater than) 100,000 CFU (colony forming units)/ ML (milliliter) ESBL ( Extended Spectrum Beta-Lactamase) Producing [DIAGNOSES REDACTED] pneumoniae . Telephone interview with the (Named Laboratory Company) Customer Service Representative (CSR) #1 on 1/18/16 at 10:00 AM, CSR #1 was asked about the C & S lab results dated 10/25/16. CSR #1 stated, .The specimen has to have .2 patient identifiers, the name and either the date of birth or social . CSR #1 was asked if the specimen had 2 patient identifiers. CSR #1 stated, It did not have it on the specimen, had to send .notification so they can recollect and call for pick up Interview with the Director of Nursing (DON) on 1/18/16 at 10:30 PM, in the Admissions office, the DON reviewed the lab specimen dated 10/25/16. The DON was asked if the urine for the C & S should be labeled with 2 patient identifiers. The DON stated, Yes .",2020-03-01
3730,ALLENBROOKE NURSING AND REHABILITATION CENTER,445485,3933 ALLENBROOKE COVE,MEMPHIS,TN,38118,2017-03-02,280,D,1,0,CJSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview the facility failed to revise the comprehensive care plan to reflect the current status for Activities, Activities of Daily Living (ADL's) and [DIAGNOSES REDACTED].#3 and 219) sampled residents reviewed of the 45 residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #3 was admitted to the facility on ,[DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 9/21/15 and updated 9/27/16 documented, .Need assistance to perform activity tasks does have left sided weakness and impaired vision in left eye Affect is flat .Potential for social isolation prefer setting within room watching tv. Invite and escort to activity interests . Interview with the Minimum Data Set (MDS) Nurse #2 on 3/1/17 at 4:05 PM, in the MDS office, MDS Nurse #2 was asked how often care plans should be updated. MDS Nurse #2 stated, Quarterly MDS Nurse #2 was asked if the care plan for activities had been revised. MDS Nurse #2 stated, The Activities Director (AD) does that. Interview with the AD on 3/1/17 at 4:10 PM, in the MDS office, the AD was asked if the care plan had been reviewed last quarter. The AD stated, No. The AD was asked if the care plan for activities that was last revised on 9/27/16 was current. The AD stated, No, it is not current. The Care plan dated 9/18/15 and updated 9/27/16 documented, .Self Care Deficit related to inability to independently perform ADLs secondary to cognitive and physical deficit. Hx (History) of Dementia, Late [MEDICAL CONDITION] . Interview with MDS Nurse #2 and the MDS Coordinator on 3/1/17 at 5:35 PM, in the MDS office, MDS Nurse #2 was asked if the care plan had been revised. MDS Nurse #2 stated, No. The MDS Coordinator was asked when should the care plan be revised. The MDS Coordinator stated, In December. 2. Medical record review revealed Resident #219 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the Kidney Care Center . form dated 4/18/16 documented, CKD ([MEDICAL CONDITION]) Stage 3 Stable . The care plan revised on 6/22/16 did not reflect the [DIAGNOSES REDACTED]. Interview with the MDS Coordinator on 1/12/17 at 10:15 AM, in the MDS office, the MDS Coordinator was asked if the [DIAGNOSES REDACTED]. The MDS Coordinator reviewed the care plan and stated, I don't see it. The MDS Coordinator was asked if she would expect it to be care planned. The MDS Coordinator stated, Yes.",2020-03-01
3747,WHARTON NURSING HOME,445510,878-880 WEST MAIN STREET,PLEASANT HILL,TN,38578,2017-03-22,282,D,1,0,PSV011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview the facility failed to update the care plan after a fall for 1 resident (#1) of 4 residents reviewed for accidents. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a Brief Interview Mental Status score of 11 (moderate cognitive impairment). Continued review revealed the resident required extensive assistance with transfers, dressing, and personal hygiene with 1-2 person assist. Review of a facility incident report dated 1/6/17 revealed Resident #1 was found on the floor in her room. Continued review revealed the facility intervention was to to encourage the resident to remain in the living area when not in bed. Interview with the Assistant Director of Nursing on 3/7/17 at 3:30 PM, in the MDS office, confirmed the facility failed to update the resident's care plan with the new intervention after the resident's fall on 1/6/17.",2020-03-01
4073,BOULEVARD TERRACE REHABILITATION AND NURSING HOME,445235,1530 MIDDLE TENNESSEE BLVD,MURFREESBORO,TN,37130,2016-11-08,428,D,1,0,W7SN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview the pharmacy failed to notify the attending physician and Director of Nursing (DON) regarding low trough (blood levels) levels of the monitored intravenous (IV) antibiotic (Vancomycin) for 1 resident (#1) of 7 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the (MONTH) and (MONTH) (YEAR) Medication Administration Records revealed Resident #1 missed doses of Vancomycin 1000 mg, an intravenous (IV) antibiotic, on 9/21/16, 9/24/16, 9/26/16, 9/27/16, 9/28/16, 9/30/16, 10/3/16, 10/10/16, 10/11/16, 10/12/16, and 10/18/16. Further medical record review of lab results revealed the IV trough level to be low on 9/21/16 level was 6.7 with normal range of 10 - 20, 9/26/16 level was 5.99 with a normal range of 10 - 20, 10/3/16 level was 8.47 with a normal range of 10 - 20, 10/10/16 level of less than 5 with a normal range of 10 - 20, and 10/13/16 level of 4 with a normal range of 5 - 40. Interview with the Medical Director on 11/7/16 at 2:45 PM per telephone, confirmed he nor his nurse practitioner were notified by the pharmacy of the low blood levels of his IV antibiotic. Interview with the Pharmacist, on 11/7/16 at 3:30 PM per telephone, confirmed that on 10/10/16, 10/13/16, and 10/18/16 the pharmacist told the nursing staff the physician needed to be contacted regarding the missed doses of the Vancomycin and repeated low trough levels. The Pharmacist stated that trough levels were to be drawn 48 hours after starting the medication and 48 hours after each doses changes. Review of the medical record revealed the trough levels were drawn appropiately but the physican was never notified. The pharmacist stated the nurses told told her the troughs were low because of the missed doses of Resident's #1 Vancomycin. Interview with the Pharmacist, on 11/8/16 at 11:10 AM per telephone, confirmed the pharmacy only requests that facilities notify physicians about lab work and never contacts them directly. She stated they do not have contact information for all their ordering physicians and rely on the facilities to talk with them. Interview with the Administrator on 11/8/16 at 11:30 AM in the conference room, confirmed the physician and DON were not notified by the pharmacy regarding low trough levels.",2019-11-01
4011,"AGAPE NURSING AND REHABILIATION CENTER, LLC",445162,505 N ROAN STREET,JOHNSON CITY,TN,37604,2016-12-22,309,D,1,0,C3FJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, it was determined the facility failed to provide sufficient discharge preparation for home health services and an antibiotic was not administered as ordered for one Resident (#1) of five Residents reviewed. The findings included: Medical record review of a Record of Admission and a Client [DIAGNOSES REDACTED].#1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Discharge Summary and Skilled-Long Term Care Orders dated 10/26/2016 revealed Resident #1 was admitted to the hospital on [DATE] with [MEDICAL CONDITION] secondary to her right lower extremity wounds. Intravenous (IV) antibiotics were started on 10/22/2016 and administered through a Midline IV Catheter. Infectious Disease (ID) was involved in Resident #1's care due to the resistant bacteria in her leg wound and recommended treatment with [MEDICATION NAME] for a period of two weeks. Continued review revealed, Resident #1 received the 10/26/2016 dose of [MEDICATION NAME] prior to discharge. Further review revealed, upon discharge from the hospital to the facility, Resident #1 needed an additional 10 days of [MEDICATION NAME]. Medical record review of a Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the discharge from the facility was planned. Medical record review of a Physician's Telephone Order dated 10/26/2016 revealed an order for [REDACTED]. Medical record review of an Interdisciplinary Progress Note dated 10/31/2016, at 10:54 AM, and completed by the Director of Social Services (DSS), revealed, .Resident is requesting to be discharged home today . Medical record review of a Physician's Telephone Order dated 10/31/2016, at 4:49 PM, revealed, Discharge home with home health .skilled nsg (nursing) . Continued review of the Interdisciplinary Progress Notes on 10/31/2016, at 4:50 PM, revealed, .Resident discharged home . Medical record review of an Interdisciplinary Progress Note dated 10/31/2016 at 4:50 PM, revealed, : .Resident discharged home with son . Medical record review of a prescription pad sheet with an order dated 11/1/2016 and signed by the facility's Nurse Practitioner revealed, .(Home Health Provider) (#2) to begin services 11/2/16 d/t (due to) change in provider services for HH (Home Health). Will need IV [MEDICATION NAME] 1 GM (gram) until 11/6/16 D/T (due to) missed dose today . Telephone interview with the Care Transition Coordinator with Home Health Provider (HHP) #1 on 12/14/2016 at 6:50 PM, revealed the HHP (#1) had provided services for Resident #1 in the past. Continued interview revealed HHP #1's business hours of operation are Monday through Friday from 8:00 AM, to 5:00 PM. Further interview confirmed the facility's DSS did not notify HHP #1 until 11/1/2016, which was the day after Resident #1 was discharged from the facility. Continued interview confirmed HHP #1 declined to provide home health services for Resident #1 and recommended the facility notify another HHP. Interview with the DSS on 12/14/2016 at 7:00 PM, in the Conference Room revealed the DSS stated, (HHP #1) had seen (Resident #1) in the past, I assumed they would again .so I called them (HHP #1) on 11/1/2016 .they refused to provide home health to (Resident #1) .recommended I call another home health (provider) . Continued interview revealed the DSS notified HHP #2 on 11/1/2016 and HHP #2's services were not initiated until the next day on 11/2/2016. Further interview confirmed the DSS was notified by Resident #1 on the morning of 10/31/2016 (at 10:54 AM), but the DSS failed to ensure home health services were arranged prior to Resident #1's discharge on 10/31/2016. Telephone interview with Registered Nurse #1 with HHP #2 on 12/14/2016 at 8:00 PM confirmed Resident #1's start of care date for home health services, including the IV [MEDICATION NAME], was 11/2/2016. Continued interview confirmed the Resident was discharged from home health services on 11/18/2016. Telephone interview with the facility's Nurse Practitioner on 12/14/2016 at 8:55 PM, confirmed the administration of the IV [MEDICATION NAME] was necessary to treat the Resident's infection and should not have been missed on 11/ . Continued interview confirmed the order for the [MEDICATION NAME] was extended from 11/5/2016 to 11/6/2016 due to the missed dose. Interview with the Administrator on 12/14/2016 at 9:27 PM, in the Conference Room, confirmed the facility failed to ensure timely arrangements for home health services prior to the Resident #1's discharge on 10/31/2016. Continued interview confirmed the facilities failure resulted in the [MEDICATION NAME] not being administered on 11/1/2016, as ordered.",2019-11-01
4010,"AGAPE NURSING AND REHABILIATION CENTER, LLC",445162,505 N ROAN STREET,JOHNSON CITY,TN,37604,2016-12-22,204,D,1,0,C3FJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, it was determined the facility failed to provide sufficient discharge preparation for home health services for one Resident (#1) of five Residents reviewed. The findings included: Medical record review of a Record of Admission and a Client [DIAGNOSES REDACTED].#1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1's Brief Interview for Mental Status (BIMS) score was 15 on a scale of zero-to-15, with 15 being the highest score achievable to indicate an intact cognition. Continued review revealed the Resident required limited assistance with all Activities of Daily Living (ADLs) except eating and bathing; and Resident #1 was independent with eating and required extensive assistance with bathing. Further review of the MDS Assessment revealed the discharge from the facility was planned. Medical record review of an Interdisciplinary Progress Note dated 10/31/2016, at 10:54 AM, and completed by the Director of Social Services (DSS), revealed, .Resident is requesting to be discharged home today . Medical record review of a Physician's Telephone Order dated 10/31/2016, at 4:49 PM, revealed, Discharge home with home health .skilled nsg (nursing) . Continued review of the Interdisciplinary Progress Notes on 10/31/2016, at 4:50 PM, revealed, .Resident discharged home . Medical record review revealed no documentation a home health provider was notified to arrange skilled nursing services, prior to, or on the day of, the Resident's discharge on 10/31/2016. Medical record review of a prescription pad sheet with an order dated 11/1/2016 and signed by the facility's Nurse Practitioner revealed, .(Home Health Provider) to begin services 11/2/16 d/t (due to) change in provider services for HH (Home Health) . Interview with the DSS on 12/14/2016 at 4:26 PM, in the Conference Room, revealed the DSS coordinated planned discharges and included arranging home health services for post-discharge care, as ordered. Further interview revealed the DSS stated, .Most people d/c'd (discharged ) to home from here need home health .it's rare that they don't . Telephone interview with the Care Transition Coordinator with Home Health Provider (HHP) #1 on 12/14/2016 at 6:50 PM, revealed the HHP (#1) had provided services for Resident #1 in the past. Continued interview confirmed the facility's DSS did not notify HHP #1 until 11/1/2016 (the day after Resident #1 was discharged from the facility). Continued interview confirmed HHP #1 declined to provide home health services for Resident #1 and recommended the facility notify another HHP. A second interview with the DSS on 12/14/2016 at 7:00 PM, in the Conference Room revealed the DSS stated, (HHP #1) had seen (Resident #1) in the past, I assumed they would again .so I called them (HHP #1) on 11/1/2016 .they refused to provide home health to (Resident #1) .recommended I call another home health (provider) . Continued interview revealed the DSS notified HHP #2 on 11/1/2016 and HHP #2 services were initiated on 11/2/2016, as ordered. Further interview confirmed the DSS was made aware of the intended discharge on the morning of 10/31/2016 at 10:54 AM, but failed to ensure home health services were arranged prior to Resident #1's discharge on 10/31/2016 at 4:50 PM (approximately six hours later). Telephone interview with Registered Nurse #1 with HHP #2 on 12/14/2016 at 8:00 PM confirmed Resident #1's start of care date for home health services was 11/2/2016 (two days after discharge from the facility). Continued interview confirmed the Resident was discharged from home health services on 11/18/2016. Interview with the Administrator on 12/14/2016 at 9:27 PM, in the Conference Room, confirmed the facility failed to ensure sufficient preparation and arrange home health services prior to the Resident's discharge on 10/31/2016.",2019-11-01
4268,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2016-10-13,278,D,1,1,LFXZ11,"**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 respiratory therapy for 2 of 31 (Residents #96 and 146) sampled residents reviewed of the 36 residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented Resident #96 had not received respiratory therapy during the past seven days. The quarterly MDS dated [DATE] documented Resident #96 had not received respiratory therapy during the past 7 days. The respiratory notes documented respiratory care was provided by the Respiratory Therapist (RT) on 3/31/16-4/7/16 and 9/22/16-9/29/16. Observations in Resident #96's room on 10/3/16 at 4:40 PM, and 10/11/16 at 5:30 PM, revealed RT #1 was performing suctioning and [MEDICAL CONDITION] care for Resident #96. The MDS assessments failed to reflect the respiratory care that was being provided to the resident. 2. Medical record review revealed Resident #146 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] documented Resident #146 was severely cognitively impaired, was totally dependent on staff for all ADLs, received oxygen, suctioning, and [MEDICAL CONDITION] care, and did not received respiratory therapy in the past 7 days. The RT notes documented respiratory care was provided by an RT 9/13/16-9/21/16 Interview with LPN #8 on 10/4/16 at 2:30 PM, in the 3rd floor MDS office, LPN #8 was asked whether the quarterly MDS dated [DATE] was accurate related to no RT. LPN #8 stated, No. It will have to be modified.",2019-10-01
1179,BOULEVARD TERRACE REHABILITATION AND NURSING HOME,445235,1530 MIDDLE TENNESSEE BLVD,MURFREESBORO,TN,37130,2018-03-07,641,D,1,1,K5H011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to accurately assess the swallowing impairment for 1 of 31 residents reviewed (Resident #121). Findings include: Medical record review revealed Resident #121 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a Pureed diet had been ordered and Speech Therapy was ordered to evaluate and treat. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #121 had no swallowing impairment and was on a mechanically altered texture diet. Interview with the Speech Therapist on 3/7/18 at 12:08 PM in the rehabilitation department confirmed Resident #121 was evaluated on 12/15/17. Further interview confirmed Resident #121 had been evaluated to have swallowing impairment and required a pureed diet for safe eating. Further interview revealed the therapy was discontinued on 12/26/17 and the resident's ability to swallow had not changed or improved from the time of the evaluation. Interview with the Director of Nursing on 3/7/18 at 3:07 PM in the conference room confirmed the resident had swallowing difficulties. Further interview confirmed the MDS dated [DATE] failed to identify the swallowing impairment.",2020-09-01
3729,ALLENBROOKE NURSING AND REHABILITATION CENTER,445485,3933 ALLENBROOKE COVE,MEMPHIS,TN,38118,2017-03-02,278,D,1,0,CJSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) for unnecessary medications and [DIAGNOSES REDACTED].#9,140 and 219) sampled residents of the 45 residents included in the stage 2 review. 1. Medical record review revealed Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of History of Urinary Tract Infections, Dementia without Behavioral Disturbance, [MEDICAL CONDITION] Disorder, [MEDICAL CONDITIONS] Fibrillation, Pain in Right and Left Knee, [MEDICAL CONDITION], Anxiety Disorder, Pain in Right Hip, Gastro-[MEDICAL CONDITION] Reflux Disease, Idiopathic Chronic Gout, Vitamin D Deficiency, Chest Pain, [MEDICAL CONDITIONS], Obesity, [MEDICAL CONDITION] Disorder, and Chronic Peripheral [MEDICAL CONDITION]. a. The (MONTH) (YEAR) MAR indicated [REDACTED] .[MEDICATION NAME] 20 MG TABLET .ONE TAB BY MOUTH TWICE DAILY . was administered on 12/17/16 to 12/22/16. .[MEDICATION NAME] ER (extended release) 450 MG .ONE BY MOUTH TWICE DAILY . was administered on 12/17/16 to 12/22/16. .XARELTO 10 MG TABLET .ONE TABLET BY MOUTH DAILY . was administered on 12/17/16 to 12/22/16. .[MEDICATION NAME] 1 MG TABLET ONE .BY MOUTH DAILY . was administered on 12/17/16 to 12/22/16. .[MEDICATION NAME] 20 MG TABLET .ONE BY MOUTH EVERY DAY . was administered 12/17/16 to 12/22/16. .[MEDICATION NAME] 1 GM (Gram) VIAL GIVE ONE IM (INTRAMUSCULAR) EVERYDAY TIMES 14 DAYS . was administered 12/17/16 to 12/22/16. .[MEDICATION NAME] .100 MG .GIVE ONE CAPSULE BY MOUTH EVERY NIGHT . was administered 12/17/16 to 12/22/16. Review of the quarterly MDS dated [DATE] revealed antipsychotic, antianxiety, anticoagulant, antibiotic, and diuretic medications were coded as being administered for 7 days. [MEDICATION NAME] ER, Xarelto, [MEDICATION NAME], and [MEDICATION NAME] were administered for a total of 6 days during the 7 day look back period. Interview with MDS Nurse #1 on 1/18/17 beginning at 3:20 PM, in the MDS office, MDS Nurse #1 was asked how the medications should be coded on the MDS. MDS Nurse #1 confirmed the medications should be coded for 6 days. b. Review of the medical record revealed an admitting [DIAGNOSES REDACTED].#9 was receiving [MEDICATION NAME] 1 mg daily. Review of the quarterly MDS dated [DATE] revealed no [DIAGNOSES REDACTED]. Interview with MDS Nurse #1 on 1/18/17 beginning at 3:20 PM, in the MDS office, MDS Nurse #1 was asked if the MDS should be coded for anxiety. MDS Nurse #1 stated, Yes. c. The Medication Administration Record [REDACTED].XARELTO 10 MG (milligrams) TABLET .1 tablet by mouth daily . was administered on 3/11/16 to 3/15/16. Xarelto was administered for a total of 6 days during the 7 day look back period. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed anticoagulants were coded as being administered for 7 days. Interview with MDS Nurse #1 on 1/18/17 at 3:20 PM, in the MDS office, MDS Nurse #1 reviewed the MARs and was asked how Xarelto should be coded on the MDS. MDS Nurse #1 stated, 6. MDS Nurse #1 was asked if the MDS was coded correctly. The MDS Nurse #1 stated, Uh-uh (No). 2. Medical record review revealed Resident #140 was admitted to the facility on [DATE] with diagnoses of Diabetes Mellitus, Convulsions, Gastro-[MEDICAL CONDITION] Reflux Disease, [MEDICAL CONDITION], Hypertension, Dementia with Behavioral Disturbances, [MEDICAL CONDITIONS] Disease, and [MEDICAL CONDITION] Disorder. The Physician order [REDACTED].[MEDICATION NAME] 25 mg tablet give one tablet daily by mouth daily . The quarterly MDS dated [DATE] did not document Resident #140 received diuretics. Interview with MDS Coordinator on 3/1/17 at 11:47 AM, in the conference room, the MDS Coordinator was asked if the MDS was accurate for the diuretic. The MDS Coordinator stated, .the diuretic should be coded for the diuretic .it is inaccurate . 3. Medical record review revealed Resident #219 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of Pneumonitis due to Inhalation of Food and Vomit, Encounter for Attention to Gastrostomy, Adult Failure to Thrive, Non Pressure Chronic Ulcer of Left Heel and Mid Foot, Hypertension, [MEDICAL CONDITIONS] Stage 3, Immune [MEDICAL CONDITION] Purpura, Enlarged Prostate, [MEDICAL CONDITION], Hearing Loss, Dysphagia, Dementia without Behavioral Disturbance, and Other Mental Disorders Due to Known Physiological Conditions. Review of the Kidney Care Center . form dated 4/18/16 documented, CKD ([MEDICAL CONDITION]) Stage 3 Stable . Review of the quarterly MDS dated [DATE] did not reflect the [DIAGNOSES REDACTED]. Interview with MDS Nurse #1 on 1/12/17 at 10:20 AM, in the MDS office, MDS Nurse #1 was shown the MDS and was asked if the MDS should be coded for the [DIAGNOSES REDACTED].#1 stated, It is not there. MDS Nurse #1 was asked if you would expect it to be on the MDS. MDS Nurse #1 stated, You would.",2020-03-01
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
5424,ETOWAH HEALTH CARE CENTER,445422,"409 GRADY ROAD, PO BOX 957",ETOWAH,TN,37331,2016-03-22,329,D,1,0,MXJV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to address a recommendation timely by Psychiatric services to provide a gradual dose reduction in an effort to discontinue an antipsychotic medication resulting in the continued use of an unnecessary drug for 1 resident (#21) The findings included: Medical record review revealed Resident #21 was admitted to the facility on [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was not scored (severely cognitive impaired) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident was coded for other behavioral symptoms not directed toward others. Medical record review of a Psychiatric services visit on 10/19/15 revealed .positive behavioral response to increased [MEDICATION NAME] (antianxiety), decreased anxiety .has been on [MEDICATION NAME] (antipsychotic) over 6 months .recommend GDR (gradual dose reduction) due to poor response, black box warning . Further review revealed the resident was prescribed [MEDICATION NAME] 50 mg BID (twice daily) and the recommended GDR was to decrease the [MEDICATION NAME] to 25 mg (milligrams) every morning and 50 mg at bedtime. Medical record review of a Physician's telephone order dated 10/27/15 revealed .per Psych recommendations decrease [MEDICATION NAME] to 25 mg by mouth every AM and 50 mg by mouth at bedtime . (8 days after the recommendations were made). Interview with the Director of Nursing (DON) and the Social Services Director (SSD) on 3/10/16 at 11:00 AM, in the Conference Room revealed both reported the Psychiatric Nurse Practitioner's recommendations were not implemented timely due to delays in forwarding recommendations to the Physician for review and approval. Continued interview confirmed the facility failed to ensure the Psychiatric Nurse Practitioner recommendations were implemented timely after the recommendation to complete a gradual dose reduction for an antipsychotic.",2019-03-01
5279,SIGNATURE HEALTHCARE OF GREENEVILLE,445351,106 HOLT COURT,GREENEVILLE,TN,37743,2016-04-25,333,D,1,0,LII611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to administer an intravenous (IV) antibiotic as ordered by the physician for 1 resident (#3) with a [MEDICAL CONDITION]-resistant Staph Infection (MRSA) of the Cerebrospinal Fluid (CSF) of 12 residents reviewed. The findings included: Resident #3 was admitted to the facility from the hospital on [DATE] at 3:30 PM with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED].stop date 10/19/15 .Dx (diagnoses)[MEDICAL CONDITION] . Medical record review of the facility's History and Physical dated 10/13/15 revealed the resident was evaluated by Infectious Disease (while in the hospital) for a positive .CSF .culture .was started on IV [MEDICATION NAME] for the infection .was positive for staph . Medical record review of the Medication Administration Record [REDACTED]. Medical record review of a nursing assessment (dated 10/12/15) by the Assistant Director of Nursing (ADON #1) revealed, Unable to give 10 PM dose of [MEDICATION NAME] IV on 12/12/15 .Unable to administer IV [MEDICATION NAME] as ordered due to unavailability from pharmacy . Medical record review of a nurse's note dated 10/13/15 revealed the resident did not receive the 6:00 AM dose of [MEDICATION NAME] on 10/13/15 because the resident had been transferred to the hospital at 3:00 AM to have the Percutaneous Intravenous Central Catheter (PICC) replaced. Interview with the ADON (#1) on 4/12/16 at 6:40 AM in the conference room revealed the resident was admitted to the facility on [DATE] at 3:30 PM. Continued interview confirmed the scheduled dose of [MEDICATION NAME] was not administered at 10:00 PM on 10/12/15 because the medication had not been delivered by the facility's pharmacy.",2019-04-01
5034,CREEKSIDE CENTER FOR REHABILITATION AND HEALING,445516,306 W DUE WEST AVENUE,MADISON,TN,37115,2016-06-16,278,D,1,0,GZPX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to assess the presence of a pressure ulcer on the Minimum Data Set (MDS) for 1 (Resident #1) resident of 12 residents reviewed for pressure ulcers. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE], discharged on [DATE], readmitted on [DATE] and discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Medical record Review of the POS [REDACTED]. Medical record review of the Nursing Admission assessment dated [DATE] at 4:27 AM by Licensed Practical Nurse (LPN) #1 revealed documentation of the presence of a Pressure Ulcer in the skin portion of the assessment for Resident #1. Medical record review of the Nursing Risk assessment dated [DATE] at 9:51 AM revealed it was completed by Registered Nurse (RN) #1. Continued review of the Nursing Risk Assessment revealed a Visual Body Map documenting Resident #1 had an abrasion to the left gluteal coccyx area (low buttock/back area). Medical record review of the Departmental Notes dated 3/17/16 at 10:39 AM revealed LPN #2 documented .late entry for 3/16/16: resident also has noted open area on coccyx . Medical record review of the Skin Inspection Report for Resident #1 dated 3/17/16 revealed Skin Not Intact-Existing by LPN #3. Medical record review of the Skin Concerns Roster dated 3/17/16 at 5:27 PM by RN #1 revealed Yes skin concern-nurse notified. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed no documentation of the presence of a pressure ulcer. Interview with MDS Coordinator LPN #6 on 6/13/16 at 12:30 PM in the MDS office, when asked how the MDS Coordinator obtained information for a comprehensive admission assessment, LPN #6 stated, I look at the wound care information, the wound treatment sheets, nurses notes, hospital documentation, NP (Nurse Practitioner) notes, interviews with the resident, family, and staff. I look at the entire chart. LPN #6 was shown the documentation in the resident's medical record indicating a Stage 1 pressure ulcer was present upon admission. LPN #6 stated, I generally look at the wound care nurse's notes. In hind sight I would make it a Stage I. Continued interview with LPN #6 confirmed the Admission MDS was inaccurate and did not document the presence of a pressure ulcer for Resident #1. Interview with the Director of Clinical Services on 6/15/16 at 9:15 AM in the Conference Room confirmed the MDS nurse should have looked at multiple sources available in the resident's medical record to identify a Stage I pressure ulcer to Resident #1. Continued interview confirmed the facility failed to provide an accurate comprehensive assessment for Resident #1.",2019-06-01
5507,CONCORDIA NURSING AND REHABILITATION -LOUDON,445253,1520 GROVE ST BOX 190,LOUDON,TN,37774,2016-02-04,312,D,1,0,XSZC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to carry out activities of daily living to maintain good personal hygiene for 1 resident (#2) of 4 residents reviewed for [MEDICAL TREATMENT] services. The findings included: Medical record review of Resident #2 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the initial Minimum (MDS) data set [DATE] revealed the resident scored 3/15 (severely cognitive impairment) on the Brief Interview for Mental Status. Further review revealed the resident required extensive assistance for transfer, dressing, and hygiene/bathing and supervision and set up for feeding. Medical record review of the 8/15 Late Loss Activities of Daily Living (ADL) Flow Sheet revealed the resident received extensive assistance with bed mobility, transfers, toilet use until around 8/8/15 the resident was totally dependent on staff. Medical record review of a progress note written by the Director of Nursing (DON) dated 8/31/15 revealed .Called (family) at 2:30 PM to update of his mother. Therapy always dresses (resident) each AM as a part of her therapy. They always dress her prior to her transport to [MEDICAL TREATMENT]. This morning there was discussion about changing the [MEDICAL TREATMENT] time until after lunch because of her receiving more nutrition prior to being dialyzed. Therapy did not dress (resident) awaiting a decision. CNAs went about their duties not knowing therapy was not dressing her. The EMTs (emergency medical technicians) came to transport- they did not look at her to see if she was ready-they did not ask the staff if she was ready-they did not tell the staff they were leaving the facility .I (DON) apologized and was regretful about his family members being upset . Interview with the DON on 2/2/16, at 11:20 AM, in the Family Room, confirmed neither therapy or nursing dressed the resident before the resident was transported to [MEDICAL TREATMENT].",2019-02-01
1352,HARTSVILLE CONVALESCENT CENTER,445256,649 MCMURRY BLVD,HARTSVILLE,TN,37074,2017-09-12,279,D,1,0,9I4J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to complete a comprehensive care plan for 1 resident (#1) of 3 residents reviewed. The findings included: 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's short term memory was intact, was moderately impaired with daily decision making skills, required total assistance of 2 + person for transfers and dressing, total dependence of 1 person for locomotion on and off the unit, and the upper and lower extremity on one side was impaired. Resident #1 had adequate hearing, had no ability to speak, and was able to make herself understood and understood others. Medical record review revealed the only care plan was dated 6/26/17. Interview with MDS Coordinator #1 and #2 on 9/11/17 at 11:30 AM in the conference room confirmed the facility failed to develop a comprehensive care plan from admission through 6/26/17.",2020-09-01
5035,CREEKSIDE CENTER FOR REHABILITATION AND HEALING,445516,306 W DUE WEST AVENUE,MADISON,TN,37115,2016-06-16,279,D,1,0,GZPX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to complete a comprehensive care plan for the care and treatment of [REDACTED].#1) resident of 12 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE], discharged on [DATE], readmitted on [DATE] and discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Medical record Review of the POS [REDACTED]. Medical record review of the Nursing Admission assessment dated [DATE] at 4:27 AM by Licensed Practical Nurse (LPN) #1 revealed documentation of the presence of a Pressure Ulcer for Resident #1. Medical record review of the Nursing Risk assessment dated [DATE] at 9:51 AM revealed it was completed by Registered Nurse (RN) #1. Continued review of the Nursing Risk Assessment revealed a Visual Body Map that documented Resident #1 had an abrasion to the left gluteal coccyx area (low buttock/back area). Medical record review of the Departmental Notes dated 3/17/16 at 10:39 AM revealed LPN #2 documented .late entry for 3/16/16: resident also has noted open area on coccyx . Medical record review of the Skin Concerns Roster dated 3/17/16 at 5:27 PM by RN #1 revealed Yes skin concern-nurse notified. Medical record review of the Skin Inspection Report for Resident #1 dated 3/17/16 revealed Skin Not Intact-Existing by LPN #3. Medical record review of the comprehensive care plan dated 2/16/16 revealed the resident was at risk for skin breakdown. Continued review of the comprehensive care plan revealed no care plan for the care and treatment of [REDACTED]. Interview with Minimum Data Set (MDS) RN #3 and LPN #6 on 6/13/16 at 12:45 PM in the MDS office confirmed the MDS nurses were responsible for initiating the comprehensive care plan upon admission of a resident. Continued interview, in reference to the Stage I pressure ulcer to Resident #1, LPN #6 stated It wasn't mentioned in the MDS and unless the wound nurse or someone else tells us, we weren't aware of the problem. Interview with the Director of Clinical Services on 6/15/16 at 9:15 AM in the Conference Room confirmed the comprehensive care plan for Resident #1 did not address the presence of a Stage 1 pressure ulcer upon admission to the facility on [DATE].",2019-06-01
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
3297,"THE WATERS OF SMYRNA, LLC",445502,202 ENON SPRINGS ROAD EAST,SMYRNA,TN,37167,2017-07-06,514,D,1,0,K8GY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to complete documentation for placement of fall mats for 1 Resident (#1) of 5 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the medication record for (MONTH) (YEAR) revealed .BILATERAL FALL MATS AT BEDSIDE - CHECK PLACEMENT EVERY SHIFT . Continued review revealed the nurse was to initial a box designated by shift for either 6AM to 6PM or 6PM to 6AM. Further review revealed 11 boxes were not initialed from (MONTH) 1 to (MONTH) 28. Interview with the Direcor of Nursing on 6/7/17 at 11:10 AM in her office, after reviewing the order for bilateral fall mats and placement to be checked every shift, when shown the documentation for (MONTH) (YEAR) confirmed the facility had failed to document the checking of placement of fall mats on 11 of 55 shifts for (MONTH) (YEAR) while resident was in the facility.",2020-09-01
692,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2018-03-01,656,D,1,0,4S6V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to develop a Comprehensive Care Plan to address the resident's issues with oral care for 1 resident (#2) of 5 residents reviewed. Findings include: Review of facility policy, Oral Hygiene, undated, revealed .Designated partners will provide care of mouth and teeth to all patients every morning and evening as needed to prevent mouth infections; prevent dental decay; prevent gum disease; and promote personal hygiene .Gently clean patient's teeth .Inspect oral cavity . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5 Day Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 Brief Interview for Mental Status (BIMS) scored as 3 and severely impaired cognitively. Continued review of the MDS revealed Resident #3 was dependent on 2 people for transfers; required extensive assistance of 1 person for dressing, eating; extensive assistance of 2 people for grooming; was dependent on 1 person for bathing; had functional limitations in both lower extremities; was frequently incontinent of bladder and always incontinent of bowel. Medical record review of the Activities of Daily Living (ADL) record revealed documentation Resident #3 received personal hygiene twice daily. Continued review revealed out of 40 opportunities for oral care, it was documented he received care on 24 occasions. Medical record review of a Speech Therapy evaluation dated 11/24/17 revealed Resident #3 had his natural teeth. Continued review revealed he had decreased bolus control (problems swallowing solid food). Further assessment revealed medication from earlier administration was noted in the oral cavity. Medical record review of weights revealed Resident #3 weighed 126 pounds on admission to the facility. Continued review revealed weight on 11/22/17 was 125 pounds; on 11/23/17 weight was 125 pounds. Further review revealed on 11/29/17 weight was 122 pounds and on 12/6/17 weight was 120 pounds. Continued review revealed Resident #3 refused to be weighed on 12/13/17. Medical record review of a Nutrition consult dated 12/4/17 revealed Resident #3 had poor intake, consuming Medical record review of the Care Plan dated 11/22/17 revealed Resident #3 was at risk for alteration in nutritional status/weight loss related to swallowing difficulty; age; polypharmacy; and [MEDICAL CONDITION]. Continued review revealed interventions included to adjust diet consistency as needed; mechanical soft with ground meat with gravy and high calorie diet; nutritional supplements of Ensure Clear 3 times daily with meals and House Supplement twice daily; encourage fluids between meals; adaptive equipment as needed; assist with meals; dietician assessment in progress. Medical record review revealed no documentation of any issues with oral care until 12/11/17 when nursing documented .Attempted to provide oral care on resident. Was able to get swab in mouth after coaching. As soon as swab placed in mouth pt. bit down and would not allow nurse to clean mouth. With help of therapist finally got resident to release bite on swab so it could be removed. Oral care not completed because resident refused . Medical record review of the care plan revealed no documentation of issues with oral care such as pocketing food and biting down on swabs. Medical record review of the Provider Progress Note dated 12/12/17 revealed .One of the daughters is very upset because she feels oral care has not been adequate. However, nursing staff have been very diligent to provide oral care and patient will frequently not except oral care by clenching teeth and biting sponges. Speech Therapy has really worked with patient on this and will be teaching family how to perform oral care as well so patient may respond to a more familiar person. Registered dietitian reports he is still only receiving around 20 bites of food an hour. Patient frequently pockets food in this puts him at great risk for aspiration pneumonia. Labs showed he was maintaining renal function okay, no dehydration notes. Failure to thrive - patient's prognosis is poor and not likely to make meaningful recovery . Medical record review of a Provider Progress Note dated 12/19/17 revealed .Diligent oral care has been attempted but patient will frequently clench and bite sponges which make cleaning difficult for nursing staff. Patient also pockets food in this puts him at great risk for aspiration pneumonia. Unfortunately he is experiencing failure to thrive. Patient's daughter is not accepting of this diagnosis . Interview with the Director of Nursing (DON) on 2/14/18 at 11:55 AM in the conference room revealed staff had tried to perform oral care for Resident #2 but he clamped down on the swab or anything placed in his mouth. Continued interview with the DON confirmed the care plan did not include the fact Resident #2 pocketed his food and also he clamped down on the swab. Further interview confirmed there were no interventions for addressing these issues.",2020-09-01
2500,"NHC HEALTHCARE, FARRAGUT",445415,120 CAVETT HILL LANE,KNOXVILLE,TN,37922,2017-10-25,279,D,1,1,1WES11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to develop a comprehensive care plan for 1 resident (#366) of 3 residents reviewed for accidents, of 23 sampled residents. The findings included: Medical record review revealed Resident #366 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) 5 Day Scheduled assessment dated [DATE], revealed Resident #366 required extensive assistance with activities of daily living (ADLs) and 2 person physical assist for transfers. Medical record review of Resident #366's Completed Care Plan dated 8/30/17, revealed, . Safety/Potential for falls .Goal .desires to be safe and will have no falls .inability to perform all ADL tasks without staff assistance .assist with ADLs .limited in .functional transfers .assist patient with mobility/transfers . Medical Record review of the MDS Unscheduled assessment dated [DATE], revealed Resident #366 required extensive assistance with ADLs and 2 person physical assist for transfers. Medical record Review of the POS [REDACTED].transfer from recliner to wheelchair and patient was facing recliner with wheelchair behind her when patients knees seemed to buckle. Patient's legs gave out and patient started going down .gently lower patient to knees on the floor . Continued review revealed, .immediate interventions .2 person assist for all transfers . Medical Record review of the Daily Skilled Nursing Notes dated 9/30/17 at 10:00 PM, revealed, .fall/let down to floor .(no) injuries noted .new intervention to have assist (2 person) for all transfers . Interview with Registered Nurse #1 on 10/24/17 at 3:55 PM, in the conference room, confirmed the MDS assessment was accurate and the resident required 2 persons for transfers. Interview with the Director of Nursing on 10/24/17 at 4:39 PM, in the conference room, confirmed, .it (MDS) should match (the care plan) .we need to be able to follow the care plan . Continued interview confirmed the facility failed to develop a comprehensive care plan that addressed the functional transfer needs for Resident #366, based on the comprehensive MDS assessment.",2020-09-01
2827,FOUR OAKS HEALTH CARE CENTER,445458,1101 PERSIMMON RIDGE RD,JONESBOROUGH,TN,37659,2017-10-04,280,D,1,1,MVC111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to develop an individualized plan of care to identify required assistance for the transfer needs of 1 resident (#62) of 3 residents reviewed for accidents. The findings included: Medical record review revealed Resident #62 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 of Mental Status (BIMS) of 3 (indicating severe cognitive impairment). Continued review revealed Resident #62 had been assessed for functional status with transfers (how the resident moves between surfaces including to or from bed/chair, wheelchair, or standing position) at a 4 indicating total dependence and required 2 plus persons for physical assistance. Review of the Care Plan dated 9/22/16 with a goal date of (MONTH) (YEAR), revealed, .Problem/Need .ADL (Activities of Daily Living) - Resident requires assistance with and/or provision for ADL's - Dx (diagnosis) of Dementia, generalized weakness, decreased mobility. Continued review of the Care Plan Approaches (interventions) revealed, .assist with ADL's as needed. Continued review of the Care Plan for Falls revealed, .Risk for falls due to hx (history) of falls, generalized weakness, non-ambulatory, decreased mobility, decreased safety awareness, Dx dementia. Review of the Approaches (to prevent falls) revealed, .Assist with ADL/transfers as needed . Continued review of the Care Plan revealed no resident-specific guidance for transfer assistance for Resident #62. Review of the Certified Nurse Aide (CNA) Completed Care Task documentation dated 7/28/17 and 7/29/17 revealed Resident #62 had been transferred on these dates with the assistance of two persons and the assistance of one person. Medical record review of nurse's entry dated 7/29/17 at 12:03 PM, revealed Resident #62 .noted to have swelling, bruising, and warmth to left lower leg mid-calf, noted tightness of muscle with palpation .new order .ultrasound of LLE (left lower extremity) . Further review revealed Resident #62 was transferred to the hospital per family request at 1:34 PM. Medical record review of the emergency department history and physical dated 7/29/17 revealed .X-ray of left lower extremity shows comminuted [MEDICAL CONDITION] tibia .severe knee [MEDICAL CONDITION] .no surgical interventions planned . Interview with the MDS Coordinator #1 on 10/3/17 at 3:40 PM, in the MDS office confirmed the MDS assessment dated [DATE] was coded correctly for transfer needs requiring total dependence and 2 plus persons for physical assistance. Further interview with the MDS Coordinator #1 confirmed she was responsible for the development of the Care Plans and failed to develop individualized interventions for Resident #62 to address her total dependence on 2 person assistance for transfer needs. Interview with the Director of Nursing on 10/3/17 at 5:50 PM, in the Conference Room, confirmed the facility failed to individualize the care plan to meet the specific needs for transfer assistance for Resident #62.",2020-09-01
4072,BOULEVARD TERRACE REHABILITATION AND NURSING HOME,445235,1530 MIDDLE TENNESSEE BLVD,MURFREESBORO,TN,37130,2016-11-08,333,E,1,0,W7SN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to ensure 1 resident (#1) was free of a significant medication error, of 7 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the (MONTH) and (MONTH) (YEAR) Medication Administration Records revealed Resident #1 missed doses of [MEDICATION NAME] 1000 mg, an intravenous (IV) antibiotic, on 9/21/16 at 9:00 PM, ordered twice a day and missed due to waiting on lab work, 9/24/16 at 12:00 PM, ordered three times a day and missed due to resident refused, 9/26/16 at 8:00 AM orderd three times a day and missed due to PICC line was discontinued, 9/27/16 at 9:00 PM ordered three times a day and missed due to waiting on labwork, 9/28/16 at 3:00 PM ordered three times a day and missed due to he was out of the facility, 9/30/16 at 3:00 PM ordered three times a day and missed due to no documented reason, 10/3/16 at 9:00 AM ordered three times a day and missed due to waiting on labwork, 10/10/16 at 3:00 PM ordered three times a day and missed due to unknown reason, 10/11/16 at 8:00 AM ordered three times a day and missed due to he was out of the facility, 10/12/16 at 4:00 PM ordered three times a day and missed due to he was out of the facility, and 10/18/16 at 9:00 AM ordered twice a day and missed due to undocumented reason. Interview with the Medical Director on 11/7/16 at 2:45 PM per telephone, confirmed his expectation is that all ordered doses of a medication, especially intravenous antibiotics, would be given as ordered. Interview with the RN Unit Manager, on 11/7/16 at 3:10 PM in the conference room, confirmed Resident #1 had missed 11 doses of his ordered IV antibiotic. Interview with the Administrator on 11/8/16 at 9:00 AM in the conference room, confirmed Resident #1 missed 11 doses of his ordered IV antibiotic, resulting in a significant medication error.",2019-11-01
2112,LAUDERDALE COMMUNITY LIVING CENTER,445354,215 LACKEY LANE,RIPLEY,TN,38063,2017-05-05,312,E,1,0,QMFO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to ensure Activities of Daily Living (ADL) were performed for 2 of 3 (Resident #50 and #61) sampled residents reviewed of the 34 included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #50 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 1/6/16 and revised on 11/1/16, documented, Focus .resident has an ADL SELF PERFORMANCE deficit r/t (related to) Dementia, Confusion; as evidenced by need for staff cueing and direction with daily tasks .Interventions .BATHING: Per shower schedule. Provide with up to extensive staff assistance with bathing . The quarterly MDS dated [DATE] was coded severely cognitively impaired for daily decision making, required extensive assistance with personal hygiene and supervision with bathing. Review of the (MONTH) (YEAR) ADL documentation flow record revealed there was no documentation that bathing was provided 26 of 30 days in April: 1, 2, 3, 4, 5,6, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 20, 21, 22, 23, 24, 25, 27, 28, 29, and 30. Interview with Licensed Practical Nurse (LPN) #6 on 4/28/17 at 10:20 AM, in the C unit, LPN #6 was asked how often Resident #50 was bathed. LPN #6 stated, I think they do every other day .gets her bath on Monday, Wednesday and Friday on 1st shift . LPN #6 was shown Resident's #50 bathing schedule that had been documented for (MONTH) and was asked what days Resident #50 received her bath or shower. LPN #6 stated, .Bed bath on the 7th .Bed bath on the 14th .19th shower . LPN #6 was asked how often residents were supposed to be bathed or showered. LPN #6 stated, .every resident is scheduled three days a week . Interview with Certified Nursing Assistant (CNA) #8 on 4/28/17 at 10:45 AM, in the C hall, CNA #8 was asked how often Resident #50 received a bath/shower. CNA #8 stated, .three times a week .second shift Monday, Wednesday and Friday . CNA #8 was asked for the schedule and documentation of Resident #50's showers. CNA #8 stated, Shows she is on the 1st shift .but the girl on the second shift gives it to her . CNA #8 was asked if the staff does not go by the shower list. CNA #8 stated. Yes .but when they moved her back here .was told she was on the second shift . CNA #8 was asked how long Resident #50 had been moved back to C hall. CNA #8 stated, .Two months . CNA #8 was shown Resident #50's shower sheet and asked how many baths/showers she received between (MONTH) 1st and the 24th. CNA #8 stated .three . CNA #8 was asked if she should have had more bath/showers than that. CNA #8 stated, Yes, supposed to get them 3 times a week . Interview with the Director of Nursing (DON) on 4/28/17 at 11:03 AM, in the DON's office, the DON was shown Resident #50's shower list and asked when Resident #50 was supposed to have her shower. The DON stated, Monday, Wednesday and Friday on first shift. The DON was shown the bath/shower documentation for Resident #50 and was asked the dates Resident #50 had a bath or shower for the month of April. The DON stated, (MONTH) the 7th bed bath .April 14th bed bath .April 19th shower .April 26th had a bed bath . The DON was asked if Resident #50 received a bath or shower three times a week. The DON stated, According to this she is not . The DON was asked could she provide bath sheets that showed Resident #50 had refused her bath or shower. The DON was unable to provide documentation that Resident #50 had refused any baths or showers and stated, I know what happened, her room changed and the shower list was not updated . 2. Medical record review revealed Resident #61 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 11/18/16 and revised on 4/12/17 documented, Focus .resident has an ADL self-care performance deficit r/t [MEDICAL CONDITION] resulting in Right Sided Weakness and [MEDICAL CONDITION]/Dysphagia. Requires up to total staff assistance with daily activity .Interventions .BATHING/SHOWERING: Per shower schedule - provide with up to total staff assistance with this task . The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #61 was severely cognitively impaired for daily decision making, totally dependent on staff for personal hygiene and bath. The Documentation Survey Report documented, .Bathing M (Monday) W (Wednesday) F (Friday) DAY SHIFT . Review of the (MONTH) (YEAR) ADL flow record revealed there was no documentation that bathing was provided on (MONTH) 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, and 24 for Resident #61. There was no documentation that evidenced Resident #61 received baths as scheduled.",2020-09-01
5758,HOLSTON MANOR,445295,3641 MEMORIAL BLVD,KINGSPORT,TN,37664,2015-12-16,313,D,1,1,VDM111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to ensure a resident received eye services and corrective glasses for one resident (#60) of 11 residents reviewed for vision concerns. The findings included: Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an Initial Social Service History completed 8/10/10 revealed .Are there sensory limitations .Is adaptive equipment needed (answer) .Res (resident) wears glasses for .vision impairment . Medical record review of a Social Progress Note dated 3/23/15 revealed .contacted eye doctor to verify last visit .stated they (vision office) would see resident on (MONTH) (YEAR) to fit resident for eye glasses and for exam . Review of an Eye Health Care Progress Note dated 9/30/15 revealed .OD (right eye) 20/25 and OS (left eye) no light perception .new eyeglasses of benefit . Interview with Licensed Practical Nurse #1 on 12/15/15 at 2:46 PM, on the 100 hall, revealed Social Worker #1 brought new nonprescription glasses to the resident for the first time on 12/15/15. Interview with Social Worker #1 and Social Worker #2 on 12/15/15 at 3:09 PM, in the Social Services office, confirmed the resident was to be seen by the eye doctor in (MONTH) but was not seen until 9/30/15. Continued interview confirmed the resident had not been provided with prescription glasses as stated on the 9/30/15 Eye Health Care Progress Note. Interview with the Director of Nursing on 12/15/15 at 4:12 PM, in the conference room, confirmed the facility failed to have the resident seen timely for eye services and failed to provide the glasses for the resident.",2018-12-01
658,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2017-09-14,514,D,1,0,TNU911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to ensure an accurate medical record for one resident (#6) of nine residents reviewed. The findings included: Medical record review revealed Resident #6 was admitted to the facility on [DATE]. Medical record review of the resident [DIAGNOSES REDACTED]. Medical record review of the resident current Medication Administration Record [REDACTED]. Interview and review of resident [DIAGNOSES REDACTED].#6 received the [DIAGNOSES REDACTED]. Further interview confirmed the resident was not hospitalized around the time of the 11/15/16, and was not being treated for [REDACTED]. Continued interview confirmed the resident's medical record was inaccurate.",2020-09-01
1413,SUMMIT VIEW OF ROCKY TOP,445259,204 INDUSTRIAL PARK RD,ROCKY TOP,TN,37769,2019-05-07,745,D,1,0,DIGG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to ensure arrangements for care were complete during an overnight leave from the facility for 1 resident (#1) prior to a leave of 3 residents reviewed. The findings included: Medical record review revealed Resident #1 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 Mental Status score of 15 (cognitively intact). Continued review revealed the resident required extensive assist for transfers, dressing, and toilet use with 1 person assist. Further review revealed the resident was always incontinent of bowel and bladder. Medical record review of Resident #1's care plan dated 1/8/19 revealed the resident required extensive assistance with all activities of daily living and toilet use. Interview with the Director of Nursing (DON) on 5/7/19 at 9:00 AM, in her office revealed .she (Resident #1) told us she was going to spend the night with her son at the hospital (was an inpatient) .she (Resident #1) arranged everything and we planned to send the van to pick her up the next morning . Continued interview confirmed the DON received a call around 11:00 PM on 4/3/19 stating the hospital had called and said the resident was there (hospital) and didn't need to be. Interview with Resident #1 on 5/7/19 at 9:30 AM, in her room revealed .DON gave me permission to stay at the hospital .no I did not talk to anyone at the hospital . Interview with the DON on 5/7/19 at 12:00 PM, in the conference room, revealed .did not contact anyone at the hospital to make sure it was okay for her to stay with her son .looking back I should have .",2020-09-01
1472,AHC CUMBERLAND,445262,4343 ASHLAND CITY HIGHWAY,NASHVILLE,TN,37218,2017-09-13,514,D,1,0,F0U711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to ensure complete and accurate medical records for 5 residents (#1, #2, #3, #4, #5) of 17 residents reviewed. The findings included: 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 scored 15 on the Brief Interview for Mental Status (BIMS) indicating he was alert, oriented, and able to make his needs known. Medical record review of physician's orders [REDACTED].#1 was ordered [MEDICATION NAME] 7.5/325 milligrams (mg) every 6 hours as needed for pain. Review of the Controlled Drug Record revealed on 8/15/17, [MEDICATION NAME] 7.5/325 mg was signed out at 9:00 PM, 10:00 PM, 2:00 AM. Continued review revealed [MEDICATION NAME] was also signed out on 8/16/17 at 6:00 AM. Medical record review of the Medication Administration Record (MAR) revealed [MEDICATION NAME] 7.5/325 mg was documented as administered at 3:40 PM on 8/15/17 and at 1:33 PM on 8/16/17. None of the other times from the evening and night shifts were documented on the MAR. Review of the facility investigation revealed Resident #1 was interviewed on 8/16/17 and stated he received pain medication about 8:30 PM on 8/15/17 but did not receive any pain medication during the night on the 11:00 PM - 7:00 AM shift and he slept through the night. 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 15 on the BIMS indicating she was alert, oriented, and able to make her needs known. Medical record review of physician's orders [REDACTED].#2 was ordered [MEDICATION NAME] 7.5/325 mg every 4 hours as needed for pain. Review of the Controlled Drug Record revealed [MEDICATION NAME] 7.5/325 mg was signed out at 12:00 AM, 2:00 AM, 6:00 AM, 6:45 AM, and 6:55 AM, all by Agency Nurse #1. Continued review of the Controlled Drug Record revealed only 1 tablet was signed out at 12:00 AM but the count was documented as 29 before the tablet was removed and 27 after the tablet was removed. Further review revealed only 1 tablet was signed out at 2:00 AM but the count was documented as 27 before the tablet was removed and 25 after the tablet was removed. Continued review revealed 1 tablet was signed out at 6:00 AM but the count was documented as 25 before the tablet was removed and 23 after the tablet was removed. Further review revealed at 6:45 AM and 6:55 AM Agency Nurse #1 documented removing 2 tablets each time. Medical review of the MAR revealed [MEDICATION NAME] 7.5/325 mg was documented as administered on 8/15 17 at 10:53 PM but nothing was documented for 8/16/17. Review of the facility investigation revealed Resident #2 was interviewed on 8/16/17 and she stated she received pain medication on the 3:00 PM - 11:00 PM shift but did not have any pain medication during the night and was not having any increase in her pain. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual MDS dated [DATE] revealed Resident #3 scored 13 on the BIMS indicating she had slight cognitive impairment. Medical review of physician's orders [REDACTED].#3 was ordered [MEDICATION NAME] 5/325 mg every 12 hours as a scheduled medication. Review of the Controlled Drug Record dated 8/5/17 revealed [MEDICATION NAME] 5/325/mg was signed out at 6:00 PM and 11:00 PM while on 8/6/17 it was signed out at 6:00 AM, 5:00 PM, and 11:00 PM. Continued review revealed on 8/7/17 [MEDICATION NAME] was signed out at 5:30 AM, 9:00 PM, and 11:00 PM while on 8/9/17 it was signed out at 9:30 PM, 10:30 PM, and one was wasted at 11:30 PM. Further review revealed on 8/10/17 [MEDICATION NAME] was signed out at 6:00 AM and on 8/13/17 was signed out at 12:00 AM and 6:00 AM. Continued review revealed on 8/14/17 [MEDICATION NAME] was signed out at 12:00 AM, again for 12:00 AM, 6:00 AM, 6:30 AM, and 6:50 AM. Further review revealed on 8/15/17 [MEDICATION NAME] was signed out at 4:00 PM and 10:00 PM while on 8/16/16 it was signed out at 12:00 AM, 6:00 AM, and 6:45 AM. All of these removals were signed out by Agency Nurse #1. Medical record review of the MAR revealed the only documentation of administration of [MEDICATION NAME] was 8/7/17 at 5:30 AM. There was no documentation for the rest of the tablets of [MEDICATION NAME] which were removed. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE] revealed Resident #4 scored 15 on the BIMS, indicating he was alert, oriented, and able to make his needs known. Medical record review of physician's orders [REDACTED]. Review of the Controlled Drug Record revealed on 8/5/17 [MEDICATION NAME] was signed out at 6:15 PM and 11:45 P0 AM; on 8/12/17 it was signed out at 2:00 AM; on 8/13/17 it was signed out at 3:15 AM; on 8/14/17 it was signed out at 12:00 AM and 6:00 AM; on 8/15/17 it was signed out at 7:00 PM' and on 8/16/17 it was signed out at 1:00 AM. All these removals were signed out by Agency Nurse #1. Medical record review of the MAR revealed no documentation on the MAR of any of these medications being administered. 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 Resident #5 scored 3 on the BIMS indicating she was severely impaired cognitively. Medical record review of physician's orders [REDACTED].#5 was ordered [MEDICATION NAME] 5/325 mg three times daily. Review of Controlled Drug Record dated 8/3/17 revealed [MEDICATION NAME] was signed out at 5:00 PM, 10:00 PM, 11:00 PM, again at 11:00 PM, and 11:30 PM. Continued review revealed on 8/4/17 [MEDICATION NAME] was signed out at 5:00 PM, 5:30 PM, 10:30 PM, and 11:00 PM. Further review revealed on 8/6/17 [MEDICATION NAME] was signed out at 5:00 AM, 5:00 PM, and 11:00 PM. Continued review revealed on 8/12/17 [MEDICATION NAME] was signed out at 12:00 AM, 4:00 AM, and 6:00 AM while on 8/13/17 it was signed out at 12:00 AM and 6:00 AM. Further review revealed on 8/14/17 [MEDICATION NAME] was signed out at 12:00 AM and 6:00 AM while on 8/15/17 it was signed out at 10:00 PM, 10:30 PM, 12:00 AM, and 6:00 AM. These removals were all signed out by Agency Nurse #1. Medical record review of the MAR revealed none of these removals were documented as having been administered. Interview on 9/13/17 at 2:20 PM in the Administrator's office, the Administrator confirmed medications were not documented on the MAR when signed out on the Controlled Drug Record. The Administrator confirmed this resulted in an incomplete medical record.",2020-09-01
1676,RAINBOW REHAB AND HEALTHCARE,445283,8119 MEMPHIS ARLINGTON ROAD,BARTLETT,TN,38133,2017-09-12,514,D,1,0,JM4F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to ensure complete bowel movement documentation for 1 (Resident #3) of 10 sample residents. The findings included: 1. Medical record review revealed Resident #3 was admitted to the facility on [DATE] Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) Resident ADL (Activities of Daily Living) Record revealed numerous shifts without any bowel documentation. The following were shifts that did not have the documentation: a. 8/19/17: day shift b. 8/20/17: night shift and day shift c. 8/22/17: day shift d. 8/23/17: day shift e. 8/24/17: day shift f. 8/25/17: day shift g. 8/28/17: day shift h. 8/29/17: night, day, and evening shifts i. 8/30/17: night shift and day shift j. 8/31/17: day shift Review of the (MONTH) (YEAR) resident ADL Record revealed numerous shifts without any bowel documentation. The following were shifts that did not have the documentation: a. 9/1/17: night shift b. 9/2/17: night shift and evening shift c. 9/3/17: night shift and evening shift d. 9/4/17: night shift and evening shift e. 9/6/17: night shift f. 9/7/17: day shift g. 9/9/17: day shift and evening shift h. 9/10/17: day shift and evening shift i. 9/11/17: night shift and day shift 2. Interview with the Clinical Reimbursement Specialist on 9/12/17 at 1:05 PM, the Clinical Reimbursement Specialist stated she expected bowel documentation to be completed every shift. She added the facility did not have an audit process in place to ensure complete documentation, and she would need to do follow up and education with the staff to ensure completion of bowel records every shift.",2020-09-01
693,THE HEALTH CENTER AT RICHLAND PLACE,445166,504 ELMINGTON AVENUE,NASHVILLE,TN,37205,2018-03-01,689,D,1,0,4S6V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to ensure residents had adequate supervision to prevent falls for 1 resident (#1) of 3 residents reviewed for falls. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 Day Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was scored 99 on BIMS ( Brief Interview for Mental score ) of 99 indicating severely impaired cognitively. Continued review of the MDS revealed Resident #1 required extensive assistance of 1 person for transfers, ambulation, dressing, eating, grooming, and bathing; was occasionally incontinent of bowel and bladder; and had functional limitation of 1 upper extremity. Medical record review of the Hospital Discharge summary dated [DATE] revealed Resident #1 was admitted with a [MEDICAL CONDITION], left humerus and ulna fractures. Continued review revealed the injury was non-operative and would be conservatively managed. Further review revealed Resident #1 had a small right convexity subdural hematoma (collection of blood in the brain on the top right side of the head) and a large left superior convexity subdural hematoma. Medical record review of the care plan dated [DATE] revealed a problem of being at risk for complications related to behavior - refuses care, combative, agitated, disorganized thoughts. Continued review of the care plan revealed Resident #1 had a problem of being at risk for orthopedic complications related to fall with fracture, refusal to wear C-collar (cervical collar), non-compliant with weight-bearing status from the humerus and ulna fracture. Further review revealed interventions included assess for signs/symptoms of infection at surgical site; notify physician of signs/symptoms of complications; Occupational Therapy screen; observe for signs/symptoms of [MEDICAL CONDITION]. Medical record review of a Provider Progress Note dated [DATE] revealed .Patient has been very lethargic and vomited x2 today. Patient's medications have been titrated due to agitation from dementia. Patient had recent titration up on [MEDICATION NAME] to 2 times daily. She also had [MEDICATION NAME] 2 times daily. [MEDICATION NAME] as needed. Nausea with vomiting - new problem. Patient did not have any recent falls. Will go ahead and initiate neuro checks as she does have history of recent new subdural hematoma. Medical record review of a Post Fall Initial Note dated [DATE] revealed on [DATE] at 5:15 PM Resident #1 was found lying on the floor in fetal position in the activities room. Continued review revealed she had been walking in the room unassisted. Further review of the note revealed the following questions: 1. Did the patient have pain after the fall? Yes 2. Description of injury: Right fracture femur 3. First aid treatment administered: X-ray sent to ER (emergency room ) for evaluation 4. Right hip range of motion: Unable to perform Review of facility investigation revealed a written statement from Certified Nurse Aide (CNA) #5 dated [DATE] at 5:30 PM, which stated .I was doing rounds and observed patient on the floor. I called for a nurse. The nurse checked her and I ran vitals, and safely assisted resident to wheelchair . Review of facility investigation revealed a statement from Registered Nurse (RN) #1 dated [DATE] which stated .Patient did not appear uncomfortable on [DATE] or [DATE]. When the tech went to get patient OOB (out of bed) patient called out in discomfort. Patient was left in bed and nurse practitioner notified on morning of [DATE] . Review of facility investigation revealed a statement from CNA #1, dated [DATE] which stated .While providing daily care during AM shift (6A - 2P) on 24th and 25th I noted no increased pain in (named resident) when getting her cleaned and up to the chair. On morning of ,[DATE] I went to get her up and saw her frown like she may be in pain so I left her in bed and went to tell nurses who came to check on patient when I told them . Review of facility investigation revealed a statement from Licensed Practical Nurse (LPN) #2 dated [DATE] which stated .At time of fall patient was assessed, no c/o (complaint of ) pain, and no apparent injuries notes. Scheduled Tylenol given as ordered as patient had been getting this prior to fall. Review of facility investigation revealed a statement from RN #3 dated ,[DATE] 18 who stated .I took care of the patient approximately 24 hours post fall on a Saturday evening shift. The patient was not in increased pain and did not otherwise show any signs of change of function during my shift. I decided to put the patient in bed and perform neurological checks per post-fall protocol. The patient was comfortable in bed and all vital signs were stable during the shift . Review of facility investigation of an undated statement from LPN #3, revealed .I worked Saturday 23rd. (named resident #1) was resting in bed most of that double shift. I did not notice any acute distress or discomfort that weekend . Medical record review of a Change in Condition report dated [DATE] revealed .Pt crying with complaints of pain upon getting up, or also lifting her left leg .she did fall on Fridat evening this past week . Medical record review of a Provider Progress Note dated [DATE] revealed .night shift nurse reports patient complains of pain to right LE (lower extremity), cries out with transfers and care, report fell on Friday. Pt very confused with dementia, unable to answer ROS (review of symptoms) question. She does however cry out and grimace in pain with passive ROM (range of motion) of right LE, at hip and knee. X-ray ordered. NWB (non weightbearing) until resulted. Highly suspect fracture d/t (due to) pt response to movement and her overall withdrawn mood today. Pt usually restless and trying to ambulate, mildly agitated and constantly busy; staff frequently engaged in distracting and occupying pt with conversation, folding linens, drawing, etc. Today she is very quiet and withdrawn, no attempts to get out of WC (wheelchair) observed . Medical record review of a Provider Progress Note dated [DATE] revealed .Patient seen for abnormal x-ray. Patient fell over the weekend Patient originally was not found to have any injury. However, she became progressively more in pain when trying x-ray of the hip was done and showed acute fracture. Patient sent to hospital for further evaluation by orthopedics . Review of facility investigation of a statement from Nurse Practitioner (NP) #1, revealed .I was called to see the patient (Resident #1) on [DATE] related to lethargy and vomiting. I ordered abdominal x-ray, blood work, and neuro checks because she did have a recent history of a SDH (subdural hematoma) I felt the most likely rationale for her symptoms was slight oversedation from [MEDICATION NAME] plus [MEDICATION NAME]/[MEDICATION NAME]. The abdominal film and blood work were within normal limits. She then had a fall on [DATE] and was not immediately found to have any injuries from nursing staff. On the night of the 25th/morning of the 26th nursing notes she was having pain and difficulty turning so this prompted an x-ray. This did reveal an assumed acute fracture on the right hip. Her family was notified and agreed to send to the ER for prompt evaluation by orthopedics . Review of facility investigation of an undated statement by NP #2, revealed .(Resident #1) had several falls prior to admission and her dementia was made worse by [MEDICAL CONDITION] related to a pretty severe non-operative cerebral hemorrhage which occurred prior to admission. During her stay she was continually confused and disoriented, frequently agitated and trying to rise from the wheelchair, bed, or chair without any awareness of personal safety and fall risk . On (MONTH) 26th I was notified at the beginning of my work day by the outgoing night shift nurse the patient was crying out in pain with transfers and personal care, especially when the right lower extremity was moved. On examination I found the patient sitting in a wheelchair but not her usual active, agitated self. She denied pain verbally but called out and grimaced with passive ROM exam of her lower extremities, more so on the right side. Because the patient was constitutionally changed with flat affect, withdrawn, refusing offer of drink, my suspicion of a possible [MEDICAL CONDITION] was heightened. The nurse reported she had fallen several days earlier but no visible injury or change in behavior or ROM was noted at the time of the fall. The pain in the right lower extremity seemed, from verbal reports by staff, to be a concern early that morning (26th). I ordered an x-ray of the right hip and knee. The results were give to my colleague who followed up with an exam of the patient and sent her out to the hospital for further evaluation and treatment . Review of facility investigation revealed Resident #1 was transferred from the hospital to Hospice where she expired on [DATE]. Review of the Death Certificate from the Medical Examiner revealed the cause of death was acute right femur fracture; the contributing cause was acute on chronic left subdural hematoma; and the death was accidental. Interview with the Director of Nursing (DON) on [DATE] at 11:55 AM in the conference room revealed Resident #1 had a fall on [DATE]; the nurse assessed her; and Resident #1 was determined to have no injury. Continued interview revealed Resident #1 was assisted to bed without problem. Further interview revealed on [DATE] the night nurse discovered Resident #1 was in increased pain which was reported to the NP and an x-ray was ordered. Continued interview revealed the DON talked to all staff who cared for Resident #1 from [DATE] - [DATE]. Further interview revealed Resident #1 complained of nausea and vomiting on [DATE] and the NP assessed her, concerned the subdural hematoma was extending. Continued interview revealed the NP ordered labs and neuro checks to assess any changes. Further interview revealed Resident #1 received Tylenol Arthritis three times daily and did not required any additional pain medication from [DATE] - [DATE]. Continued interview revealed Resident #1 had [MEDICAL CONDITION] and the NP questioned whether the resident sustained [REDACTED]. Further interview the DON confirmed Resident #1 was not supervised adequately to prevent a fall.",2020-09-01
5700,SWEETWATER NURSING CENTER,445456,978 HWY 11 SOUTH,SWEETWATER,TN,37874,2016-01-06,333,D,1,1,QMXV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to ensure residnets are free from significant medication errors for 1 resident (#117) of 30 residents reviewed. The findings included: Medical record review revealed Resident #117 was admitted to the facility on [DATE] at 2:30 PM, with [DIAGNOSES REDACTED]. Continued medical record review revealed the resident was discharged on [DATE] at 4:30 PM, to home. Medical record review of the Interdisciplinary Progress Notes dated 9/18/15 revealed Resident #117 arrived at the facility at 2:30 PM, was alert and oriented times 3 (person, place and time), and was able to make needs known. Medical record review of Resident #117's Medication Administration Record [REDACTED]. Continued medical record review of the [MEDICATION NAME] (blood thinner), [MEDICATION NAME]/sol [MEDICATION NAME] (breathing treatment), Levamir (8:oo PM) (long acting insulin), Methocarbam (muscle relaxer), [MEDICATION NAME] Diskus (breathing treatment), [MEDICATION NAME] (antidepressant); [MEDICATION NAME] (antianxiety), [MEDICATION NAME] (antihypertensive); Klonopin (antianxiety), [MEDICATION NAME] (stomach acid), Fish Oil, and [MEDICATION NAME] (cough syrup), had no initials or signatures indicating they had been administered. Medical record review of Resident #117's Diabetic Medication Administration Record [REDACTED]. Interview with Registered Nurse (RN) #1, Licensed Practical Nurse (LPN) #1, and the Director of Nursing (DON) on 1/6/16 at 6:50 AM, at the 200 nurse's desk, confirmed after review of Resident #117's MAR, no signatures or initials indicating the resident received her medications for the evening of 9/18/15 were present. Continued interview confirmed RN #1 stated the nightshift processes the admission orders [REDACTED]. Interview by telephone with LPN #3 on 1/6/16 at 2:35 PM, confirmed she was the nurse assigned to Resident #117 on 9/18/15, for the evening shift. Continued interview revealed the medications and the MARs do not arrive until about 2:30 AM, and stated .so we look at the doctors admission orders [REDACTED]. Interview with LPN #1 on 1/6/16 at 3:12 PM, at the 200 desk confirmed if a resident is admitted to the facility and needs medications, the nurse can obtain what is available from the back up supply, and stated .if it is something we don't have we call our pharmacy and they call a pharmacy here in town and they deliver it here to the facility .I guess that wasn't done in this case .",2019-01-01
4140,MT PLEASANT HEALTHCARE AND REHABILITATION,445374,904 HIDDEN ACRES DR,MOUNT PLEASANT,TN,38474,2016-11-03,224,J,1,0,J51L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to ensure safe feeding practices were provided to a swallow-impaired, aspiration-risk resident when a syringe was used to force feed food and liquids for 1 resident (#1) of 6 residents who were totally dependent on staff for eating. This failure placed all residents at risk for aspiration and requiring total dependence on staff for eating 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 of a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on [DATE] at 3:00 PM in the Administrator's office. F224 is Substandard Quality of Care The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 60 day Minimum (MDS) data set [DATE] revealed Resident #1 had adequate hearing, clear speech, could make self understood, was able to understand others, was severely cognitively impaired per the ,[DATE] score on the Brief Interview for Mental Status, was totally dependent with one person assist for eating, had no swallowing disorder, and received 95 minutes of speech therapy. Medical record review of the Physician telephone Orders revealed the following: [DATE] a regular textured diet was ordered. [DATE] .ST (Speech Therapy) to eval (evaluate) + (and) tx (treat) as indicated .for cognitive deficit and swallowing secondary to dementia . [DATE] diet texture changed to mechanical soft. [DATE] the diet was changed to mechanical soft with pureed (blenderized food) meat. [DATE] the diet was changed to pureed. [DATE] .Offer nectar thick liquids Q 2 (every 2 hours) Hydration while awake . [DATE] .DC (discontinue) ST services eff (effective) [DATE] . [DATE] .Admit to Hospice effective this day . Medical record review of the Speech Therapy (ST) Evaluation and Plan of Treatment dated [DATE] revealed Resident #1 had mildly impaired swallowing abilities, and the Assessment for Swallowing section documented .Clinical S/S (signs and symptoms) of Dysphagia (swallowing difficult)): effortful mastication (chewing process) . The ST Recertification and Update of Treatment Plan dated [DATE] to [DATE] revealed the skilled services provided was dysphagia therapy and the diet was changed to pureed due to pocketing (food getting stuck in mouth), increased feeding time and lethargy. Further review revealed Resident #1 had used general swallowing techniques/precautions and upright posture during meals 70% (percent) of the time by [DATE], was tolerating the pureed diet while spoon fed by staff, caregiver/staff were educated on safe swallowing strategies including bite/sip, small bites, and positioning. The swallowing treatment training included small bites/sips (,[DATE] to ,[DATE] teaspoon) and facilitation of body positioning to increase safety with intake. Resident #1's Swallow Ability was moderately impaired and had declined since the initial evaluation when he was mildly impaired. Medical record review of the Progress Notes revealed the following: [DATE] .unable to swallow meds (medications) whole . [DATE] .Is having difficulty swallowing so meds are being crushed in applesauce . [DATE], [DATE], .takes meds crushed . [DATE] .takes meds crushed in applesauce with some problems . [DATE], [DATE], [DATE] .takes meds crushed . or .takes meds crushed in applesauce . [DATE] .Swallowing difficulty at times .Swallowing Deficits . [DATE], [DATE], [DATE] .takes meds crushed . or .takes meds crushed in applesauce . [DATE] .Takes meds crushed in applesauce with some difficulty . [DATE] at 11:26 AM .Unable to make needs known .takes meds crushed . [DATE] at 3:33 PM .takes meds crushed and at 11:08 PM . Has difficulty swallowing at times though able to clear with cough . [DATE] at 3:11 PM .Takes meds crushed in applesauce with extreme encouragement . and at 10:18 PM .takes several minutes to swallow meds. Able to swallow with no cough noted . [DATE] at 12:29 AM .Refused meds this HS (bedtime) with several attempts made . and at 11:44 AM .takes meds crushed . [DATE] at 2:20 AM .Resident noted to be holding crushed meds in mouth for extended time, many attempts made to get resident to swallow at which he eventually does . and at 7:52 PM .Unable to make needs known .Takes meds crushed . [DATE] at 1:19 AM .Refused HS meds with several attempts made . and at 10:44 PM .Has difficulty with swallowing at times. Meds crushed . [DATE] .Takes meds in applesauce with extreme encouragement to swallow . [DATE] at 2:29 PM .Resident had a decline this week, now requiring to be fed, diet changed to puree due to difficulty swallowing, unable to follow directions . and at 10:55 PM .Thickened liquids in use. Holds liquids in mouth for extended period of time . [DATE], [DATE] .Unable to make needs known .Takes meds crushed . [DATE] .Unable to make needs known .Takes meds crushed . [DATE] at 1:48 AM .Refused HS (bedtime) meds with several attempts made . and at 12:46 PM .Takes meds crushed in applesauce with extreme encouragement to swallow . [DATE] .Takes meds crushed in applesauce with extreme encouragement to swallow . [DATE] .Unable to make needs known .Takes meds crushed . [DATE] at 11:21 AM .Unable to make needs known .Takes meds crushed . and at 10:55 PM .Holds fluids in mouth extended periods . [DATE] .Holds fluids in mouth at times though no cough or choking noted. Takes meds crushed . [DATE] at 9:19 AM .Takes meds crushed in applesauce with extreme encouragement . and at 10:25 PM .Continues to have difficulty swallowing at times . [DATE], [DATE] .meds administered crushed in applesauce . or .takes meds crushed . [DATE] at 9:59 AM .Takes meds crushed in applesauce with extreme encouragement . and at 11:47 PM .has difficulty swallowing at times . [DATE] .Takes meds crushed . [DATE] at 3:16 AM .meds administered crushed in applesauce . at 1:47 PM .Takes meds crushed in applesauce with extreme encouragement . and at 2:34 PM .Takes meds crushed in applesauce with some difficulty . [DATE] at 2:25 AM .refused HS meds with several attempts made . and at 2:10 PM .Takes meds crushed in applesauce . [DATE] .Unable to make needs known .Takes meds crushed . [DATE] at 12:04 AM .Takes meds crushed .Holds liquids in mouth at times . and at 10:45 AM .Unable to make needs known .Takes meds crushed . [DATE] at 12:22 AM .crushed meds .; at 10:42 .receiving ST 5 times a week due to Dysphagia and Cognitive Deficits .unable to follow simple directions . and at 9:58 PM .Unable to hold cups or take meds from nurse. Meds crushed, has difficulty swallowing at times . [DATE] .Continues to have swallowing difficulties at times . [DATE] .Takes meds crushed in applesauce . [DATE] at 1:14 AM .takes meds crushed in applesauce with episodes of holding meds in mouth for extended time before swallowing . and at 3:25 PM .Unable to make needs known .Takes meds crushed . [DATE] at 3:19 AM .takes meds crushed in applesauce with episodes of holding meds in mouth for extended time before swallowing . and at 11:40 AM .Unable to make needs known .Takes meds crushed . [DATE] at 2:43 AM .takes meds crushed in applesauce with episodes of holding meds in mouth for extended time before swallowing .; at 10:55 AM .Takes meds crushed . and at 10:48 PM .Continues to have shakiness of hands, unable to use utensils or glass/cup without assist . [DATE] at 10:37 AM .takes meds crushed in applesauce . and at 10:55 PM .has coughed at times with free water, able to clear .has shakiness of hands when attempting to hold cup of liquid . [DATE] .takes meds crushed, unable to hold med cup or drinking cup . [DATE] at 4:18 PM .Takes meds crushed . and at 11:52 PM .takes meds crushed with significant difficulty swallowing . [DATE] at 11:51 AM and 12:07 PM .Unable to make needs known .Takes meds crushed . and at 2:17 PM .spoke with daughter/POA (Power of Attorney) .re (regarding) lethargy . [DATE] at 3:14 AM .takes meds crushed in applesauce with episodes of holding meds in mouth for extended time before swallowing . and at 2:23 PM .Takes meds crushed in applesauce . [DATE] at 3:01 AM .takes meds crushed in applesauce . at 2:50 PM .Meal assist per staff with delayed swallow noted .Takes meds crushed . and at 11:06 PM .Decline in condition noted related to swallowing .increased confusion . [DATE] at 11:31 AM and [DATE] at 1:42 PM .Unable to make needs known .Meal assist per staff with delayed swallow noted .Takes meds crushed . and at 10:15 PM .Swallowing difficulties continues at times . [DATE] at 12:46 AM .Meds administered crushed with difficulty at times . and at 9:55 AM .Takes meds crushed in applesauce with some encouragement . [DATE] at 3:57 PM and [DATE] at 3:26 PM .Unable to make needs known .Meal assist provided per staff with delayed swallowing noted . [DATE] at 10:56 AM and 12:21 PM .Unable to make needs known .Takes meds crushed . [DATE] .takes meds crushed in applesauce with some encouragement . [DATE] .meds administered crushed in applesauce with difficulty at times; will hold in mouth with much encouragement made to swallow . [DATE] and [DATE] .Takes meds crushed in applesauce with some encouragement . [DATE] .patient during meal supper noted coughing during feeding will advise therapy . [DATE] .Takes meds crushed in applesauce with some encouragement . [DATE] at 11:30 PM .No further emesis noted, had earlier after lunch x (times) 1. Afebrile . [DATE] at 2:15 PM .Moderately large emesis noted during activity in dining room. Afebrile . [DATE] at .1:30 PM Res (resident) consumed 100% of meal with asst (assist) with no dysphagia. Res vomited very large amt (amount) of liquid et (and) pureed food. Res entered Cheyne-Stokes (abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing) respirations et was unresponsive. Nurse at this x (time) went to supply closet to obtain suction equipment .at 1:34 PM Re-entered room. Noted absence of pulse, B/P (blood pressure) et respirations. Skin pale/gray et cool to touch. RN (Registered Nurse) #1 Supervisor notified .at 1:40 PM Pronounced deceased . by (RN #1) @ (at) this time. Call placed (Hospice nurse) .at 1:45 PM RP (Responsible Party) et son notified of passing of resident .(RP) instructed funeral home to be called .at 3:50 PM Remains released to funeral home . Interviews with Licensed Practical Nurse (LPN) #5 on [DATE] at 2:55 PM and at 4:25 PM on the long hall and the conference room, on [DATE] at 11:10 AM in the conference room, on [DATE] at 4:10 PM in the conference room, and on [DATE] at 8:30 AM on the long hall revealed Resident #1 had general decline as time passed including pocketing food, and had ,[DATE] vomiting episodes after eating. Further interview revealed LPN #5 had .fed (Resident #1) Magic Cup (nutritional supplement) and fluids ,[DATE] times by syringe .a couple of months before hospice started .I gave Magic Cup and water by syringe the morning of [DATE] . and (Resident #1) .wanted water and could no longer suck on a straw .I didn't want him dehydrated . When questioned about the resident's advanced directive of no artificial feeding, why was a syringe okay to use, the LPN stated .because not able to suck through straw and when you held a cup to the lips the resident could blow into it so I tried a syringe, he knew to swallow once in mouth . When asked why the LPN used the syringe the LPN stated .I was trying to help the man out, I don't know if Certified Nurse Aide (CNA) #4 was trained to use syringe . When asked what CNA #4 was doing when the LPN entered the resident's room on [DATE] at lunch, the LPN stated the CNA .was spoon feeding the resident lunch and I told her there was a syringe available if she needed it . When asked what the LPN did after she was aware the resident was projectile vomiting on [DATE] immediately after eating lunch, the LPN stated she got called to the resident's room .I was going to try to suction but he had already passed . When asked what happened to the syringe, the LPN stated .I told CNA #4 to throw it away because there was no doctor's order for it . When asked if the LPN had informed Hospice, her supervisors, the physician, the resident or responsible party/Power of Attorney of the use of the syringe prior to Resident #1's death, the LPN stated No. Interviews with CNA #4 on [DATE] at 9:25 AM and on [DATE] at 10:15 AM and 12:35 PM, in the conference room and the nursing station revealed CNA #4 had been spoon feeding Resident #1 lunch on [DATE] when LPN #5 entered the resident's room and informed the CNA .syringe in drawer and she told me to try to use it. I got syringe out, liquefied the pureed food with the fluid on the tray and put a little in his mouth, he swallowed, I asked if he wanted more and he said 'Uh Huh', I took my time feeding him and he ate all the food, 100%, and when I was done feeding he started vomiting. His head of bed was up but I put it up as high as it could go and yelled for help. (CNA #1) came to the room and she yelled for (LPN #5) to come to the room .(LPN #5) and (RN #1) came in the room .resident had thrown up so bad and stopped breathing . When asked when she was spoon feeding the resident lunch, how had the resident been accepting the food by mouth, the CNA stated .he wasn't taking it like before . When asked why she used the syringe, CNA #4 stated .(LPN #5) told her the LPN had been using the syringe throughout the day with magic cup and juice and he did fine . When asked what happened to the syringe, CNA #4 stated .(CNA #1) told her that (LPN #5) told (CNA #1) to tell (CNA #4) to get the syringe out of there, I threw it in the trash in the resident's room then I removed it and took it to the hopper room trash . Interview with CNA #1 on [DATE] at 2:40 PM, in the conference room when asked regarding events of [DATE] at lunch, revealed the CNA heard her name yelled out with urgency and she went next door and saw Resident #1 vomiting and (CNA #1) yelled for (LPN #5) to come to the room and .by the time (LPN #5) got there (to room) (Resident #1) took 2 breaths and nothing .(LPN #5) whispered to me to tell (CNA #4) to get the syringe out of the room, I looked at (LPN #5) but told (CNA #4) what (LPN #5) had said and I went back to finish feeding my resident . Interview with CNA #7 on [DATE] at 9:15 AM, in the conference room revealed CNA #7 was assigned to Resident #1 mostly toward the end of his life and there were times he refused to open his mouth to eat. Further interview revealed CNA #7 had .spoon fed Resident #1 on [DATE] breakfast with approximately 50% intake . Further interview revealed Resident #1 .swallowing good and drank a lot of liquids . Telephone interview with RN #1 on [DATE] at 1:25 PM, revealed when asked when the RN became aware of the syringe use, stated .I was told after the fact. Apparently fed by syringe at lunch according to the (CNA #4) and (LPN #5) had told her to feed with syringe. (LPN #5) told me she had told the CNA that if (resident) didn't eat there was a syringe in there and she could use that .I got the information after he was pronounced . Telephone interviews with Hospice Patient Care Coordinator on [DATE] at 8:45 AM and 10:00 AM, and on [DATE] at 10:30 AM, revealed when asked if hospice syringe fed residents stated .we don't push .eating, we educate .this is part of the dying process when they do not want to eat anymore .their body shuts down and no need to eat or drink unless they ask for something . The interview revealed hospice had no policy on syringe use and .Always told not to do it .not even a part of equipment provided staff . Further interview revealed, when asked if hospice was aware the facility had used a syringe to feed Magic Cup and fluid on ,[DATE] occasions and lunch on [DATE] after which the resident projectile vomited and died , the patient Care Coordinator stated No, was not aware. Why would you do that? Interviews with the Speech Therapist on [DATE] at 11:10 AM and on [DATE] at 8:40 AM, in the therapist office and/or the conference room revealed Resident #1 was provided speech therapy for swallowing from [DATE] to [DATE] and the texture of the food was downgraded progressively until was totally pureed due to increasing problems with dysphagia and swallowing problems. Further interview revealed the pureed diet was primarily due to pocketing, increased time feeding and lethargy. Further interview revealed .he was definitely an aspiration risk when I changed the diet to pureed due to lethargy and there are no circumstances you should use a syringe .such a high risk for everything to go wrong and my biggest fear was for aspiration . Interviews with the Director of Nursing (DON) on [DATE] at 3:40 PM, [DATE] at 10:50 AM and 4:40 PM, [DATE] at 12:53 PM, and [DATE] at 8:35 AM and 1:45 PM, in the conference room revealed the facility did not have a policy on syringe feeding a resident and did not have a policy on aspiration/aspiration precautions. Further interview revealed the DON was not aware a syringe was being used to feed a resident prior to the event. The DON stated she had been notified by RN #1 of Resident #1's death on [DATE] and of being fed lunch with a syringe, vomiting and then the death after the resident was pronounced and had left the building. When asked what the facility did after they were aware of the syringe feeding, the DON stated .interviewed the CNA and LPN, wrote up and suspended the LPN, and did one-on-one training with the CNA with verbal warning and planning to do full staff in-service on inappropriate use of a syringe at next staff meeting . Telephone interviews with the Medical Director on [DATE] at 12:17 PM and [DATE] at 12:50 PM, revealed when asked when he had become aware the facility had used a syringe, stated .aware after the fact fluids given by syringe by the nurse . Further interview revealed, when asked if he was aware a CNA had fed Resident #1 lunch by syringe with 100% intake, projectile vomited and then died , stated .I didn't know (Resident #1) got pureed food by syringe. Don't recall facility telling me . Further interview revealed when asked if feeding with a syringe, thereby forcing the food into mouth, could have contributed to the projectile vomiting and death, stated .He had significant issues already and reasonable to say aspirated but with medical issues something else could be going on . Refer to F154 J, F155 J, and F157 [NAME]",2019-11-01
4273,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2016-10-13,329,D,1,1,LFXZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to ensure that behaviors and side effects were monitored for 1 of 5 ( Resident #92) sampled residents reviewed for unnecessary medications. The findings included: Medical record review revealed Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum (MDS) data set [DATE], and the quarterly MDS dated [DATE] documented Resident #92 had no cognitive impairment, had no behaviors, required staff assistance for all activities of daily living, and received antidepressant medications 7 days. The care plan dated 10/3/16 documented, .at risk for and/or experiencing depression .Taking medications as prescribed ([MEDICATION NAME] 25mg (milligrams) daily) .Approach .10/3/2016 .Monitor behaviors per tracking tool . Interview with the Social Services Director (SSD) on 10/13/16 at 1:49 PM, in the chapel, the SSD was asked how residents are monitored for behaviors related to depression. The SSD stated, .The nurses let us know. They are supposed to check that on the nurses note . Interview with Registered Nurse (RN) #1 on 10/13/16 at 3:15 PM, RN #1 was asked how the resident was monitored for behaviors. RN #1 stated, There is no documentation for behavior monitoring in this record. The nurse failed to check the box (in electronic medical records system) for side effect monitoring .",2019-10-01
4431,CREEKSIDE CENTER FOR REHABILITATION AND HEALING,445516,306 W DUE WEST AVENUE,MADISON,TN,37115,2016-10-24,501,L,1,0,CT4U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to ensure the Medical Director assisted the facility to identify, evaluate, and address/resolve medical and clinical concerns/issues that affect resident care and quality of life by failing to ensure physicians were notified of abnormal blood glucose results; failing to ensure care plans were followed for diabetic residents; failure to prevent significant medication errors; failure to prevent neglect of residents with medication not administered according to physician orders; and failure to ensure accurate and complete documentation. These failures 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 all facility residents. The Administrator (NHA) was notified of the Immediate Jeopardy on 10/24/16 at 3:25 PM in the Conference Room. The findings included: The Medical Director of the facility is the physician of record for all the residents. Interview with the Medical Director on 10/19/16 at 2:30 PM in the Conference Room revealed he was sure the staff were notifying the Nurse Practitioners of abnormal blood sugar results Continued interview revealed he had reviewed all residents with a [DIAGNOSES REDACTED]. Refer to F157 K, F224 L SQC, F281 L, F332 L SQC, F333 L SQC, F353 L, F490 L, F493 [MI]",2019-10-01
3741,"COLLIERVILLE NURSING AND REHABILITATION, LLC",445495,490 WEST POPLAR AVENUE,COLLIERVILLE,TN,38017,2017-03-02,278,D,1,0,4B1111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment to reflect the current status for [MEDICAL CONDITION] medications, Range of Motion (ROM) impairment, and Respiratory Therapy (RT) services for 3 of 23 (Resident #38,114, and 123) sampled residents of the 47 residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimal Data Set ((MDS) dated [DATE] revealed the Resident was coded as receiving antidepressant medications on 0 days of the 7 day look back period. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Interview with MDS Coordinator #1 on 3/1/17 at 10:05 AM, in the MDS office, MDS Coordinator #1 was asked if antidepressants should have been coded a 0. The MDS Coordinator stated, No .should have been marked a 7 (7 of 7 days of the look back period) .[MEDICATION NAME] and [MEDICATION NAME] are both antidepressants. 2. Medical record review revealed Resident #114 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Significant change in status MDS dated [DATE] documented Resident #114 had impairment on both lower extremities. The quarterly MDS assessment dated [DATE] documented Resident #114 had no limitations on either lower extremity. Interview with MDS Coordinator #1 on 3/1/17 at 5:05 PM, in the MDS office, the MDS Coordinator was asked if ROM limitation on the 1/18/16 MDS for Resident #114 was correct documenting no limitations. The MDS Coordinator stated No, they are incorrect . 3. Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] documented severe cognitive impairment and dependence on staff for all activities of daily living. The MDS documented Resident #123 received oxygen therapy, suctioning, [MEDICAL CONDITION] care, and required a ventilator/respirator while a resident at the facility. The MDS documented, .Respiratory therapy: number of days .0 . Review of the RT notes revealed Resident #123 received RT services daily on 10/20/16-10/27/16. Interview with the MDS Coordinator #1 on 3/2/17 at 4:02 PM, in the 3rd Floor MDS office, MDS Coordinator #1 was asked whether the documentation for 0 days of RT was correct on Resident #123's quarterly MDS. MDS Coordinator #1 stated, Should be 7 days. She's always been a vent (ventilator) patient. She's had RT since she's been here.",2020-03-01
1033,HUNTINGDON HEALTH & REHABILITATION CENTER,445210,635 HIGH STREET,HUNTINGDON,TN,38344,2019-08-19,659,D,1,0,WG8Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to ensure the comprehensive care plan was followed for behaviors for 2 of 3 (Resident #1 and #2) sampled residents reviewed. The findings include: 1. Medical record review revealed Resident #1 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored an 11 on the Basic Interview of Mental Status (BIMS), which indicated moderately impaired cognition for decision making. The Comprehensive Care Plan for Resident #1 dated 8/4/19 documented, .Behaviors (Resident #1 was on the giving end of a resident to resident altercation on 8/4/19): Staff to escort resident, one on one staff to the dining room to e hall dining. And staff are to escort resident back to room, one on one by staff from dining room . Interviews with Certified Nursing Assistant (CNA) #1, #2, #3, Licensed Practical Nurse (LPN) #1, and #2 on 8/19/19, in the Conference Room, CNA #1, #2, #3, LPN #1, and #2 confirmed they did not escort Resident #1 to the dining room on 8/7/19. Interview with LPN #1 on 8/19/19 at 10:25 AM, at the Nurses' Station, LPN #1 stated, .I was at the nursing station and heard hitting and screams .We went into the dining room and the CNA was pulling Ms. (Named Resident #1) out .we immediately placed her on 1:1 observation .If she (Resident #1) is going to eat we (staff) are to escort her to the [NAME] dining so staff can be with her . Interview with the Director of Nursing (DON) on 8/19/19 at 12:10 PM, in the Conference Room, the Director of Nursing (DON) stated, .The staff didn't follow the care plan of escorting resident to the dining room . 2. Medical record review revealed Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] revealed Resident #2 scored an 11 on the BIMS, which indicated moderately impaired cognition for decision making . The Comprehensive Care Plan dated 8/7/19 documented, .Behaviors 8/7/19 resident was on the receiving end of a resident to resident altercation .Check for adverse reaction and monitor for 72 hours for adverse reaction . Review of the Nurses' Notes for Resident #2 dated 8/7/19-8/9/19 revealed there was no documentation of an assessment of adverse reactions or her state of emotional well being. Interview with the DON on 8/19/19 at 12:10 PM, in the Conference Room, the DON confirmed there was no documentation of Resident #2's emotional well being after the incident 8/7/19 for 72 hours. The DON stated, .No documentation .nothing about her emotional well being .",2020-09-01
1412,SUMMIT VIEW OF ROCKY TOP,445259,204 INDUSTRIAL PARK RD,ROCKY TOP,TN,37769,2019-05-07,677,D,1,0,DIGG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to ensure the necessary services to maintain personal hygiene were arranged for 1 resident (#1) of 3 residents reviewed. The findings included: 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 a Brief Interview Mental Status (BIMS) score of 15 (cognitively intact). Continued review revealed the resident required extensive assist for transfers, dressing, and toilet use with 1 person assist. Further review revealed the resident was always incontinent of bowel and bladder. Medical record review of Resident #1's care plan dated 1/8/19 revealed the resident required extensive assistance with all activities of daily living and toilet use. Interview with the Director of Nursing (DON) on 5/7/19 at 9:00 AM, in her office ,revealed .she (Resident #1) told us she was going to spend the night with her son at the hospital .we planned to send the van to pick her up the next morning . Continued interview confirmed the DON received a call at approximately 11:00 PM on 4/3/19 stating the hospital had called and said the resident was there (at the hospital) and didn't need to be. Further interview revealed .I got another call stating they were sending her to the ER (emergency department) because she was confused, combative, and aggressive . Interview with Resident #1 on 5/7/19 at 9:30 AM, in her room, revealed she attended a doctor's appointment on 4/3/19 located at an acute care hospital and after the appointment went to visit her son who was a patient in the hospital. Continued interview revealed .the Director of Nursing gave me permission to spend the night at the hospital . Interview with Certified Nursing Assistant (CNA) #1 on 5/7/19 at 10:30 AM, in the conference room, revealed Resident #1 required extensive assistance with transfers, was incontinent of bowel and bladder, and wore briefs. Interview with Licensed Practical Nurse (LPN) #2 on 5/7/19 at 11:00 AM, in the conference room, revealed .I wouldn't think she should spend the night at the hospital .discussed with DON .sent her evening medications with her . Interview with the Admission Coordinator on 5/7/19 at 11:15 AM, in her office, revealed she arranged transportation for the resident for the orthopedic appointment on 4/30/19 and the Activities Assistant escorted the resident to the appointment. Interview with the Activities Assistant (AA) on 5/7/19 at 11:40 AM, in the conference room, confirmed she had attended the orthopedic appointment with Resident #1 and after the appointment the resident went to visit her son (in the hospital) and the AA returned to the facility. Interview with the DON on 5/7/19 at 12:00 PM, in the conference room, revealed .did not contact anyone at the hospital to make sure it was okay for her (Resident #1) to stay with her son .looking back I should have . In summary, the resident required assistance with toileting and all ADL care and the facility failed to arrange those services for Resident #1 prior to the resident spending the night with her son in the hospital.",2020-09-01
3726,HUMBOLDT NURSING AND REHABILITATION CENTER,445441,3515 CHERE CAROL RD,HUMBOLDT,TN,38343,2017-03-29,314,D,1,0,ZWOY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to ensure wound assessments were done for 1 of 5 (Resident #9) sampled residents reviewed with a pressure ulcer. The findings included: Closed medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Wound Assessment Report(s) revealed the following: a. An assessment dated [DATE] documented a pressure ulcer on the sacrum that was identified 8/13/16. The wound was present on admission and it is unstageable due to slough/eschar and measures 7.0 centimeters (cm) long, 5.0 cm wide and 0.0 cm deep. b. An assessment dated [DATE] documented stage 4 pressure ulcer on the sacrum that was identified 8/13/16. The ulcer measures 6.0 cm long, 4.0 cm wide and 3.5 cm deep. Review of the medical record revealed Resident #9 was hospitalized from [DATE] to 10/7/16 and 10/12/16 to 10/19/16. The Departmental Notes dated 10/7/16 documented, . Admission Assessment, Re-admission . Resident has a pressure ulcer on sacrum . Wounds referred to wound care . There was no assessment of this pressure ulcer. There was no wound assessment present from 10/7/16 (the day the resident returned from the hospital) to 10/12/16 (the day the resident was admitted to the hospital). Interview with the Treatment Nurse on 3/29/17 at 12:47 PM, in the Director of Nursing (DON) office, the Treatment nurse was asked if there was a wound assessment performed on the resident after he returned from the hospital on [DATE]. The Treatment Nurse stated, .not that I can find in here (medical record) . At 1:21 PM, the Treatment nurse stated, The admission nurse did chart that he had a pressure ulcer on his sacrum (on the Admission Assessment, Re-admission Departmental Notes) .",2020-03-01
1880,LIFE CARE CENTER OF COPPER BASIN,445310,166 COPPER BASIN INDUSTRIAL PARK PO BOX 518,DUCKTOWN,TN,37326,2018-08-13,658,D,1,0,RPHQ11,"**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 one resident (#1) of 3 residents reviewed for wound management. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed a [DIAGNOSES REDACTED]. Review of the quarterly Minimum (MDS) data set [DATE] revealed Resident #1 was severely cognitively impaired, required assistance or two persons for all activities of daily living, and had chronic wounds to the right hip and right great toe. Medical record review of Physician's Progress Notes dated 7/15/18 revealed an order for [REDACTED]. Interview with the Director of Nursing (DON) on 8/13/18 at 3:30 PM, in the conference room, confirmed the facility failed to follow a physician's order timely for a wound care consult.",2020-09-01
852,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-12-19,684,D,1,0,RPNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to follow physician orders [REDACTED].#1) of 9 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged home from the facility on 11/15/17. Medical record review of the hospital discharge Physician order [REDACTED]. 1. [MEDICATION NAME] (diuretic) 40 milligram (mg) 1 tab by po (by mouth) once every day (Q D) as needed ( PRN) fluid retention. Patient Instruction: Take when short of breath (SOB), lower extremity swelling, or if you gain 2 pounds (lb) in 1 day or 5 pounds in 5 days. Medical record review of the facility Physician order [REDACTED]. 1. [MEDICATION NAME] 40 mg 1 po Q D PRN r/t (related to) SOB, or BLE (bilateral lower extremity) [MEDICAL CONDITION], or 2 lb wt (weight) gain in 1 day (D) or 5 lb in 5 days. 2. Daily Weights. Review of the Telephone Physician order [REDACTED]. On 11/9/17 .Daily weights-record on MAR (Medication Administration Record) . On 11/10/17 .CBC (Complete Blood Count), BMP (Basic Metabolic Panel), BNP (B-type Natriuretic Peptide) ([MEDICAL CONDITION], shortness of breath) Please call provider for any critical values . On 11/13/17 .1. Daily weights .2. [MEDICATION NAME] 20 mg Q daily x 7 days .3. Repeat CBC, BMP,BMP on Wednesday 11/15/17 . Review of the Pharmacy Delivery Ticket dated 11/13/17 revealed [MEDICATION NAME] 20 mg had been delivered to the facility for Resident #1. Medical record review of the 11/2017 MAR revealed the following: 1. [MEDICATION NAME] 40 mg po Q D PRN r/t SOB, or BLE [MEDICAL CONDITION], or 2 lb wt gain in 1 day or 5 lb in 5 days was administered on 11/13/17 and 11/14/17. [MEDICATION NAME] 20 mg Q D x 7 days ordered on [DATE] was not on the 11/2017 MAR. Medical record review of the weight documentation on the Admission Screen, 11/2017 MAR, the computer, or Daily AM Weight form revealed: 11/2/17-181 11/3/17-180 11/4/17-183.4 (an increase of 3.4 lb in 1 day, required PRN [MEDICATION NAME], not administered) 11/5/17-183.8 11/8/17-187 11/13/17-187.4 11/14/17- 192.6 (received 40 mg [MEDICATION NAME] administration) 11/15/17-196 (received 40 mg [MEDICATION NAME] administration) The facility failed to obtain and document weights for 6 of 14 days of the admission on 11/6/17, 11/7/17, 11/9/17, 11/10/17, 11/11/17 and 11/12/17. Interview with Licensed Practical Nurse (LPN) #6 on 12/13/17 at 2:40 PM in the conference room confirmed the LPN provided direct care to Resident #1. Further interview confirmed the LPN signed the 11/13/17 order for [MEDICATION NAME] 20 mg and failed to transcribe the order on the MAR. Interview with the Director of Nursing (DON) on 12/13/17 at 4:05 PM, 12/14/17 at 1:55 PM, 12/18/17 at 2:55 PM, and 12/19/17 at 10:00 AM in the conference room confirmed the facility failed to transcribe the 11/13/17 [MEDICATION NAME] 20 mg order onto the MAR and failed to administer the mediation as ordered. Further interview revealed the nursing staff .would have to weigh the person to know if the weight increased in order to administer the 40 mg [MEDICATION NAME] . Further interview confirmed the facility failed to obtain daily weights for the resident and failed to administer the PRN 40 mg [MEDICATION NAME] on 11/4/17 after a weight gain. Further interview confirmed the facility failed to obtain the 10/10/17 laboratory tests as ordered and failed to notify the physician.",2020-09-01
674,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-03-10,697,D,1,0,TO3W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to follow physician orders [REDACTED].#12) sampled residents reviewed of the 12 residents included in the sample. The findings include: 1. Medical record review revealed Resident #12 was admitted to the facility with Hospice services on 2/12/19 at 2:00 PM with [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED].[MEDICATION NAME] ER (extended release) 60 mg (milligram) tablet take one tablet po (by mouth) q (every) 12 hrs (hours) . Review of the ADMINISTRATION RECORD dated 2/12/19 revealed the [MEDICATION NAME] ER 60 mg po was not administered as ordered on [DATE] or 2/13/19. Review of the Comprehensive Care Plan documented, .has potential for pain related to [MEDICAL CONDITION] .Administer medication for pain as ordered and document effectiveness . 2. During an interview with Registered Nurse (RN) #1 on 3/5/19 at 10:45 AM in the conference room, RN #1 was asked what time Resident #12 received the [MEDICATION NAME] ER as ordered. RN #1 stated, On the 13th at 9:00 AM a prn (as needed) dose .Didn't get it ([MEDICATION NAME] ER 60 mg) on the 12th. During an interview with Licensed Practical Nurse (LPN) #3 on 3/10/19 at 3:55 PM at the 200 Hall nurses' desk, LPN #3 was asked if Resident #12 was given his pain medication as ordered when he was admitted on [DATE]. LPN #3 stated, If Hospice is bringing them we would use from Hospice. He did not come with his meds. We should have gotten a hard script for the [MEDICATION NAME] and sent to pharmacy. We would get the next day in the evening. During review of Resident #12's Administration Record with LPN #3, she was asked if the first dose of the scheduled [MEDICATION NAME] ER 60 mg was given on 2/13/19 at 6:00 PM. LPN #3 stated, Correct. During an interview with the Director of Nursing (DON) on 3/10/19 at 4:05 PM in the DON office, the DON was asked when Resident #12 received the [MEDICATION NAME] ER 60 mg tablet that was ordered every 12 hours. The DON stated, On new admits (admissions) we don't get their meds (medications) till the evening run the next day. Evening run is at 5:00 PM or later. Nurse says between 9:00 PM and 9:30 PM the next evening. We didn't have it since Hospice didn't bring it . The DON confirmed Resident #12 did not receive the scheduled [MEDICATION NAME] ER 60 mg every 12 hours as ordered on admission on 2/12/19 and 2/13/19.",2020-09-01
3026,THE VILLAGE AT GERMANTOWN,445482,7930 WALKING HORSE CIRCLE,GERMANTOWN,TN,38138,2017-10-05,309,D,1,1,EMV311,"**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 intravenous (IV) therapy for 1 of 3 (Resident #74) sampled residents reviewed receiving IV fluids. The findings included: Medical Record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders dated 7/12/17 revealed an order that documented, .Order Date 07/10/17 .Start Date 07/11/17 [MEDICATION NAME] 1 gram IV .QD (every day) .x (times) 10 days. Review of the MEDICATION RECORD . revealed Resident #74 received IV antibiotic [MEDICATION NAME] on the following days: 7/12/17, 7/13/17, 7/14/17, 7/15/17, 7/16/17, 7/17/17, 7/18/17, 7/19/17, 7/20/17. Resident #74 received 9 days of IV antibiotics instead of 10 days as ordered. Interview with the Interim Director of Nursing (DON), in an empty resident's room [ROOM NUMBER], the Interim DON was asked how many doses of the IV antibiotic did Resident #74 receive. Interim DON stated 9. The Interim DON was shown the physician's order and was asked how many doses of IV antibiotic Resident #74 was supposed to receive. The Interim DON stated,10. The Interim DON was asked did the staff follow the physician's order. The Interim DON stated, Not according to what's on that MAR (medication administration record) .",2020-09-01
1772,CONCORDIA NURSING AND REHABILITATION-NORTHHAVEN,445297,3300 BROADWAY NE,KNOXVILLE,TN,37917,2018-01-22,656,D,1,0,5M9L11,"**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 personal hygiene care for 1 resident (#2) and failed to follow the care plan for surgical wound care for 1 resident (#3) of 4 resident care plans reviewed. The findings included: 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 12/2017, revealed .weekly bath on Wednesday and Saturday . Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 with a Brief Interview of Mental Status Score (BIMS) of 14/15 (cognitively intact) and required moderate to maximum assistance of one person for bathing and personal hygiene, was incontinent of urine, and had limitations in range of motion to the left lower extremity. Review of the Documentation Survey Report (monthly documentation of resident care) dated 12/2017, revealed no documentation Resident #2 was showered or assisted with personal hygiene care from 12/17 /17 to 12/26/17 (10 consecutive days). Interview with Resident #2 on 1/19/18 at 12:04 PM, in the resident's room, revealed the resident was alert and oriented. Continued interview revealed in (MONTH) of (YEAR) the resident had gone . a week without a shower . Further interview revealed .you had to ask for one (shower) here or you didn't get it .I will never come back here .I just stayed on them to do my showers until I got one, I should not have had to do that . Interview with the Director of Nursing (DON) on 1/22/18 at 12:15, in the activity office, confirmed the facility failed to follow the resident's care plan for ADL care for Resident #2. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's care plan dated 5/15/17 revealed the resident had an abdominal surgical wound and was to receive wound care twice daily. Review of the Treatment Administration Record (TAR) dated 10/1/17 through 1/19/18 revealed there was no documentation wound care was performed on Friday 10/13/17 on the evening shift; on Wednesday 10/18/17 on the evening shift; Thursday 11/16/17 on the evening shift; Tuesday 11/28/17 on the day shift; Thursday 12/14/17 on the day shift; and on 12/29/17 on the day shift. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 with a Brief Interview of Mental Status Score of 15/15 (cognitively intact) and the resident was dependent upon moderate assistance of one or two persons for all activities of daily living (ADL). Interview with Resident #3 on 1/19/18 at 12:38 PM, in the resident's room, revealed the resident was alert and oriented. Continued interview revealed during the months of October, (MONTH) and (MONTH) of (YEAR), the facility neglected to perform surgical wound care twice daily. Further interview revealed Resident #3 documented dates and times her wound care was performed in a notebook she kept in her room and she had advised nursing staff when wound care was not done. Interview and with the Director of Nursing (DON) on 1/22/18 at 12:15 PM, in the activity office, confirmed the facility failed to follow the care plan for wound care for Resident #3.",2020-09-01
4145,MT PLEASANT HEALTHCARE AND REHABILITATION,445374,904 HIDDEN ACRES DR,MOUNT PLEASANT,TN,38474,2016-11-03,282,J,1,0,J51L11,"**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 safe feeding practices to be provided to a swallow-impaired, aspiration-risk resident when a syringe was used to force feed food and liquids for 1 resident (#1) of 6 residents who were totally dependent on staff for eating. This failure placed all residents at risk for aspiration and requiring total dependence on staff for eating 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 of a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on 11/2/16 at 3:00 PM in the Administrator's office. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 60 day Minimum (MDS) data set [DATE] revealed Resident #1 had adequate hearing, clear speech, could make self understood, was able to understand others, was severely cognitively impaired per the 3/15 score on the Brief Interview for Mental Status, was totally dependent with one person assist for eating, had no swallowing disorder, and received 95 minutes of speech therapy. Medical record review of the care plan initiated on 5/3/16 and updated 7/27/16 revealed .At risk for alteration in nutrition with risk for dehydration AEB (as evidenced by) .impaired cognitive ability with episode confusion and fluctuation in po (by mouth) intake .Interventions included .Observe for changes that may effect intake (i.e .difficulty swallowing .) . Further review revealed the interventions were updated on 8/23/16 to include .swallow precautions . Medical record review of the Speech Therapy (ST) Evaluation and Plan of Treatment dated 4/24/16 revealed Resident #1 had mildly impaired swallowing abilities, and the Assessment for Swallowing section documented .Clinical S/S (signs and symptoms) of Dysphagia (swallowing difficulty): effortful mastication (chewing proces)) . The ST Recertification and Update of Treatment Plan dated 6/6/16 to 7/3/16 revealed the skilled services provided was dysphagia therapy and the diet was changed to pureed (blenderized food) due to pocketing (food getting stuck in mouth), increased feeding time and lethargy. Further review revealed Resident #1 had used general swallowing techniques/precautions and upright posture during meals 70% (percent) of the time by 7/3/16, was tolerating the pureed diet while fed by staff, caregiver/staff were educated on safe swallow strategies including bite/sip, small bites, and positioning. The swallow treatment training included small bites/sips (1/2 to 1/3 teaspoon) and facilitation of body positioning to increase safety with intake. Resident #1's Swallow Ability was moderately impaired, and had declined since the initial evaluation when he was mildly impaired. Interviews with Licensed Practical Nurse (LPN) #5 on 10/24/16 at 2:55 PM and 4:25 PM on the long hall and the conference room, on 10/25/16 at 11:10 AM in the conference room, on 10/26/16 at 4:10 PM in the conference room, and on 11/3/16 8:30 AM, on the long hall revealed Resident #1 had general decline as time passed including pocketing food, had 2-3 vomiting episodes after eating, had .fed (Resident #1) Magic Cup (nutritional supplement) and fluids 2-3 times by syringe .a couple of months before hospice started .I gave Magic Cup and water by syringe the morning of 10/1/16 . (Resident #1) .wanted water and could no longer suck on a straw .I didn't want him dehydrated . When asked since the resident's advanced directive stated no artificial feeding why was a syringe okay to use, the LPN stated .because not able to suck through straw and when you held a cup to the lips the resident could blow into it so I tried a syringe, he knew to swallow once in mouth . When asked what Certified Nurse Aide (CNA) #4 was doing when the LPN entered the resident's room on 10/1/16 at lunch, the LPN stated the CNA .was spoon feeding the resident lunch and I told her there was a syringe available if she needed it . When asked why the LPN used the syringe, the LPN stated .I was trying to help the man out, I don't know if CNA #4 was trained to use syringe . Interviews with CNA #4 on 10/25/16 at 9:25 AM and 11/2/16 at 10:15 AM and 12:35 PM, in the conference room and the nursing station revealed CNA #4 had been spoon feeding Resident #1 lunch on 10/1/16 when LPN #5 entered the resident's room and informed the CNA .syringe in drawer and she told me to try use it. I got syringe out, liquefied the pureed food with the fluid on the tray and put a little in his mouth, he swallowed, I asked if he wanted more and he said 'Uh Huh', I took my time feeding him and he ate all the food, 100% and when I was done feeding he started vomiting. His head of bed was up but I put it up as high as it could go and yelled for help. (CNA #1) came to room and she yelled for (LPN #5) to come to room .(LPN #5) and (RN #1) came in the room .resident had thrown up so bad and stopped breathing . When asked when she was spoon feeding the resident lunch how had the resident been accepting the by mouth food, the CNA stated .he wasn't taking it like before . When asked why she used the syringe, CNA #4 stated .(LPN #5) told her the LPN had been using the syringe throughout the day with magic cup and juice and he did fine . When asked what happened to the syringe, CNA #4 stated .(CNA #)1 told her that (LPN #5) told (CNA #1) to tell (CNA #4) to get the syringe out of there, I threw it in the trash in the resident's room, and then I removed it and took it to the hopper room trash . Interviews with the Speech Therapist on 10/26/16 at 11:10 AM, andon 11/3/16 at 8:40 AM, in the therapist office and the conference room revealed Resident #1 was provided speech therapy for swallowing from 4/24/16 to 7/3/16 and the pureed diet was initiated due to increased swallowing problems and later due to pocketing, increased time feeding and lethargy. Further interview revealed .he was definitely an aspiration risk when I changed the diet to puree due to lethargy and there are no circumstances you should use a syringe .such a high risk for everything to go wrong and my biggest fear was for aspiration . The facility failed to follow the swallow precaution intervention on the care plan. Refer to F154 J, F155 J, F157 J, F224 J SQC, F225 J SQC, F226 J SQC, F 241 J SQC, and F278 [NAME]",2019-11-01
4489,CUMBERLAND HEALTH CARE AND REHABILITATION INC,445262,4343 ASHLAND CITY HWY,NASHVILLE,TN,37218,2016-09-21,282,D,1,0,KCHW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to follow the comprehensive care plan for 2 residents (#1, #2) residents of 8 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the comprehensive care plan dated 5/26/16 revealed .(Resident #1) is receiving antidepressant drugs on a regular basis . Interventions included, .Conduct 1 on 1 visit with (Resident #1) to discuss current status and adjustment to lifestyle changes . Social Service (SS) was to visit 1 Time Weekly Starting 05/26/2016. Review of the Clinical Notes revealed a visit from SS on 5/13/16 and 8/22/16. Continued review revealed no other documentation was noted from SS in the resident's medical record. Interview with the MDS Coordinator on 8/31/16 at 11:30 AM, in the MDS office confirmed SS did not visit with Resident #1 weekly as indicated on the care plan. The MDS Coordinator confirmed the facility failed to follow the comprehensive care plan. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of the comprehensive care plan revealed a problem of wandering. Interventions included, .Check location/whereabouts of (resident) every 30 minutes on each shift . Further review revealed no documentation of every 30 minute checks per shift were present in the medical record for Resident #2. Interview with the DON on 8/31/16 at 1:30 PM, in the Conference Room confirmed the facility failed to check on the whereabouts of Resident #2 every 30 minutes.The DON confirmed the facility failed to follow the comprehensive care plan.",2019-09-01
875,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2017-05-25,309,D,1,0,K3HH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to follow the physician's orders for laboratory tests for 1 of 20 (Resident #71) sampled residents reviewed of the 33 included in stage 2. The findings included: Medical record review revealed Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's telephone orders dated 10/7/16 documented, CBC (complete blood count), with Diff (differential), CMP (Comprehensive Metabolic Panel) D-Dimer, PT ([MEDICATION NAME] Time) /INR (International Normalized Ratio) (on) 10/11/16 . There were no laboratory results dated [DATE] for the CBC with Diff, CMP, D-Dimer, PT/INR found in the medical record. Interview with the Interim Director of Nursing (IDON) on 5/23/17 at 10:10 AM, in the hallway outside her office, the IDON stated she could not locate the laboratory results.",2020-09-01
3345,LIFE CARE CENTER OF OLD HICKORY VILLAGE,445509,1250 ROBINSON ROAD,OLD HICKORY,TN,37138,2018-12-19,635,D,1,0,E35X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to have complete and accurate written orders to provide essential care to a resident upon admission to the facility for 1 (Resident #6) of 8 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 the 14 Day Minimum Data Set ((MDS) dated [DATE] revealed Resident #6 scored 15 on the Brief Interview for Mental Status indicating he was alert, oriented, and able to make his needs known. Continued review of the MDS revealed Resident #6 required extensive assist of 2 people for transfers, dressing, toileting, and bathing; limited assistance with grooming; had an indwelling catheter and was frequently incontinent of bowel. Medical record review of physician's orders [REDACTED].Indwelling foley catheter; Size; Bulb; Care every shift; Dx:________ . Interview with the Administrator and Director of Nursing (DON) on 12/19/18 at 3:37 PM confirmed the order on 11/20/18 was incomplete and did not contain the size of the catheter or the size of the bulb of the catheter. Continued interview revealed the DON confirmed the physician failed to document a [DIAGNOSES REDACTED].",2020-09-01
3233,THE HIGHLANDS OF DYERSBURG HEALTH & REHAB,445497,350 EAST TICKLE STREET,DYERSBURG,TN,38024,2018-02-07,622,E,1,1,G1QP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to have required discharge and transfer documentation for 4 of 5 (Resident #29, 45, 93, and 146) discharged sampled residents reviewed. The findings included: The facility's Documentation of Transfer/Discharges Policy documented, .1. All documentation concerning the transfer or discharge of a resident must be recorded in the resident's medical record .3. Documentation from the charge nurse, or his/her designee, concerning the transfers or discharges must include, as a minimum, and as they apply: a. The reason(s) for the transfer or discharge; b. That an appropriate notice was provided to the resident and/or representative .d. The date and time of the transfer or discharge; e. The new location of the resident; f. The mode of transportation; g. A summary of the resident's overall medical, physical, and mental condition .k. The signature of the person recording the data in the medical record . 1. Medical record review revealed Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The facility was unable to provide nurses' notes, a transfer/discharge form or any other documentation of the transfer to the hospital on [DATE]. Interview with the Director of Nursing (DON) on 2/7/18 at 5:25 PM, in the DON office, the DON was asked if there was a transfer form or any document regarding this transfer for Resident #29. She stated, .I know we have them on the floor. The nurse that sent this resident out to the hospital has been contacted and will be putting in a late entry when she returns. 2. Medical record review revealed Resident #45 was admitted on [DATE] with [DIAGNOSES REDACTED]. The discharge Minimum Data Set ((MDS) dated [DATE] documented .discharge assessment .return anticipated . The facility was unable to provide nurses' notes, physician orders, transfer/discharge form or any other documentation that resident had been discharged to the hospital on [DATE]. Interview with the DON on 2/7/18 at 8:44 PM, in her office, the DON was asked if there should have been a discharge form completed when Resident #45 was discharged to the hospital. The DON stated, Yes. The DON was asked if something should have been written in the nurse's notes explaining why the resident had to be discharged to the hospital. The DON stated, Yes. 3. Closed medical record review revealed Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the nurses' notes revealed a note dated 11/7/17 at 4:45 PM. No other nurses' notes, discharge planning documentation, or discharge information was observed in the medical record. The facility was unable to provide any documentation related to the discharge on 11/8/17. Interview with the Medical Records Nurse, on 2/7/18 at 5:04 PM, in the conference room, the Medical Records Nurse stated, We don't have a discharge or transfer form, or documentation of discharge. Interview with the Social Worker on 2/7/18 at 5:26 PM, in the Social Services office, the Social Worker was asked if she had any information about Resident #93's discharge on 11/8/17. The Social Worker stated, I don't know why I would have done a discharge with home health for one night .I don't remember anything .I keep the packet that I send to them (receiving facility or home health), that way it shows that I sent it to them and what the information was that I sent. The Social Worker was unable to provide documentation of discharge planning or that information had been sent to a home health agency. Interview with the DON on 2/7/18 at 5:43 PM, in the DON office, the DON was unable to find discharge documentation for Resident #93. The DON was asked if there should be documentation of the discharge. The DON stated Yes ma'am . 4. Closed medical record review revealed Resident #146 was admitted to the facility on [DATE] with a readmission on 8/23/17 with [DIAGNOSES REDACTED]. The nurses' notes dated 12/1/17 documented a report was called to the receiving facility. Review of the medical record did not reveal an order for [REDACTED]. Interview with the Social Worker on 2/7/18 at 3:16 PM, in the Social Worker office, the Social Worker was asked who made the arrangements for transfer on Resident #146. The Social Worker stated, The previous Administrator .she contacted (Named Behavior Facility) .I sent over the referral .she was accepted .the Administrator thought the resident was no longer appropriate for this setting .they placed her in a long term psychiatric facility. Interview with the DON on 2/7/18 at 3:32 PM, in the conference room, the DON was asked what was the standard procedure for transfers and discharges. The DON stated, For discharges .if going to the hospital .get MD (Medical Doctor) order .notify family .call report .arrange to send them out .call EMS (Emergency Medical Services) .it's the same for the transfer. The DON was asked if it's acceptable to not have doctor's orders for transfers and discharges. The DON stated, No, it is not acceptable. Interview with the Medical Records Nurse on 2/7/18 at 3:54 PM, on the West nursing station, the Medical Records Nurse was asked to review the resident's medical records. The medical records nurse was asked if she could find the discharge orders for transfer. The Medical Record Nurse stated, No.",2020-09-01
4138,MT PLEASANT HEALTHCARE AND REHABILITATION,445374,904 HIDDEN ACRES DR,MOUNT PLEASANT,TN,38474,2016-11-03,155,J,1,0,J51L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to honor the Advanced Directives for a resident with swallowing and aspiration risks for 1 resident (#1) of 6 residents who were totally dependent on staff for eating. This failure placed all residents at risk for aspiration and requiring total dependence on staff for eating 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 of a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on [DATE] at 3:00 PM in the Administrator's office. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's Physician order [REDACTED].Do Not Attempt Resuscitation, Comfort Measures-Relieve pain and suffering .Use oxygen, suction, and manual treatment of [REDACTED]. was signed by the resident's Power of Attorney and the Medical Director on [DATE]. Medical review of the Speech Therapy (ST) Evaluation and Plan of treatment dated [DATE] revealed Resident #1 had .Clinical S/S (signs and symptoms) of Dysphagia (difficulty swallowing): effortful mastication (chewing process) . The ST Recertification and Update of Treatment Plan dated [DATE] to [DATE] revealed the diet was changed to pureed (blenderized food) due to pocketing (food getting stuck in mouth), increased feeding time and lethargy. The treatment plan further revealed Resident #1 had used general swallowing techniques/precautions and upright posture during meals 70% (percent) of the time by the [DATE] discharge, was tolerating pureed diet while fed by staff, caregiver/staff educated on safe swallowing strategies including bite/sip, small bites, positioning. The swallowing treatment training included small bites/sips (,[DATE] to ,[DATE] teaspoon) and facilitation of body positioning too increase safety with intake. Medical record review of the Progress Notes revealed the following: [DATE] at 11:30 PM .No further emesis noted, had earlier after lunch x (times) 1. Afebrile . [DATE] at 2:15 PM .Moderately large emesis noted during activity in dining room. Afebrile . [DATE] at .1:30 PM Res (resident) consumed 100% of meal with asst (assist) with no dysphagia. Res vomited very large amt (amount) of liquid et (and) pureed food. Res entered Cheyne-Stokes (abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing) respirations et was unresponsive. Nurse at this x (time) went to supply closet to obtain suction equipment .at 1:34 PM Re-entered room. Noted absence of pulse, B/P (blood pressure) et respirations. Skin pale/gray et cool to touch. RN (Registered Nurse) #1 Supervisor notified .at 1:40 PM Pronounced deceased . Interviews with Licensed Practical Nurse (LPN) #5 on [DATE] at 2:55 PM and at 4:25 PM on the long hall and the conference room, on [DATE] at 11:10 AM in the conference room, on [DATE] at 4:10 PM in the conference room, and on [DATE] at 8:30 AM, on the long hall revealed Resident #) had been pocketing food, and had ,[DATE] vomiting episodes after eating. Further interview revealed the LPN had .fed (Resident #1) Magic Cup (nutritional supplement) and fluids ,[DATE] times by syringe .a couple of months before hospice started .I gave Magic Cup and water by syringe the morning of [DATE] . and (Resident #1) .wanted water and could no longer suck on a straw .I didn't want him dehydrated . When asked why the LPN used the syringe, the LPN stated .I was trying to help the man out . When questioned of the resident's advanced directive of no artificial feeding why was a syringe okay to use, the LPN stated .because not able to suck through straw and when you held a cup to the lips the resident could blow into it so I tried a syringe, he knew to swallow once in mouth . When asked what happened to the syringe, the LPN stated .I told Certified Nurse Aide (CNA) #4 to throw it away because there was no doctor's order for it . When asked when you saw CNA #4 spoon feeding the resident lunch and you told CNA #4 the syringe was available for use you knew there was a possibility the CNA would use it, would you consider that force feeding, the LPN stated I guess I would. When asked since the resident did not want artificial feeding and you used a syringe to force food and fluid into his mouth, do you think you violated his rights, the LPN stated .it was against his wishes .I took away his autonomy . Interviews with CNA #4 on [DATE] at 9:25 AM and on [DATE] at 10:15 AM and 12:35 PM, in the conference room and the nursing station revealed CNA #4 had been spoon feeding Resident #1 lunch on [DATE] when LPN #5 entered the resident's room and informed the CNA .syringe in drawer and she told me to try use it. I got syringe out, liquefied the pureed food with the fluid on the tray and put a little in his mouth, he swallowed .he ate all the food, 100% and when I was done feeding he started vomiting . When asked when she was spoon feeding the resident lunch how had the resident been accepting the by mouth food, the CNA stated .he wasn't taking it like before . When asked why she used the syringe, CNA #4 stated .(LPN #5) told her the LPN had been using the syringe throughout the day with magic cup and juice and he did fine . When asked what happened to the syringe, CNA #4 stated .(CNA #1) told her that (LPN #5) told (CNA #1) to tell (CNA #4) to get the syringe out of there, I threw it in the trash in the resident's room then I removed it and took it to the hopper room trash . Telephone interviews with the Hospice Patient Care Coordinator on [DATE] at 8:45 AM and 10:00 AM, and on [DATE] at 10:30 AM, when asked regarding the resident's POST status and having a syringe used to force food into the mouth how that would affect resident's rights stated .syringe is force feeding . Refer to F154 [NAME]",2019-11-01
681,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-10-22,580,D,1,1,IWI711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to immediately notify the physician of [DIAGNOSES REDACTED] (low blood glucose level results) for 1 of 3 (Resident #36) sampled residents reviewed for significant change in condition. The findings include: Medical record review revealed Resident #36 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A progress notes dated 9/8/19 at 10:31 PM, documented, .at the beginning of the tour pt's (patient's) blood sugar was 115, No insulin was given. one hour later pt's blood sugar had dropped 48. pt (Patient) was given PEPSI cola, 1 amp ([MEDICATION NAME]) of [MEDICATION NAME] ([MEDICATION NAME]), 1 carton of milk with 2 packs of sugar, 1 small can of sprite. 20 minutes later pt's blood sugar was 101. pt was not given any insulin this tour. pt will continue to be monitored. The facility was unable to provide documentation that the physician was immediately notified on 9/8/19 of the low blood glucose level of 48. A progress note dated 9/18/19 at 2:52 AM, documented, [MEDICATION NAME] 1 MG (milligram) HYPOKIT Inject 1 mg subcutaneously as needed for BLOOD SUGAR BELOW 50 AND UNCONSCIOUS OR UNABLE TO SWALLOW .BLOOD SUGAR 40, resident unable to swallowing (swallow) just letting juice run down face. The facility was unable to provide documentation that the physician was immediately notified on 9/18/19 of the low blood glucose level of 40. Interview with the Director of Nursing (DON) on 10/21/19 at 1:30 PM, in the Conference room, the DON confirmed the facility was unable to provide documentation the physician was immediately notified of Resident #36's change in condition of [DIAGNOSES REDACTED] and that the physician should have been notified of these [DIAGNOSES REDACTED] episodes.",2020-09-01
2633,WOODBURY HEALTH AND REHABILITATION CENTER,445435,119 WEST HIGH STREET,WOODBURY,TN,37190,2018-05-31,656,D,1,1,SLTY11,"**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 related to falls for 1 resident (#68) of 3 residents reviewed for falls. The findings included: Resident #68 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #68 was discharged to an Assisted Living facility on 11/21/17. Medical record review of Resident #68's care plan dated 6/7/17 revealed .Problem .The resident is at risk of injury from falls .Approaches .Lock wheels on bed/wheelchair . Medical record review of the facility's Fall Scene Investigation Report' dated 9/12/17, revealed .(Resident #68) began to sit down and the bed (wheels unlocked per housekeeping) slid out from under her, causing the fall .Summary . It is unlikely this fall would've happened if wheels to bed were in locked position . Interview with the Director of Nursing on 5/31/18 at 3:38 PM, in the conference room, confirmed the facility's failure to implement Resident #68's comprehensive care plan, which indicated the bed wheels be in locked position, resulted in a preventable fall.",2020-09-01
1641,COUNTRYSIDE HEALTHCARE AND REHABILITATION,445280,3051 BUFFALO ROAD,LAWRENCEBURG,TN,38464,2017-07-20,323,D,1,0,4V9N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to implement accident prevention interventions for 1 of 3 (Resident #4) sampled residents reviewed for falls. The findings included: Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Nurse's Note dated 4/24/7 documented, .resident lying on floor .laughing/joking . The Resident Incident Report dated 4/24/17 documented, .found resident on floor beside bed in room . A Nurse's Note dated 5/16/17 documented, .slid out of w/c (wheel chair) trying to get on toilet in pt (patient) bathroom . The Resident Incident Report dated 5/15/17 documented, .found resident on floor in his bathroom with chair alarm alarming . Interview with the Director of nursing (DON) on 7/19/17 at 4:29 PM, in the conference room, the DON was asked what was the facilities procedure for unattended falls. The DON stated, .We update the care plan .implement fall precaution .complete neuro (Neurological) checks .every 15 minutes times 4 .every 30 minutes times 2 .then every hours . The DON was asked if it was appropriated to not follow the facilities policy for fall risk assessments and complete neuro checks for documented unattended falls. The DON stated, No. The facility was unable to provide a Neurological Flow Sheet for Resident #4 after the 3 documented unattended falls.",2020-09-01
4137,MT PLEASANT HEALTHCARE AND REHABILITATION,445374,904 HIDDEN ACRES DR,MOUNT PLEASANT,TN,38474,2016-11-03,154,J,1,0,J51L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to inform the responsible party/Power of Attorney of a change in the treatment when a 60 cubic centimeter syringe was used to force feed food and liquid for 1 resident (#1) of 6 residents who were totally dependent on staff for eating. This failure placed all residents at risk for aspiration and requiring total dependence on staff for eating 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 of a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on [DATE] at 3:00 PM in the Administrator's office. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician telephone Orders revealed an order on [DATE] for a pureed (blenderized food) diet. Continued medical record review revealed no physician orders from admission to discharge, to syringe feed Resident #1. Medical record review of the Speech Therapy Evaluation and Plan of Treatment dated [DATE] revealed Resident #1's diet was changed to pureed due to pocketing (food getting stuck in mouth), increased feeding time and lethargy. Further review revealed Resident #1 had used general swallowing techniques/precautions and upright posture during meals 70% (percent) of the time by [DATE], was tolerating the pureed diet while fed by staff, caregiver/staff were educated on safe swallowing strategies including bite/sip, small bites, and positioning. The swallowing treatment training included small bites/sips (,[DATE] to ,[DATE] teaspoon) and facilitation of body positioning to increase safety with intake. Medical record review of the Progress Notes revealed the following: [DATE] at 11:30 PM .No further emesis noted, had earlier after lunch x (times) 1. Afebrile . [DATE] at 2:15 PM .Moderately large emesis noted during activity in dining room. Afebrile . [DATE] at .1:30 PM Res (resident) consumed 100% of meal with asst (assist) with no dysphagia (difficulty swallowing). Res vomited very large amt (amount) of liquid et (and) pureed food. Res entered Cheyne-Stokes (abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing) respirations et was unresponsive. Nurse at this x (time) went to supply closet to obtain suction equipment .at 1:34 PM Re-entered room. Noted absence of pulse, B/P (blood pressure) et respirations. Skin pale/gray et cool to touch. RN (Registered Nurse) #1 Supervisor notified .at 1:40 PM Pronounced deceased . Interviews with Licensed Practical Nurse (LPN) #5 on [DATE] at 2:55 PM and at 4:25 PM on the long hall and the conference room, on [DATE] at 11:10 AM in the conference room, on [DATE] at 4:10 PM in the conference room, and on [DATE] at 8:30 AM on the long hall revealed Resident #1 had been pocketing food and had ,[DATE] vomiting episodes after eating. Further interview revealed the LPN had .fed (Resident #1) Magic Cup (nutritional supplement) and fluids ,[DATE] times by syringe .a couple of months before hospice started .I gave Magic Cup and water by syringe the morning of [DATE] . and (Resident #1) .wanted water and could no longer suck on a straw .I didn't want him dehydrated . When asked why the LPN used the syringe, the LPN stated .I was trying to help the man out . When asked what happened to the syringe the LPN stated .I told Certified Nurse Aide (CNA) #4 to throw it away because there was no doctor's order for it . When asked when you saw CNA #4 spoon feeding the resident lunch and you told CNA #4 the syringe was available for use you knew there was a possibility the CNA would use it, would you consider that force feeding, the LPN stated I guess I would. Continued interview, when asked if the LPN had informed Hospice, her supervisors, the physician, the resident or responsible party/Power of Attorney of the use of the syringe prior to Resident #1's death, the LPN stated No. Further interview revealed, when asked since the resident did not want artificial feeding and you used a syringe to force food and fluid into his mouth, do you think you violated his right to make the decision in the change of the method of being fed, the LPN stated .it was against his wishes .I took away his autonomy . Interviews with CNA #4 on [DATE] at 9:25 AM and [DATE] at 10:15 AM and 12:35 PM, in the conference room and the nursing station revealed CNA #4 had been spoon feeding Resident #1 lunch on [DATE] when LPN #5 entered the resident's room and informed the CNA .syringe in drawer and she told me to try to use it. I got syringe out, liquefied the pureed food with the fluid on the tray and put a little in his mouth, he swallowed .he ate all the food, 100% and when I was done feeding he started vomiting . When asked when she was spoon feeding the resident lunch how had the resident been accepting the by mouth food, the CNA stated .he wasn't taking it like before . When asked why she used the syringe, CNA #4 stated .(LPN #5) told her the LPN had been using the syringe throughout the day with magic cup and juice and he did fine . When asked what happened to the syringe, CNA #4 stated .(CNA #1) told her that (LPN #5) told (CNA #1) to tell (CNA #4) to get the syringe out of there, I threw it in the trash in the resident's room, and then I removed it and took it to the hopper room trash . Telephone interviews with the Hospice Patient Care Coordinator on [DATE] at 8:45 AM and 10:00 AM, and on [DATE] at 10:30 AM, when asked regarding the resident's POST status and having a syringe used to force food into the mouth how that would affect resident's rights stated .syringe is force feeding . Interviews with the Speech Therapist on [DATE] at 11:10 AM and on [DATE] at 8:40 AM, in the therapist office and the conference room revealed Resident #1's pureed diet was primarily due to pocketing, increased time feeding and lethargy. Further interview revealed .he was definitely an aspiration risk when I changed the diet to pureed (on [DATE]) due to lethargy and there are no circumstances you should use a syringe .such a high risk for everything to go wrong and my biggest fear was for aspiration . Interviews with the Director of Nursing (DON) on [DATE] at 3:40 PM, [DATE] at 10:50 AM and 4:40 PM, [DATE] at 12:53 PM, and [DATE] at 8:35 AM and 1:45 PM. Further interview revealed the DON was not aware a syringe was being used to feed a resident prior to the event. The DON stated she had been notified by RN #1 of Resident #1's death on [DATE] and of being fed lunch with a syringe, vomiting and then the death after the resident was pronounced and had left the building.",2019-11-01
854,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-12-19,842,D,1,0,RPNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to maintain a complete and accurate medical record for 1 resident (#1) of 9 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged home from the facility on 11/15/17. Medical record review of the hospital discharge Physician order [REDACTED]. 1. [MEDICATION NAME] (diuretic) 40 milligram (mg) 1 tab by po once every day (Q D) as needed (PRN) fluid retention. Patient Instruction: Take when short of breath (SOB), lower extremity swelling, or if you gain 2 pounds (lb) in 1 day or 5 pounds in 5 days. 2. [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME] a [MEDICATION NAME][MEDICATION NAME]) 0.5 mg-2.5mg/3 milliliters (ml) 3 ml inhalation 4 times daily (QID). Medical record review of the facility Physician order [REDACTED]. 1. [MEDICATION NAME] 40 mg 1 po Q D PRN r/t (related to) SOB, or BLE (bilateral lower extremity) [MEDICAL CONDITION], or 2 lb wt (weight) gain in 1 day (D) or 5 lb in days. 2. [MEDICATION NAME] 0.5-2.5mg/3 ml inhalation QID (4 times a day) 3. Daily Weights. Review of the Telephone Physician order [REDACTED]. On 11/9/17 .Daily weights-record on MAR (Medication Administration Record) . On 11/10/17 .CBC (Complete Blood Count), BMP (Basic Metabolic Panel), BNP (B-type Natriuretic Peptide) ([MEDICAL CONDITION], shortness of breath) Please call provider for any critical values . On 11/13/17 .1. Daily weights .2. [MEDICATION NAME] 20 mg Q daily x 7 days .3. Repeat CBC, BMP,BNP on Wednesday 11/15/17 . Review of the Pharmacy Delivery Ticket dated 11/13/17 revealed [MEDICATION NAME] 20 mg had been delivered to the facility for Resident #1. Medical record review of the 11/2017 MAR revealed the following: 1. [MEDICATION NAME] 40 mg po Q D PRN r/t SOB, or BLE [MEDICAL CONDITION], or 2 lb wt gain in 1 day or 5 lb in 5 D was administered on 11/13/17 and 11/14/17. 2. [MEDICATION NAME] 0.5-2.5mg/3 ml inhalation QID at 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM. Of the 50 opportunities for administration 16 treatments were not administered with no supporting documentation for 14 administrations. [MEDICATION NAME] 20 mg Q D x 7 days ordered on [DATE] was not on the 11/2017 MAR. Medical record review of the weight documentation on the Admission Screen, 11/2017 MAR, the computer, or Daily AM Weight form revealed: 11/2/17-181 11/3/17-180 11/4/17-183.4 (an increase of 3.4 lb in 1 day, required PRN [MEDICATION NAME], not administered) 11/5/17-183.8 11/8/17-187 11/13/17-187.4 11/14/17- 192.6 (received 40 mg [MEDICATION NAME] administration) 11/15/17-196 (received 40 mg [MEDICATION NAME] administration) The facility failed to obtain and document weights for 6 of 14 days of the admission on 11/6/17, 11/7/17, 11/9/17, 11/10/17, 11/11/17 and 11/12/17. Interview with Licensed Practical Nurse (LPN) #6 on 12/13/17 at 2:40 PM in the conference room confirmed the LPN provided direct care to Resident #1. Further interview confirmed the LPN signed the 11/13/17 order for [MEDICATION NAME] 20 mg and failed to transcribe the order on the MAR. Further interview revealed the LPN was not aware she was to document the reason for not administering a medication on the back of the MAR. Interview with the Director of Nursing (DON) on 12/13/17 at 4:05 PM, 12/14/17 at 1:55 PM, 12/18/17 at 2:55 PM, and 12/19/17 at 10:00 AM in the conference room confirmed the facility failed to transcribe the 11/13/17 [MEDICATION NAME] 20 mg order onto the MAR. Further interview revealed if the medication was not administered the DON expected the reason to be documented on the back of the MAR and the facility failed to do so. Further interview revealed the nursing staff .would have to weigh the person to know if the weight increased in order to administer the 40 mg [MEDICATION NAME] . Further interview confirmed the facility failed to obtain daily weights for the resident. The facility failed to maintain a complete and accurate medical record.",2020-09-01
5168,LIFE CARE CENTER OF RHEA COUNTY,445494,10055 RHEA COUNTY HIGHWAY,DAYTON,TN,37321,2016-05-24,514,D,1,0,BR2U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to maintain complete and accurate clinical records related to the Treatment Administration Record (TAR) documentation for 1 resident (#5) of 3 residents reviewed for orthotic devices. The findings included: Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician's telephone order dated 5/2/16 revealed Clarification via Tennessee ortho (orthopedic): WBAT (weight bearing as tolerated) R (right) knee .DC (discontinue) knee immobilizer .May use knee brace when ambulating . Medical record review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed knee immobilizer to right knee was checked 12 times after the 5/2/16 order to discontinue the knee immobilizer and had not been changed to use the knee brace. Interview with the Wound Care Nurse #2 on 5/24/16 at 1:20 PM, in the Private Dining Room confirmed she checked the knee immobilizer on the TAR but knew the resident had on a knee brace. Continued interview revealed the nurse checked the TAR as a device not as a knee immobilizer or knee brace. Interview with Licensed Practical Nurse (LPN) #4 on 5/24/16 at 1:30 PM, in the Private Dining Room confirmed the TAR should have been changed on 5/2/16 to discontinue the knee immobilizer and use the knee brace.",2019-05-01
1183,BOULEVARD TERRACE REHABILITATION AND NURSING HOME,445235,1530 MIDDLE TENNESSEE BLVD,MURFREESBORO,TN,37130,2017-05-02,514,D,1,0,E04V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to maintain complete and accurate medical records for 2 residents (#2, #4) of 8 residents reviewed. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].IV (intravenous) NS (normal saline) at 125ml/hr (milliliters per hour times) 2 liters, hypovolemia. Medical record review of a physician's orders [REDACTED]. Medical record review revealed the facility did not have a policy for hypodermoclysis in effect at the time the procedure was administered on 12/30/16 to Resident #2. Interview with the Director of Nursing (DON) on 4/10/17 at 2:30 PM in the conference room confirmed she failed to write the verbal order from the physician for the procedure hypodermoclysis and the facility did not have a policy in effect for the procedure hypodermoclysis on 12/30/16. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Re-Admit Admission Assessment for 1/13/17 revealed the admission assessment was not done. Interview with the DON on 4/12/17 at 5:00 PM in her office confirmed the nurse failed to complete the Re-Admit Admission Assessment on 1/13/17.",2020-09-01
1467,AHC CUMBERLAND,445262,4343 ASHLAND CITY HIGHWAY,NASHVILLE,TN,37218,2018-07-11,842,D,1,0,0OIK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to maintain complete and acurat medical records for 3 (Resident #1, #2, #3) of 5 residents reviewed. 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 Resident #1 scored 11 on the Brief Interview for Mental Status (BIMS) indicating she was mildly cognitively impaired. Continued review of the MDS revealed Resident #1 was dependent on 1 person for bathing. Review of the shower schedule for Resident #1 revealed she was to be bathed on the 3:00 PM - 11:00 PM shift on Tuesday-Thursday-Saturday. Medical record review of the Certified Nurse Aide (CNA) documentation of showers revealed no showers were documented as being given on 5/3/18, 5/5/18, 5/12/18, 5/15/18, 5/19/18, 5/24/18, 5/26/18, 5/29/18, and 5/31/18. Continued medical record review of documentation of showers revealed no shower was documented as being given on 7/3/18. Medical record review of the documentation of Resident #1 being incontinent of bowel and bladder was documented by the CNAs on the ADL form. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS revealed Resident #2 scored 15 on the BIMS indicating she was alert, oriented, and able to make her needs known. Continued review of the MDS revealed Resident #2 was totally dependent on 1 person for bathing. Review of the shower schedule revealed Resident #2 was scheduled to have a shower on the 11:00 PM - 7:00 AM shift on Monday-Wednesday-Friday. Medical record review of the CNA documentation of showers revealed no documentation of showers on 5/2/18, 5/7/18, 5/11/18, 5/14/18, 5/16/18. 5/18/18, 5/23/18, 5/25/18, and 5/30/18. 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 scored 10 on the BIMS indicating he was moderately cognitively impaired. Continued review revealed he was dependent on 2 people for bathing. Review of the shower schedule revealed Resident #3 was scheduled for a shower on the 3:00 PM - 11:00 PM shift on Monday-Wednesday-Friday. Medical record review of the CNA documentation of showers revealed he had a bed bath each night from 7/1/18 - 7/10/18 and should have had a shower on 7/2/18, 7/4/18, 7/6/18, and 7/19/18. Interview with the Administrator and Director of Nursing (DON) on 7/11/18 at 12:25 PM in the Conference Room revealed the DON confirmed no one really checks the CNA documentation of care for completeness on a daily basis but they try to check and educate staff on daily charting.",2020-09-01
3108,MCKENDREE VILLAGE,445491,4347 LEBANON ROAD,HERMITAGE,TN,37076,2019-01-30,697,D,1,0,QD4E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to monitor a resident's pain in accordance with professional standards of practice as stated in the Lippincott Manual of Nursing Practice for 1 (Resident #3) of 7 residents reviewed for pain. The findings include: Medical record review revealed Resident #3 was admitted to the facility on [DATE] and discharged to another LTC facility on 1/28/19 with [DIAGNOSES REDACTED]. Medical record review of the 14 Day Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 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 #3 required extensive assistance of 1 person with transfers, bed mobility, and dressing; extensive assistance of 2 people with toileting; and was dependent on 1 person for grooming and bathing. Medical record review of the Medical Administration Record (MAR) for 1/2019 revealed Resident #3 was ordered Pain Assessment daily on the 7:00 AM - 7:00 PM shift. Continued review of the MAR indicated [REDACTED]. During interview on 1/30/19 at 2:20 PM in the conference room, the Director of Nursing confirmed the lack of documentation on 13 occasions, indicating if it is not documented it is not done.",2020-09-01
657,DIVERSICARE OF SMYRNA,445160,200 MAYFIELD DRIVE,SMYRNA,TN,37167,2017-09-14,309,D,1,0,TNU911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to monitor and evaluate the effectiveness of interventions for identified behaviors in order to attain and maintain the highest practicable psychosocial well-being for 1 (Resident# 3) of 9 sampled residents. The findings included: Medical record review revealed Resident#3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/4/17, revealed Resident# 3 had a BIMS (Brief Interview for Mental Status) score of 14, indicative of intact cognitive status. Resident #3's Behavior Section of the MDS indicated [MEDICAL CONDITION] and other behavior not directed towards others. Medical record review of the plan of care developed on 3/24/08, revealed an established problem, Episodes of socially inappropriate behaviors AEB (as evidenced by) places washcloths down the front of his pants, urinates on floor and causes odor in his room, refuses care, may refuse showers at times due to his being embarrassed about his incontinence. Keeps urinal on bedside table. Interventions included: Explain the need for care trying to be provided; psych (psychiatric) eval (evaluation) and tx (treatment) as indicated; be calm in manner and approach. If resident is resistant try reproaching; encourage and then praise resident for using call light when assistance is needed; social services to visit prn (as needed); remind the resident of the need for good hygiene and odor control; Male tech if available and remove soiled linens from resident closet and bedside stand, dresser daily to eliminate odors. Medical record review of Nursing Notes, from (MONTH) and (MONTH) (YEAR) revealed on 7/18/17 at 9:07 PM Resident# 3 was noted with a history of poor hygiene habits such as pours urine at bedside. Hiding dirty laundry in closet. Medical record review of Nursing Notes dated 7/25/17 at 2:56 PM, revealed, When staff ask resident to change his clothes and to get shaved resident started yelling at staff. I'm not wet! Medical record review of Nursing Notes dated 7/31/17 at 6:32 AM, revealed, Refused x (times) 2 this morning to have brief changed which was wet, started yelling and cursing at nurse. Medical record review of Nursing Notes dated 8/8/17 at 11:15 PM, revealed, (Resident #3) was noted to like to pour urine on bedroom floor and hiding dirty laundry in closet, causing a strong smell in room and making his roommate very uncomfortable. Medical record review of the Nursing Note dated 8/16/17 at 1:13 AM, revealed, Has behavior issue such as pour urine on the floor often, hiding dirty laundry in places. Medical record review of Social Service documentation revealed no Social Services involvement regarding the identified behaviors. Interview with the Social Services Director (SSD) #1 on 9/12/17 at 8:30 AM, confirmed she had not been involved with Resident #3 and was not aware of Resident #3's inappropriate behaviors. Interview with the Director of Nursing (DON) on 9/12/17 at 10:00 AM, revealed monitoring of behaviors was documented by the nurses on the Medication Administration Record [REDACTED]. Further interview with the DON at 3:05 PM, after a review of Resident #3's MAR, confirmed the implementation of care plan approaches were not being monitored to evaluate effectiveness of interventions to further develop a systematic approach in care and services in order for Resident#3 to attain his highest practicable psychosocial well-being.",2020-09-01
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
5930,LIFE CARE CENTER OF GRAY,445479,791 OLD GRAY STATION ROAD,GRAY,TN,37615,2015-11-18,157,D,1,1,4LDS11,"**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 a resident's emergent transfer to teh hospital for 1 resident (#86) of 12 residents and 3 families reviewed. The findings included; Resident #86 was admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. Review of a Nurse's Note dated 9/2/15 at 7:35 PM, revealed .observed patient with labored breathing as evidenced by accessory muscle use .patient on O2 (oxygen) at 3 LPM (liters per minute). LPN (Licensed Practical Nurse) Charge Nurse able to obtain O2 Sat (saturation) of 70%. This nurse unable to contact the responsible party .Left message to return call. Notified MD (physician) of patient's current condition. Received new order to transfer to ER (emergency room ) . Interview with RN (Registered Nurse) #1 on 11/17/15 at 3:00 PM, at the 100 Hall Nurse's Station confirmed I called the daughter one time prior to calling the doctor for the order to transport. There was no answer, I left no message at that time, got the order and transported the patient, who was visibly cyanotic and struggling to breathe. I called the daughter back, still no answer, and left a message for the daughter to call back. Interview with the Assistant Director of Nursing on 11/17/15 at 3:40 PM, confirmed the resident's wife came in the next day to visit, did not know the resident went to the hospital, and was upset she wasn't notified.",2018-11-01
400,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-11-13,157,D,1,1,UJ6N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to notify the physician and family of a fall for 1 resident (#43) of 8 residents reviewed for falls, of 29 residents reviewed. The findings included: Medical record review revealed Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. Review of the significant change MDS dated [DATE] revealed the resident required extensive assist of 2 persons for bed mobility, transfers, toilet use; and extensive assist of 1 person for locomotion on the unit, dressing, and eating. Medical record review of a nursing note dated 9/15/17 at 8:45 PM revealed, .Night nurse here for shift report. Night nurse taken to resident's room for report. Night nurse verbalizes understanding to this nurse's shift report. Resident lying on floor mat. Resident's eyes closed, respirations even and unlabored. Skin warm, dry and normal color . Medical record review of a nursing note dated 9/15/17 at 9:30 PM revealed, .This nurse and staff observe resident sitting on mat. Resident offered water per this nurse. Resident refuses to drink water. Resident covered with blanket for comfort. This nurse leaves room with door open due to no residents in hallway . Medical record review of the SBAR - Change of Condition (Situation, Background, Action, Response) created on 9/16/17 at 12:14 AM with an effective date (meaning the time/date of incident) of 9:07 PM, revealed, .Resident observed sitting on floor in her room. Resident was scooting across floor . Medical record review of a nursing noted dated 9/16/17 at 7:32 AM revealed, .Post Fall: Head to toe assessment - greyish/blue colored bruise & (and) swelling across forehead - tissue soft to palpate .Quarter size blue bruise with raised area top of head. Bruise remains bridge of nose; swelling with reddish bruise lt (left) eye. Old bruising both hands & scattered bruises BUE & BLE (bilateral upper extremities and bilateral lower extremities) .Bruise rt (right) side rib area. No c/o (complaint of) pain. Rested quietly during the night in low bed - mattress beside bed . Medical record review of a nursing note dated 9/16/17 at 6:39 PM revealed, .Notified of increase in bruising and [MEDICAL CONDITION] to the nose, forehead, and eyes of this resident S/P (after) fall last night. Spoke with the hospice medical director .Medical director for hospice at this time wants to wait for the hospice nurse to evaluate the resident and speak with the family on their wishes . Medical record review of a nursing note dated 9/16/17 at 7:50 PM revealed, .Talked with D.O.N. (Director of Nursing) regarding resident previous fall. Hospice called and nurse came in .Asked to call family to see if they wanted to send resident to ER (emergency room ) or not .Talked with (family member) . Interview with Registered Nurse (RN) #1 on 11/7/17, at 8:04 AM, at the south nurses' station, revealed RN #1 was notified of Resident #43's facial bruising on 9/16/17, at approximately 6:30 PM, approximately 21 1/2 hours after the fall. The RN then notified the hospice physician and family at that time. Further interview confirmed the facility failed to notify the physician and family of the fall in a timely manner.",2020-09-01
4139,MT PLEASANT HEALTHCARE AND REHABILITATION,445374,904 HIDDEN ACRES DR,MOUNT PLEASANT,TN,38474,2016-11-03,157,J,1,0,J51L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to notify the physician and the responsible party a swallow-impaired, aspiration-risk resident was force fed food and liquids by a syringe for 1 resident (#1) of 6 residents who were totally dependent on staff for eating. This failure placed all residents at risk for aspiration and requiring total dependence on staff for eating 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 of a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on 11/2/16 at 3:00 PM in the Administrator's office. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Licensed Practical Nurse (LPN) #5 on 10/25/16 at 11:10 AM, in the conference room revealed the LPN had .fed (Resident #1) Magic Cup (nutritional supplement) and fluids 2-3 times by syringe .a couple of months before hospice started .I gave Magic Cup and water by syringe the morning of 10/1/16 ., and Resident #1 .wanted water and could no longer suck on a straw .I didn't want him dehydrated .I had not told the doctor, the resident or the responsible party of the syringe use . Interviews with the Speech Therapist on 10/26/16 at 11:10 AM, and on 11/3/16 at 8:40 AM, in the therapist office and the conference room revealed the pureed (blenderized food) diet was due to pocketing (food getting stuck in mouth), increased time feeding and lethargy. Further interview revealed .he was definitely an aspiration risk when I changed the diet to pureed (5/30/16) due to lethargy and there are no circumstances you should use a syringe .such a high risk for everything to go wrong and my biggest fear was for aspiration . Telephone interview with the Medical Director on 10/27/16 at 12:17 PM, when asked if he was aware Resident #1 had been fed by a syringe stated .I became aware after the fact that fluids were given by syringe by a nurse . Continued interview revealed, when asked if he was aware a Certified Nurse Aide (CNA) had fed Resident #1 food by a syringe, stated .I was not aware a CNA fed food by syringe .don't recall facility telling me that . The facility failed to notify the physician and the responsible party Resident #1 had been syringe fed food and fluids. Refer to F154 J and F155 [NAME]",2019-11-01
1126,PINE MEADOWS HEALTH CARE,445232,700 NUCKOLLS ROAD,BOLIVAR,TN,38008,2017-05-18,157,D,1,1,7VZO11,"**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 significant changes in a resident's status for 1 of 20 (Resident #87) sampled residents of the 32 residents included in the stage 2 review. The findings included: Closed medical record revealed Resident #87 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented Resident #87 was cognitively intact, required extensive assistance with activities of daily living, and had no functional limitations in range of motion. Confidential QA (Quality Assurance) document - allegation of neglect (Resident #87) (undated) documented, .She stated that around 5:45-6:00 [NAME]M. she made her round on the resident and noted he was not speaking as he had been earlier and was staring. She immediately got the night nurse to check him. They both went into the room and the resident was cold to touch. His blood pressure was 90/50 and he started responding by nodding his head when they asked him questions . Written statement by Registered Nurse (RN) #1 (undated) documented, .At approximately 545 AM, the CNA (Certified Nursing Assistant) call me to his room. She stated he was not talking to her. We checked his vitals. I noted his skin was cool so I replaced his blanket and sheet . Written statement by CNA #3 (undated) documented, .On Thursday Feb (February) 2nd (YEAR) .When I went in to check on (Resident #87) around 5:45am-6:00am he was lying like he was sleeping with his eyes open and he was cold to the touch. He would not answer me. I called for the nurse. She came right away to check on him. The nurse tried to take (Resident #87)'s O2 (oxygen) but his fingertips were very cold. The nurse told me to take his BP (blood pressure) and it was 90/50. The nurse and I kept talking to (Resident #87) to try to get a response. (Resident #87) did not talk but he nodded his head in response to the nurse and I . Interview with the Director of Nursing (DON) on 5/16/17 at 1:10 PM, in the Break Room, the DON was asked if the physician was notified when the resident became unresponsive in the night. The DON stated, .Not to my knowledge .there was not any documentation of that incident . The DON was asked if there should have been documentation describing the earlier incident with the resident. The DON stated, .oh yes, there should have been . The DON was asked if the family was notified. The DON stated, Not to my knowledge. The DON was asked if she expected her staff to notify the physician when there is a change in status. The DON stated, Yes, the nurse should have notified the doctor. Telephone interview with (Named Physician) on 5/17/17 at 11:47 AM, (Named Physician) was asked if he was familiar with Resident #87. (Named Physician) stated, .I see a lot of residents .I will look at the medical records on my computer . (Named Physician) was asked if the facility notified him of Resident #87's non-responsive episode at 6:00 AM on 2/3/17. (Named Physician) stated, .they will notify me .I don't remember if they did, I get a lot of phone calls . (Named Physician) was asked if he expected for the facility to notify him when a resident becomes non-responsive. (Named Physician) stated, .well sure .I would send them to the emergency room unless maybe they were a DNR (Do not Resuscitate) .",2020-09-01
850,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-12-19,580,D,1,0,RPNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to notify the physician services of the failure to administer an as needed diuretic as ordered after a weight gain as ordered; the failure to obtain daily weights as ordered; the failure to obtain laboratory tests as ordered; and the failure to administer a daily diuretic as ordered for 1 resident (#1) of 9 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged home from the facility on 11/15/17. Medical record review of the hospital discharge Physician order [REDACTED]. 1. [MEDICATION NAME] (diuretic) 40 milligrams (mg) 1 tab by po (by mouth) once every day as needed (PRN) fluid retention. Patient Instruction: Take when short of breath (SOB), lower extremity swelling ([MEDICAL CONDITION]), or if you gain 2 pounds (lb) in 1 day or 5 pounds in 5 days. Medical record review of the facility Physician order [REDACTED]. 1. [MEDICATION NAME] 40 mg 1 po Q D PRN (every day as needed) r/t (related to) SOB, or BLE (bilateral lower extremity) [MEDICAL CONDITION], or 2 lb wt (weight) gain in 1 day (D) or 5 lb in 5 days. 2. Daily Weights. Review of the Telephone Physician order [REDACTED]. On 11/9/17 .Daily weights-record on MAR (Medication Administration Record) . On 11/10/17 .CBC (Complete Blood Count), BMP (Basic Metabolic Panel), BNP (B-type Natriuretic Peptide) ([MEDICAL CONDITION], shortness of breath) Please call provider for any critical values . On 11/13/17 .1. Daily weights .2. [MEDICATION NAME] 20 mg Q daily x 7 days .3. Repeat CBC, BMP,BNP on Wednesday 11/15/17 . Review of the Pharmacy Delivery Ticket dated 11/13/17 revealed [MEDICATION NAME] 20 mg had been delivered to the facility for Resident #1. Medical record review of the 11/2017 MAR revealed the following: 1. [MEDICATION NAME] 40 mg po Q D PRN r/t SOB, or BLE [MEDICAL CONDITION], or 2 lb wt gain in 1 day or 5 lb in 5 days was administered on 11/13/17 and 11/14/17. [MEDICATION NAME] 20 mg Q D x 7 days ordered on [DATE] was not on the 11/2017 MAR. Medical record review of the weight, in pounds, documentation on the Admission Screen, 11/2017 MAR, the computer, or Daily AM Weight form revealed: 11/2/17-181 11/3/17-180 11/4/17-183.4 (an increase of 3.4 lb in 1 day, required PRN [MEDICATION NAME], not administered) 11/5/17-183.8 11/8/17-187 11/13/17-187.4 11/14/17- 192.6 (received 40 mg [MEDICATION NAME] administration) 11/15/17-196 (received 40 mg [MEDICATION NAME] administration) The facility failed to obtain and document weights for 6 of 14 days of the admission on 11/6/17, 11/7/17, 11/9/17, 11/10/17, 11/11/17 and 11/12/17. Medical record review revealed no laboratory test results for 10/10/17 as ordered for the CBC, BMP and BNP. Review of the Admission Nursing Note dated 11/2/17 revealed Resident #1 had 1+ [MEDICAL CONDITION] on bilateral lower extremities. Interview with Licensed Practical Nurse (LPN) #6 on 12/13/17 at 2:40 PM in the conference room confirmed the LPN provided direct care to Resident #1. Further interview confirmed the LPN signed the 11/13/17 Physician order [REDACTED]. Interview with the Director of Nursing (DON) on 12/13/17 at 4:05 PM, 12/14/17 at 1:55 PM, 12/18/17 at 2:55 PM, and 12/19/17 at 10:00 AM in the conference room confirmed the facility failed to transcribe the 11/13/17 [MEDICATION NAME] 20 mg order onto the MAR and failed to administer the mediation as ordered. Further interview revealed if the medication was not administered the DON expected the reason to be documented on the back of the MAR. Further interview revealed the nursing staff .would have to weigh the person to know if the weight increased in order to administer the 40 mg [MEDICATION NAME] . Further interview confirmed the facility failed to obtain daily weights for the resident and failed to administer the PRN 40 mg [MEDICATION NAME] on 11/4/17 after a weight gain. Further interview confirmed the facility failed to obtain the 10/10/17 laboratory tests as ordered and failed to notify the physician. Interview with the Nurse Practitioner (NP) #1 on 12/18/17 at 2:30 PM in the conference room confirmed the NP had not been notified the daily weights had not been obtained, the PRN [MEDICATION NAME] had not been administered after the weight gain on 11/4/17, the 10/10/17 laboratory tests were not obtained and the [MEDICATION NAME] 20 mg daily order had not been transcribed or administered.",2020-09-01
4470,LIFE CARE CENTER OF TULLAHOMA,445238,1715 N JACKSON ST,TULLAHOMA,TN,37388,2016-09-15,157,D,1,0,143711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to notify the physician to obtain orders for follow up, parameters for limitations, and care of a walking boot for 1 resident (#1) of 3 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Continued medical record review revealed Resident #1 was admitted to the facility in a walker boot. Medical record review of admission orders [REDACTED]. Medical record review of the facility's Physician's Progress Note dated 4/10/16 revealed, .Pt (patient) was placed in a boot .(follow up with) Ortho (Orthopedic) in 2 weeks . Medical record review of the facility's Physician's Progress Note dated 5/11/16 revealed, .Pt came (with) boot S/P (status [REDACTED]. Interview with the Physician's Assistant (PA) on 9/14/16 at 10:30 AM in the conference room stated, We totally dropped the ball with no ortho (orthopedic) orders on admission. Interview with Licensed Practical Nurse (LPN) #1 on 9/14/16 at 11:00 AM in the conference room revealed the nursing staff thought Physical Therapy (PT) would call for orders for Resident #1 related to follow up with an Orthopedic Physician and parameters for the walker boot usage, and PT thought nursing was following up on the orders. Continued interview with the LPN revealed the LPN stated, We dropped the ball there. Interview with the PT Director on 9/14/16 at 1:40 PM in the PT office revealed when a resident was admitted with a cast, splint, or boot they usually come with orders relating to the limitations, follow up, and weight bearing status. Continued interview revealed the PT Director stated the resident had a walking boot and they are usually weight bearing. We wouldn't have called Ortho because she wasn't surgical. Usually the Admission Nurse will call and clarify any missing orders. Interview with the Director of Nursing (DON) on 9/14/15 at 2:25 PM in the conference room revealed, when asked who was responsible for obtaining additional orders from the physician when a resident was admitted with a boot to their leg, the DON stated, The Admission Nurse or PT would clarify orders for the boot. Continued interview revealed the DON confirmed the facility failed to notify the physician to obtain physician orders [REDACTED].#1's fracture, follow up care, and walking boot until 5/11/16.",2019-09-01
3840,BETHESDA HEALTH CARE CENTER,445427,444 ONE ELEVEN PLACE,COOKEVILLE,TN,38501,2017-02-23,157,D,1,0,DI9N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to notify the resident's family member of an orthopedic consultation appointment for 1 resident (#5) of 10 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 a Nurse Practitioner's (NP) note dated 12/8/16 revealed .Patient complains of left hand pain; has PRN (as needed) medication available; nursing aware. Daughter requests referral to orthopedic doctor regarding hand .will order. Patient denies other needs at present . Medical record review of the nursing notes from 12/8/16 through 12/29/16 revealed no documentation a referral had been made for an orthopedic consultation or the resident's family had been notified of an appointment for an orthopedic consultation. Medical record review of an orthopedic physician's note dated 12/29/16 revealed No change in current care plan. Patient to follow up .with (orthopedic physician) in 2 weeks. Interview with Resident #5's daughter on 2/22/17 at 1:40 PM, in the facility's living room, revealed Resident #5's daughter was not notified of an appointment with the orthopedic physician on 12/29/16. Continued interview revealed the daughter happened to come for a visit and was told the resident was ready for the appointment and the daughter had accompanied the resident to the appointment. Continued interview revealed the daughter had reported to the Administrator of not being notified of the orthopedic physician's appointment. Interview with the Administrator on 2/22/17 at 1:55 PM, in the Administrator's office, confirmed the daughter had reported not being made aware of the physician's appointment. Interview with the Director of Nursing (DON) on 2/23/17 at 7:30 AM,in the DON's office confirmed there was no documentation the daughter was notified of the orthopedic consultation on 12/29/16.",2020-02-01
5505,CONCORDIA NURSING AND REHABILITATION -LOUDON,445253,1520 GROVE ST BOX 190,LOUDON,TN,37774,2016-02-04,157,D,1,0,XSZC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to notify the responsible party of a medication change for 1 resident (2) of 4 residents reviewed for medication management. The findings included: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 30 day Minimum (MDS) data set [DATE] revealed the resident was not scored (severely cognitive impairment) on the Brief Interview for Mental Status. Further review revealed the resident required total assistance of staff for transfer, dressing, eating, and hygiene/bathing. Medical record review of the written admission physician's orders [REDACTED].Rivastigmine (generic [MEDICATION NAME]) 6 mg (milligrams) cap PO (by mouth) 2X day . Medical record review of a Pharmacy Interchange order dated 4/24/15 revealed .DC (discontinue) [MEDICATION NAME] 6 mg capsule when the current supply of medication is exhausted .New order Donepezil HCL (generic for [MEDICATION NAME]) FC (film coated) 5 mg tablet 1tab by mouth at bedtime for 4 weeks then increase to 10 mg at bedtime . The rationale listed stated the Donepezil is being recommended over generic Rivastigmine capsules and [MEDICATION NAME] because Donepezil is comparably effective, better tolerated, administered once daily rather than twice daily, and is ranked equally in the Geriatric Pharmaceutical Care Guidelines. Further review of the order revealed a physician's signature. Medical record review of the Medication Record from 4/24/15-4/30/15 revealed the resident received Rivastigmine capsules 6 mg twice daily. Medical record review of nurse's progress notes for 4/24/15, on admission and when the pharmacy interchange was received or on 5/1/15 (when [MEDICATION NAME] was started) revealed the responsible party had not been notified. Medical record review of the printed physician's orders [REDACTED].Donepezil HCL F/C 5mg table 1 tab by mouth at bedtime for 4 weeks then increase to 10mg at bedtime . Medical record review of the Medication Record for 5/1/15-5/7/15 revealed the resident received 6 doses (did not get the 8 PM dose on 5/7/15 because order was changed prior to 8 PM) of Donepezil 5 mg at bedtime. Medical record review of the Medication Record for 5/8/15 revealed the medication was changed to [MEDICATION NAME] 6 mg twice daily. Medical record review of a Physician's telephone order dated 5/8/15 revealed .No substitutions for medication without prior approval/order from the MD (physician) . Another telephone order dated 5/8/15 revealed .Do not change med times .No med changes without notifying spouse .No psychoactive or dementia med changes except for with approval of neurologist . Interview with the Executive Director on 2/4/16, at 2:40 PM, in the Family Room, confirmed the medication was changed from [MEDICATION NAME] to [MEDICATION NAME] per the pharmacy recommendation and the responsible party was not notified prior to the change.",2019-02-01
1879,LIFE CARE CENTER OF COPPER BASIN,445310,166 COPPER BASIN INDUSTRIAL PARK PO BOX 518,DUCKTOWN,TN,37326,2018-08-13,580,D,1,0,RPHQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to notify the responsible party of change in physical status and treatment plan for 1 resident (#1) of 3 residents reviewed for wound management. The findings Included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed a [DIAGNOSES REDACTED]. Review of the quarterly Minimum (MDS) data set [DATE] revealed Resident #1 was severely cognitively impaired, required assistance or two persons for all activities of daily living, and had chronic wounds to the right hip and right great toe. Medical record review of Physician's Progress Notes dated 7/15/18 revealed an order for [REDACTED].#1's responsible party of the change in treatment until 8/3/18 (19 days later). Interview with the Director of Nursing (DON) on 8/13/18 at 3:30 PM, in the conference room, confirmed the facility failed to notify the responsible party for Resident # 1 of the change in the resident's treatment plan timely.",2020-09-01
3346,LIFE CARE CENTER OF OLD HICKORY VILLAGE,445509,1250 ROBINSON ROAD,OLD HICKORY,TN,37138,2018-12-19,690,D,1,0,E35X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to obtain an appropriate indication for indwelling catheter use for 1 (Resident #1) of 3 residents reviewed for indwelling urinary catheters. The findings included: Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 Day Minimum Data Set ((MDS) dated [DATE] revealed Resident #6 scored 15 on the Brief Interview for Mental Status (BIMS) indicating he was alert, oriented, and able to make his needs known. Continued review of the MDS revealed Resident #6 required extensive assist of 2 people for transfers, dressing, toileting, and bathing; limited assistance with grooming; had an indwelling catheter and was frequently incontinent of bowel. Medical record review of physician's orders [REDACTED].Indwelling foley catheter; Size; Bulb; Care every shift; Dx:________ . Interview with the Administrator and Director of Nursing (DON) on 12/19/18 at 3:37 PM confirmed the order on 11/20/18 was incomplete and did not contain the size of the catheter or the size of the bulb of the catheter. Continued interview revealed the DON confirmed the physician failed to document a [DIAGNOSES REDACTED].",2020-09-01
3713,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2017-03-03,281,D,1,0,UP9L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to perform a complete skin assessment and failed to notify appropriate individuals of the resident's refusal to cooperate for 1 resident (#3) of 14 residents reviewed. The findings included: Review of facility policy, Abuse Prevention Program, updated 1/19/17, revealed .The facility will not tolerate resident abuse or treatment by anyone including staff members, other residents, consultants, volunteers, staff of other agencies, family members, legal guardians, friends, or other individuals .All personnel must promptly report any incident or suspected incident of resident abuse, mistreatment, or neglect including injuries of unknown origin .Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being .an injury should be classified as an injury of unknown origin when the source of the injury was not observed or known by any person. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 scored 11 on the Brief Interview for Mental Status indicating he was slightly impaired cognitively. Continued review revealed Resident #3 required supervision with transfers and grooming; assistance with dressing and bathing; and was continent of bowel and bladder. Medical record review of nursing notes dated 11/16/16 at 10:09 AM, revealed .Podiatrist on site this am and this writer was called to tx (treatment) room to observe resident's right foot. The 2nd toe on the right foot is necrotic with blackened skin to entire toe. Tissue is peeling around the edges with wet exudate oozing. When questioned resident states he was in shower when the injury occurred. His foot got caught in the w/c (wheelchair). It bled and his nurse put a bandage on it. The foot is swollen, reddened, and slightly warm to touch. Resident states it does not hurt . Medical record review of a nursing note date 11/16/16 at 12:56 PM revealed .PT (patient) presents with RT (right) second toe black in color, small amount of serous thin drainage. Dorsal foot cool to touch, unable to palpate pedal pulse. Spoke with Nurse Practitioner at Wound Center. Orders to send to ER (emergency room ). Medical record review of the ER records dated 11/16/16 revealed the reason for the visit was .I cut my foot in the shower about 1 1/2 weeks ago . Necrotic right 2nd toe. Continued review revealed the statement .Right foot second digit black in color with drainage noted and swelling. Pt thinks he hit it on a WC while in the bathroom maybe several days ago . Review of diagnostic studies completed revealed a completely occluded right posterior tibial artery; complete occlusion of both popliteal arteries; complete occlusion of left anterior tibial artery. Resident #3 was admitted to the hospital and did not return to the facility. Review of the facility investigation dated 11/17/16 and a statement from the Director of Nursing (DON) revealed .I spoke with 3 CNAs (Certified Nursing Aides) who were assigned to Resident #3 and in the past 2 weeks the resident has refused his shower and has not been in the shower room per all three CNAs. I even spoke to the day shift tech and she said she had not given him a shower on days either because he is an evening shower. I then spoke to the Registered Nurse (RN) who works 3-11 (3:00 PM - 11:00 PM) on the shower days of Resident #3 and she said he refused his showers this week and last week. I also spoke with the MDS Coordinator who states he is care planned that he refuses showers because he has a fear of falling. A skin assessment was done on the resident on 11/13/16 and there was nothing on the assessment about the resident's toe. When asked by the Wound Care Nurse did she look at the toe of Resident #3 the assessing nurse (RN #1) stated she did not. He refused to let her. This nurse was written up and educated on the importance of doing the skin assessments from head to toe and if the resident refused she should have notified the DON/ADON or unit manager so we could talk to the resident about the importance of checking his skin weekly . Review of a written statement from RN #1 dated 12/11//16 revealed .(Resident #3) was always non-compliant with showers and often refused to disrobe for skin assessments. And this was the case on 11/13/16 . Review of a written statement dated 11/26/16 from CNA #2 revealed .refused his showers and refused to let his clothing and bedding be changed when I took care of him this past year. I've also witnessed him refuse the same things since I've been working back here . Interview with the Administrator and DON on 2/9/17 at 10:15 AM, in the conference room revealed this resident was non-compliant with showers and also refused care often. Continued interview confirmed RN #1 did not assess the resident's feet on 11/13/16 because he refused and also confirmed RN #1 failed to notify the unit manager or DON of the resident's refusal. Further interview revealed the facility was unable to determine a cause of the injury because the resident kept changing his story of how and when it occurred and no staff would state they had seen the injury and put a dressing on the toe as stated by the resident.",2020-03-01
4775,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2016-07-14,323,D,1,0,YE4H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to prevent a fall during a shower for 1 resident (#1) of 3 residents reviewed for falls. The findings included: Medical record review revealed Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum (MDS) data set [DATE] revealed Resident #1 had moderately impaired cognitive skills, short and long term memory impairment, and was totally dependent for bathing with 1 person assist. Medical record review of the Care Plan dated 4/5/16 revealed .encourage Res (Resident) not to ambulate or transfer per self . Medical record review of the Nursing assessment dated [DATE] revealed .This elder was assisted in the shower chair by Certified Nursing Assistant (CNA). The CNA turned around to grab shampoo this elder then stood up and fell .sustained a laceration to left eyebrow .ice pack applied, area cleaned and steri strips (one steri strip) applied . Review of the facility investigation revealed a witness statement by CNA #2 dated 6/14/16 .as I was getting the shampoo this resident tried to stand and fell . Interview with the Director of Nursing on 7/12/16 at 1:30 PM, in the conference room confirmed the CNA turned to grab the shampoo and Resident #1 stood up and fell to the floor.",2019-07-01
3842,BETHESDA HEALTH CARE CENTER,445427,444 ONE ELEVEN PLACE,COOKEVILLE,TN,38501,2017-02-23,333,D,1,0,DI9N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to prevent significant medication errors for 1 resident (#5) of 3 residents reviewed for transcription medication errors of 10 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 nursing notes dated 1/31/17 revealed patient went loa (leave of absence) to tn (Tennessee) heart to have a procedure done via daughters personal car at 11 am Medical record review of a nursing note dated 2/1/17 at 11:30 AM revealed admitted per wheelchair in private car with daughter to the service of Dr .after having a heart cath with a balloon and 2 stents done. Medical record review of a nursing note, authored by Licensed Practical Nurse #1, dated 2/10/17 at 4:22 PM revealed patient has been confused the past few days and patient daughter called and went over patient medications with daughter .that was changed on admission and daughter called Dr .office and office called nurse explained admission orders [REDACTED]. Talked to NP (Nurse Practitioner) .and went over orders from 2/1/17 and gave verbal order to restart the following medications [MEDICATION NAME] .[MEDICATION NAME] .[MEDICATION NAME] .[MEDICATION NAME] .[MEDICATION NAME] .[MEDICATION NAME] .potassium .[MEDICATION NAME] .and [MEDICATION NAME] . Medical record review of the hospital Medication Reconciliation form dated 1/31/17 revealed .List below all of the patient's medications .prior to Admission and Discharge .Continued review of the hospital Medication Reconciliation form revealed the following medications were to be continued at discharge on 2/1/17 [MEDICATION NAME] 10 mg (milligrams) daily (cognition enhancing medication); [MEDICATION NAME] 1 tablet daily (vitamin); [MEDICATION NAME] 10 mg daily (allergy medication); [MEDICATION NAME] 100 mg daily (antidepressant); [MEDICATION NAME] 137 mcg (micrograms) (medication to treat [MEDICAL CONDITION]); [MEDICATION NAME] 100 mg twice a day ([MEDICATION NAME]); [MEDICATION NAME] 40 mg daily (diuretic); Potassium Chloride 20 meq (milliequivalents) (medication to prevent or treat low blood levels of potassium); and [MEDICATION NAME] 5 mg at bedtime (medication to help control sleep). Review of facility documentation authored by the Director of Nursing (DON) on 2/22/17 revealed the resident had missed 9 doses of [MEDICATION NAME], 9 doses of [MEDICATION NAME], 9 doses of [MEDICATION NAME], 9 doses of [MEDICATION NAME], 18 doses of [MEDICATION NAME], 9 doses of [MEDICATION NAME], 9 doses of [MEDICATION NAME], 9 doses of Potassium Chloride, and 9 doses of [MEDICATION NAME]. Interview with the NP on 2/22/17 at 10:45 AM, in the NP office revealed the NP was aware of the medications not administered as ordered upon readmission on 2/1/17 through 2/10/17. Continued interview revealed the change in confusion could be related to the anesthesia the resident had on 1/31/17 during the cardiac catheterization procedure and the resident's daughter had reported the procedure was prolonged and may have lasted 3 hours. Further interview revealed the resident may have had a TIA ([MEDICAL CONDITION]). Continued interview revealed the decline in cognition could also be a progression of the resident's Dementia. Further interview with the NP revealed I don't think missing the medications would cause a decline in cognitive functioning. Interview with the Director of Nursing (DON) on 2/22/17 at 1:50 PM, in the Administrator's office, revealed the facility staff were unfamiliar with the hospital Medication Reconciliation form, and had read the form incorrectly and had discontinued the medications in error. Further interview revealed 3 nurses had checked the orders and had read the form incorrectly. Continued interview confirmed the resident did not receive 9 doses of [MEDICATION NAME], 9 doses of [MEDICATION NAME], 9 doses of [MEDICATION NAME], 9 doses of [MEDICATION NAME], 18 doses of [MEDICATION NAME], 9 doses of [MEDICATION NAME], 9 doses of [MEDICATION NAME], 9 doses of Potassium Chloride, and 9 doses of [MEDICATION NAME] from 2/1/17 through 2/10/17.",2020-02-01
1305,DIVERSICARE OF MARTIN,445249,158 MT PELIA RD,MARTIN,TN,38237,2017-05-17,505,D,1,1,BGDQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to promptly notify the attending physician of abnormal lab results for 1 of 19 (Resident #40) sampled residents reviewed of the 31 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #40 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A physician's telephone order dated 2/2/17 documented, .Obtain UA (urinalysis) c (with) C & S (culture and sensitivity) . A nurse's note dated 2/3/17 documented, .Urine obtained for UA via sterile in and out cath (catheterization) . Review of the urinalysis results dated 2/3/17 revealed the following abnormal values: Glucose 50 MG/DL (milligrams per deciliter) High with reference range of Negative Blood Small with reference range of Negative Leukocytes Esterase Moderate with reference range of Negative [NAME] Blood Cell 5-15 with reference range of 0-4 Red Blood Cell 5-15 with reference range of 0-4 Squamous [MEDICATION NAME] 5-15 with reference range of 0-4 Bacteria Few with reference range of None Amorphous Crystal Rare with reference range of None The urinalysis results contained a handwritten note that documented, faxed MD (Medical Doctor) 2/3/17 . Review of the urine culture and sensitivity results dated 2/5/17 revealed greater than 100,000 CFU/ML (Colony Forming Units per milliliter) [MEDICATION NAME] species. The facility was unable to provide documentation that the physician had been notified of the results of the culture and sensitivity. Interview with the Director of Nursing (DON) on 5/16/17 at 4:01 PM, in the nursing office, the DON was asked to describe what happened regarding the urinalysis results for Resident #40. The DON stated, We got an order for [REDACTED]. The results of the CBC and CMP were faxed to him on the 13th. On the 15th, he went out to the hospital for an acute change in status per the family's request . The DON was asked if anyone followed up with the physician regarding the UA and C& S results. The DON stated, No .I don't know if he looked at the results when he was here on the 9th or not, but it was in the chart . Telephone interview with Resident #40's Primary Care Doctor (PCP) on 5/17/17 at 8:52 AM, the PCP was asked if he was notified of the UA and C& S results for Resident #40. The PCP stated, If I was it wasn't before he went in the hospital (2/15/17) The PCP was asked if he had been notified of the results, would he have treated Resident #40 for a Urinary Tract Infection. The PCP stated, I don't know if I would have treated him or not; he wasn't symptomatic . Interview with the DON on 5/17/17 at 3:24 PM, in the conference room, the DON was asked what the facility policy was regarding notifying a physician about abnormal lab results. The DON stated, We don't have a policy, but my expectation is that we notify them immediately to 72 hours depending on the symptoms .",2020-09-01
4984,FAYETTEVILLE HEALTH AND REHABILITATION CENTER,445320,4081 THORNTON TAYLOR PARKWAY,FAYETTEVILLE,TN,37334,2016-06-23,323,D,1,0,QLLM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to provide adequate supervision to prevent injury for a resident who was wandering for 1 (Resident #2) of 7 residents reviewed. This failure resulted in potential harm to the resident. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Discharge Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 was severely impaired cognitively. Continued review of the MDS revealed Resident #2 required extensive assist of two people with transfers, dressing, and grooming; was dependent on one person for bathing; required extensive assist of one person for eating; and was always incontinent of bowel and bladder. Further review of the MDS revealed Resident #2 exhibited behaviors of screaming at others and wandering. Review of incident reports revealed Resident #2 had several falls: 1. 1/4/16 at 11:41 AM - unobserved fall in her room 2. 1/10/16 at 8:21 PM - fall in the dining room 3. 2/2/16 at 11:35 AM - fall in dining room 4. 2/26/16 at 6:31 AM - fall in room 5. 3/20/16 at 1:04 AM - fall with fracture 6. 4/16/15 at 6:30 Am - fall in room Medical record review of nurses' notes dated 3/20/16 at 1:05 AM, revealed .Resident noted to be on floor on rt (right) side of bed on rt (right) side. Upon assessment wide area of discoloration to anterior of hip. c/o (complaining of) severe leg and hip pain. MD (physician) notified and ordered to send to ER (emergency room ) to eval (evaluate) and tx (treat). Resident left facility at 1:25 AM via ambulance service . Review of the History and Physical from the hospital dated 3/20/16 revealed x-ray of the right hip showed a .right subcapital femoral neck fracture which will be surgically repaired Monday morning . Continued review of hospital documents revealed Resident #2 required a blood transfusion and had the hip surgically repaired before returning to the facility on [DATE]. Medical record review of the care plan dated 2/20/15 with a problem of .Wandering with potential for elopement . with interventions to include .Allow resident to wander but monitor closely. Provide hazardous free area for mobilization of wheel chair. Provide diversional activities to resident . Medical record review of nursing notes from 1/1/16 through 3/20/16 revealed the resident continued to wander and there was no documentation the care plan was revised since the current interventions were ineffective in addressing the continued wandering. Interview with the Director of Nursing (DON) on 6/20/16 at 2:40 PM in the Admissions Office revealed the Certified Nurseing Aides (CNA) found Resident #2 on her knees with her torso on the bed in another resident's room (#139). Continued interview revealed the CNAs stood resident up and placed Resident #2 in a wheelchair; took her to her own room; stood her up and attempted to ambulate her when she hollered in pain and was unable to weight bear. Telephone interview with CNA #1 on 6/21/16 at 9:35 AM, revealed she and another CNA found Resident #2 in another resident's room (#139) kneeling on the floor with the rest of her body on the bed. Continued interview revealed Resident #2 often laid across the ends of beds. Further interview revealed they helped the resident to the wheelchair and put her in bed in her room then got the nurse to come and look at her. Telephone interview with CNA #2 on 6/21/16 at 9:50 AM, revealed Resident #2 was in another room (#139) kneeling on the floor. Continued interview revealed CNA #1 and CNA #2 got her up and took her to her room then went to get the nurse. Further interview revealed they could see she was in a lot of pain so they lifted her into the chair and then into bed. Telephone interview with Licensed Practical Nurse (LPN) #2 on 6/22/16 at 12:40 PM revealed she was called on her cell phone because the CNA wanted her in the room of Resident #2. Continued interview revealed when she arrived the resident was in bed and in obvious pain so she assessed the resident and determined she needed to go to the ER. Further interview revealed the CNA stated Resident #2 must have rolled out of bed. Continued interview revealed a few days later LPN #2 was called by the DON who stated they had watched the video and saw the CNAs push Resident #2 from room 139, down the hall, across the dining room, and into her room in a wheelchair. Further interview revealed apparently. Further interview revealed the CNAs tried to get Resident #2 to ambulate to her room and did not realize she was hurt. Continued interview revealed when they got to the resident's room they put her to bed. Further interview revealed at the time of the incident Resident #2 was independent with ambulation. Continued interview revealed the last time she cared for Resident #2 the resident was dependent with transfers and wheel chair bound. Interview with the Administrator on 6/21/16 at 3:15 PM in the Administrator's office, stated Resident #2 fell to her knees and broke her hip. Continued interview revealed the femur head was broken off but there was no definitive root cause analysis. In further interview the Administrator stated the hip could have been cracked and the head snapped with movement to the chair and/or bed. Review of the Monthly Summary dated 3/1/16 revealed Resident #2 had unclear speech and was sometimes understood so she was considered to be severely impaired cognitively. Continued review revealed Resident #2 required limited assistance with transfers; required extensive assistance with dressing, eating, toileting, and grooming; was total dependence with bathing; was always incontinent of bowel and bladder. Review of the Monthly Summary dated 5/18/16 revealed Resident #2 revealed the resident had clear speech and was understood but had memory problems so was considered to be moderately impaired cognitively. Continued review of the summary revealed Resident #2 was total dependence for transfers, dressing, eating, toileting, bathing, and grooming; used a wheelchair; had a foley catheter in place; and was always incontinent of bowel. Review of the facility investigation dated 3/20/16 revealed Resident #2 was found by Certified Nursing Aides (CNAs) in another room (#139) with her knees on the floor and her torso on the bed. Continued review revealed the resident was unable to weight bear and had a large area of bruising on her anterior right hip. Further review revealed an investigation was started at that time. Continued review revealed the nurse documented Resident #2 rolled out of bed onto the floor and the CNAs put the resident into bed before the nurse arrived. Further review revealed no one knew how the fracture occurred. Continued review revealed the camera system was checked and showed the CNAs taking Resident #2 in a wheelchair from another room (#139) into her own room. Further review revealed the statements of the CNAs did not match the video Interview with the DON on 6/22/16 at 11:30 AM in the Admissions Office, confirmed the interventions on the care plan for wandering were ineffective which resulted in potential harm to Resident #2.",2019-06-01
1414,SUMMIT VIEW OF ROCKY TOP,445259,204 INDUSTRIAL PARK RD,ROCKY TOP,TN,37769,2017-06-28,204,D,1,1,YWM011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to provide an appropriate discharge plan for one resident (#115) of 2 residents reviewed for admission/transfer/discharge. The findings included: Medical record review revealed Resident #115 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Nurses' Notes dated 6/6/17, revealed the resident was sent to local hospital due to aggressive behavior toward staff and having sexual behaviors toward a particular resident. Continued review revealed the resident returned to the facility on [DATE]. Interview with the Director of Nursing (DON) on 6/28/17, at 7:45 AM, in the DON's office, revealed the resident had sexual behaviors toward one resident, and the facility had to keep the residents separated from the one another. Continued interview revealed Resident #115 progressively had gotten worse and the facility had sent Resident #115 to the hospital on [DATE] for sexual and aggressive behaviors. The DON stated the resident had hit a nurse. The resident was returned to the facility on [DATE]. The DON stated the resident had dementia. The DON stated the facility had been in communication with the [NAME]on City V[NAME] The DON stated the facility had been trying to make arrangements for a transfer to the Veterans Administration (VA) home in [NAME]on City, and had been told to transport the resident to the [NAME]on City emergency room and to refuse to take him back. The DON stated the VA informed the facility to refuse to accept him back and then he would be admitted to the VA Mountain Home. Interview with Admission/Social Services Director on 6/28/17, at 7:50 AM, in the admission office, revealed the resident had behaviors and was in the facility's secured unit. Resident was sent to local hospital on [DATE] due to aggressive and sexual behaviors had gotten worse. She stated the facility took the resident back on 6/7/17. Continued interview confirmed the facility had had communications with the VA Mountain Home with regards to the transfer. The Admissions Director stated the VA facility had advised the facility to transport the resident to [NAME]on City and to refuse to accept back. Admission Director stated the Anderson County Emergency Medical Services would not transport, so arrangements were made with a contract transportation service company. The transportation service transported the resident to the [NAME]on City Hospital emergency room and refused to accept the resident back, in order for the resident to be placed in the VA Mountain Home.",2020-09-01
4278,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2016-10-13,514,D,1,1,LFXZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to provide and maintain accurate and complete medical records for 1 of 36 (Resident #135) sampled residents included in the stage 2 review. The findings included: Medical record review revealed Resident #135 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 15 and was coded for a Stage 2 Pressure Ulcer on admission. Review of the Nursing Admission Information dated 8/19/16 revealed, FULL BODY SKIN EVALUATION with an X marked on the outer right ankle .*Narrative Notes: (R) (right) ankle c (with) open area .No Breakdown or pressure sores . Interview with LPN #7 on 10/13/16 at 10:30 AM, at the 2nd floor nursing station, LPN #7 was asked to explain the contradiction in documentation. LPN #7 stated, .I don't why I wrote that, I really don't .because I was in hurry probably . I know she came here with the sore on her ankle .that x was marked on the wrong side of the ankle, it should have been on the inside .I do that all the time LPN #7 was asked if the resident had the right medial (inner) ankle wound at the time of admission. LPN #7 stated, Yes ma'am she did, I just put it in the wrong place .why I wrote no breakdown or pressure sores I don't know, obviously she had the wound, only it was on the inside of her ankle. Interview with the Director of Nursing (DON) on 10/13/16 at 7:00 PM, in the lobby outside the Administration office, the DON was asked how to determine which of these 2 statements are correct when they are documented in the same paragraph. The DON stated, It would require further assessment. It sort of contradicts itself . Documentation in the medical record was inaccurate and contradictory. Review of the Interdisciplinary Care Plan dated 8/21/16 revealed, Problem .(R) Medial Ankle .Stage 1 with a line drawn through it .Stage 2 with a line drawn through it .R. Medial Ankle .Stage 4 . Interview with LPN #3 on 10/13/16 at 11:30 AM, in the chapel, LPN #3 was asked who dated/initiated the care plan. LPN #3 stated, I did .I wrote this first line. LPN #3 was asked who marked through her documentation. LPN #3 stated, I don't know .I don't know why that is marked out .I can't explain it . The care plan was updated but not dated or signed when the change was made.",2019-10-01
1856,SIGNATURE HEALTH OF PORTLAND REHAB & WELLNESS CENT,445306,215 HIGHLAND CIRCLE DRIVE,PORTLAND,TN,37148,2017-09-21,329,D,1,0,DUCD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to provide justification for antibiotic use for a urinary tract infection [MEDICAL CONDITION] in 1 resident (#13) of 24 residents reviewed for unnecessary medications and adverse drug reactions from the antibiotic use. The findings included: Medical record review of the Face Sheet revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] revealed Resident #13 was severely cognitively impaired. Medical record review of a Nurse's Note dated 10/31/16 revealed a urinalysis (UA) was obtained with no documented signs and symptoms or rationale for obtaining the U[NAME] Review of a physician's orders [REDACTED].#13 was started on [MEDICATION NAME] (an antibiotic) 1 gram intramuscular 11/1/16 and on 11/2/16 for .Resident's UA showed bacteria and WBC's (white blood cells), awaiting culture and sensitivity report, first dose of [MEDICATION NAME] given . The final urine culture and sensitivity report, dated 11/2/16, revealed .No growth in 48 hours . On 11/4/16 Resident #13 was sent to the emergency room (ER) for an acute psychiatric evaluation. The ER diagnosed Resident #13 with a UTI and returned him to the facility with an order for [REDACTED].#13's record which indicated a symptomatic UTI, such as, a change in mental status from his baseline, fever, suprapubic pain or foul smelling urine. Further record review did not reveal any documentation from the 11/4/16 ER visit. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Interview with Licensed Practical Nurse (LPN) #3 on 9/21/17 at 10:30 AM in her office revealed the facility followed McGeer's criteria (a national standard for infection surveillance in long-term care facilities), for determining infections and antibiotic use. Additionally, LPN #3 provided the (MONTH) (YEAR) Line Listing Monthly Infection Report which revealed Resident #13 was started on [MEDICATION NAME] on 11/1/16 and then switched to [MEDICATION NAME] on 11/4/16 for seven days. The report revealed it was not a .true infection .",2020-09-01
5045,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2016-05-25,314,G,1,0,V91S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to provide necessary treatment and services to promote healing and prevent worsening of pressure ulcers for one resident (#9) of 3 residents reviewed for pressure ulcers, of 17 sampled residents, resulting in Harm to Resident #9. The findings included: Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) with an assessment date of 11/28/15 revealed the resident had a Brief Interview for Mental Status (BIMS) of 3 (severely impaired cognition) with no behaviors present during the assessment period. The resident was totally dependent on staff for all levels of activities of daily living (ADLs) and the resident had function limitation in range of motion of upper and lower extremity. Medical record review of the facility's admission assessment and interim care plan dated 11/4/15 revealed the resident was a high risk for skin breakdown. On admission the resident was identified as having red area with broken skin on the coccyx, left ankle with a red scab area, and left lateral foot with a dark purple area. Medical record review of the care plan developed 11/4/15 with a revision date of 2/17/16 revealed the resident had impaired skin integrity with skin tear on sacrum, and a dark area on the left lateral foot. Interventions included administer treatment as ordered, monitor wounds for healing progress, or lack and notify MD/NP (physician or nurse practitioner) as needed, and weekly skin assessments. Medical record review revealed the resident was sent to the hospital, with the pressure areas, and was discharged from the hospital in (MONTH) (YEAR), after receiving treatment for [REDACTED]. The resident was in the hospital for several days and was assessed as having a stage II sacral ulcer while in the hospital and at discharge. Medical record review of a skin assessment dated [DATE] revealed the resident scored 12 indicating the resident was a high risk for pressure ulcers. Medical record review of the wound care nursing notes and weekly skin assessments from (MONTH) (YEAR) to (MONTH) (YEAR) revealed the resident's sacral stage II ulcer was slowly healing. Medical record review of the physician reconciliation orders for (MONTH) (YEAR) revealed the resident's wound treatment protocol included cleanse wound with normal saline or wound cleaner and cover with Alginate silver. Medical record review of a nurses' note dated 2/20/16 for 7 PM - 7AM, revealed the treatment for [REDACTED]. Further medical record review revealed no documentation regarding the area of the wound or whether the wound was healed. Medical record review revealed no further documentation for wound care after 2/20/16. Medical record review of the Weekly Skin Integrity Review dated 2/25/16, revealed the resident was assessed with [REDACTED]. Further review revealed the skin review stated if there was an open area, proceed to appropriate skin condition record. Medical record review revealed the skin condition record was not in the chart and there was no documentation of the stage or characteristics of the wound. Medical record review revealed no further documentation regarding the presence of a wound on the sacral area, the condition of the resident's skin after the Weekly Skin Integrity Review note dated 2/25/16, and no documentation of wound care treatments being performed. Medical record review of nurses' notes dated 3/3/16 at 10:00 AM, revealed the resident was assessed as having altered mental status, respiratory distress, and an elevated temperature. The resident was started on [MEDICATION NAME] (antidiuretic), [MEDICATION NAME] (antibiotic), and [MEDICATION NAME] (steroid), with orders for a chest x-ray, and a new urinary catheter was inserted. Further review revealed the resident was later transferred to the emergency room . Medical record review of the emergency room records dated 3/3/16 revealed the resident was admitted to the hospital with [REDACTED]. Further review of the emergency room records revealed the stage III decubitus ulcer, which was noted to be present on admission to the emergency room , was a potential source for the [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON) on 5/26/16 at 1:30 PM, revealed the wound nurse was responsible for doing weekly wound assessments on residents with pressure ulcers and writing a summary note in the nursing notes. Medical record review of the hospital discharge note dated 12/23/15, with the DON, confirmed the resident was discharged from the hospital with a stage II decubitus ulcer. The DON reviewed the resident's weekly skin inspection review sheets dated 2/25/16 and confirmed the skin inspection review sheet identified the resident had an open area on the sacrum. Further interview confirmed the sheet did not identify the stage of the wound. The DON confirmed the next skin inspection review was dated 3/3/16, when the resident was in the hospital. Medical record review and interview with the DON confirmed there was no documentation of wound assessments or wound care being completed after the treatment was discontinued on 2/20/16. Interview with the Wound Care Nurse on 5/26/16 at 4:00 PM, revealed the nurse was new to the position and was not in the wound care position during the months of (MONTH) and (MONTH) (YEAR). The Wound Care Nurse confirmed the resident was admitted to the facility with a pressure ulcer and was receiving treatment for [REDACTED]. Further medical record review and interview confirmed the Wound Care Nurse could not explain the lack of documentation in the nurses' notes and weekly skin inspections during this period of time (from 2/20/16) since she was not performing wound care duties during that time. Medical record review and interview with the Wound Care Nurse confirmed, according to the hospital record dated 3/3/16, the resident was admitted to hospital with a Stage III sacral ulcer. Interview with the Wound Care Nurse on 5/26/16 at 7:00 PM, confirmed the facility was unable to produce any documentation regarding the status of Resident #9's skin and wounds from the time the treatments were discontinued on 2/20/16, until the resident's discharge to the emergency roiagnom on [DATE]. The Wound Care Nurse confirmed the former wound care nurse was terminated for failure to complete wound care treatments according to the physicians' orders.",2019-05-01
2154,ROGERSVILLE CARE & REHABILITATION CENTER,445359,109 HWY 70 NORTH,ROGERSVILLE,TN,37857,2018-08-15,755,D,1,1,51X511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to provide pharmaceutical services to meet the needs of 1 resident (#66) of 38 residents reviewed. The findings include: Medical record review revealed Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Interview with the Director of Nurses (DON) on 8/15/18 at 10:30 AM, in the conference room, revealed the verbal order was sent to the pharmacy, and entered into the computer system. Review of the Medication Administration Record [REDACTED]. The resident received 50 mg daily from 2/1/18 to 2/15/18. Medical record review of the pharmacy medication reorder form dated 2/16/18 revealed [MEDICATION NAME] 50 mg tablet was reordered. Medical record review of the pharmacy's Change Report (provided to the DON from the pharmacy) dated 2/15/18 revealed a pharmacy technician at the pharmacy changed the [MEDICATION NAME] 50 mg to [MEDICATION NAME] 100 mg every day. Interview with the Pharmacist on 8/15/18 at 10:25 AM, via telephone, revealed a new technician (who is no longer employed with the pharmacy) changed the order to 100 mg [MEDICATION NAME], filled the 100 mg [MEDICATION NAME] order, and sent it to the facility. At the time of the change the MAR indicated [REDACTED]. Further interview confirmed the pharmacy did not dispense the correct dosage of the [MEDICATION NAME] to the facility. Interview with the DON on 8/15/18 at 8:00 AM, in the conference room, confirmed the resident received 4 days (2/17, 2/18, 2/19 and 2/20/2018) of 100 mg of [MEDICATION NAME] and not the 50 mg which was ordered and the pharmacy had not dispensed the correct dose.",2020-09-01
1774,CONCORDIA NURSING AND REHABILITATION-NORTHHAVEN,445297,3300 BROADWAY NE,KNOXVILLE,TN,37917,2018-01-22,677,D,1,0,5M9L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to provide showers and assistance with personal hygiene for 1 resident (#2) of 4 residents reviewed for Activities of Daily Living (ADL). The findings included: 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 12/2017, revealed .weekly bath on Wednesday and Saturday . Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 with a Brief Interview of Mental Status Score (BIMS) of 14/15 (cognitively intact) and required moderate to maximum assistance of one person for bathing and personal hygiene, was incontinent of urine, and had limitations in range of motion to the left lower extremity. Review of the Documentation Survey Report (monthly documentation of personal care provided) dated 12/2017, revealed no documentation Resident #2 was showered or assisted with personal hygiene from 12/17 /17 to 12/26/17 (10 consecutive days). Telephone interview with Family Representative #1 on 1/19/18 at 8:30 AM revealed on or about 12/20/17 Resident #2 was transported to her Physician's office from the facility by ambulance for an outpatient appointment. Continued interview revealed the Physician noted the resident's poor hygiene and body odor during his examination of the resident and inquired if the resident was recovering from surgery at home or in a skilled nursing facility. Further interview revealed the family representative informed the physician the resident was recovering at home. Interview with Resident #2 on 1/19/18 at 12:04 PM, in the resident's room, revealed the resident was alert and oriented. Continued interview revealed in (MONTH) of (YEAR) the resident had gone . a week without a shower . Further interview revealed .you had to ask for one (shower) here or you didn't get it .I will never come back here .I just stayed on them to do my showers until I got one, I should not have had to do that . Continued interview revealed Resident #2 reported to the nursing staff on multiple occasions her requests for showers or personal hygiene assistance were not honored by staff members. Interview with the Director of Nursing (DON) on 1/22/18 at 12:15, in the activity office, confirmed the facility failed to provide ADL care for Resident #2 from 12/17/17 to 12/26/17.",2020-09-01
5616,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2016-01-05,312,D,1,0,8BJL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to provide showers per Physician orders [REDACTED].# 3, #4, #16) of 11 residents reviewed. The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the shower schedule and ADL (activities of daily living) Tracking Form for (MONTH) (YEAR) revealed the resident was ordered to receive 3 showers weekly. Continued review revealed Resident #3 was not showered from 4/19/15 to 4/27/15 (9 consecutive days). There were no indications present in the medical record the resident had refused care. Interview with Resident #3 on 12/7/15 at 3:00 PM, in the resident's room revealed the alert and oriented resident reported the facility failed to provide showers or bed baths as ordered regularly, but the resident could not recall specific dates or times or any negative consequences to her as a result. The resident stated she had frequently addressed her concerns to the unit nurses and the former Director of Nursing to no avail, but could not recall specifically when she last had reported her concerns related to personal care to the facility. The resident stated she had filed formal complaints related to shortages of towels and wash cloths in the facility which had been reported to her by staff members recently. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the shower schedule and ADL (activities of daily living) Tracking form for (MONTH) (YEAR) revealed the resident was ordered to receive 3 showers weekly. Continued review revealed Resident #4 received only one shower a week during the time period of 11/1/15 to 11/14/15 (2 showers in 14 days) and the resident missed 1 shower on 11/16/15 during the week of 11/15-21/15. The resident received 3 showers in an 18 day period and was to have received 7 showers during the same time period per the shower schedule. Interview with Resident #4 on 12/7/15 at 6:05 PM, in the resident's room revealed the resident was alert and oriented in all spheres. The resident reported on a regular basis he had missed showers as scheduled during 11/2015 due to shortages of bath towels when his showers were rescheduled for later in the day and the CNAs forgot to perform them when towels became available later in the shift. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the ADL tracking forms and shower schedules for (MONTH) (YEAR) revealed the resident was ordered to receive 3 showers weekly. Continued review revealed during the week of 5/21/15 to 5/28/15 the resident was showered once in 7 days. Interview and review of the ADL tracking forms for Resident #4 with the Interim Director of Nursing (DON) on 12/9/15 at 10:00 AM, in the conference room confirmed the facility failed to shower Resident #4 as directed. Interview and review of the ADL Tracking Forms with the Staff Development Coordinator (SDC) on 1/5/16 at 5:00 PM, in the conference room confirmed the facility had failed to shower Resident's #3 and #16 as directed.",2019-01-01
4146,MT PLEASANT HEALTHCARE AND REHABILITATION,445374,904 HIDDEN ACRES DR,MOUNT PLEASANT,TN,38474,2016-11-03,309,J,1,0,J51L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to provide the necessary care and services for a resident with swallowing difficulty and at risk for aspiration and receiving Hospice care when a syringe was used to force feed food and liquids for 1 resident (#1) of 6 residents who were totally dependent on staff for eating. This failure placed all residents at risk for aspiration and requiring total dependence on staff for eating 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 of a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on [DATE] at 3:00 PM in the Administrator's office. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum (MDS) data set [DATE] revealed Resident #1 had adequate hearing, clear speech, could make self understood, was able to understand others, was severely cognitively impaired per the ,[DATE] score on the Brief Interview for Mental Status, was totally dependent with one person assist for eating, had no swallowing disorder, and received 95 minutes of speech therapy. Medical record review of the care plan initiated on [DATE] and updated [DATE] revealed the focus on .At risk for alteration in nutrition with risk for dehydration AEB (as evidenced by) .impaired cognitive ability with episode confusion and fluctuation in po (by mouth) intake .Interventions included .Observe for changes that may effect intake (i.e .difficulty swallowing .) . Further review revealed the interventions were updated on [DATE] to include .swallow precautions . Medical record review of the Physician telephone Orders revealed the following: [DATE] was a regular textured diet. [DATE] .ST (Speech Therapy) to eval (evaluate) + (and) tx (treat) as indicated .for cognitive deficit and swallowing secondary to dementia . [DATE] diet texture was changed to mechanical soft. [DATE] the diet was changed to mechanical soft with pureed (blenderized food) meat. [DATE] the diet was changed to pureed. [DATE] .Offer nectar thick liquids Q 2 (every 2 hours) Hydration while awake . [DATE] .DC (discontinu)) ST services eff (effective) [DATE] . [DATE] .Admit to .Hospice effective this day . Medical record review of the Speech Therapy (ST) Evaluation and Plan of Treatment dated [DATE] revealed Resident #1 had mildly impaired swallowing abilities, and the Assessment for Swallowing section documented .Clinical S/S (signs and symptoms) of Dysphagia (swallowing difficulty): effortful mastication (chewing process) . The ST Recertification and Update of Treatment Plan dated [DATE] to the discharge on [DATE] revealed the skilled services provided was dysphagia therapy and the diet was changed to pureed due to pocketing (food getting stuck in mouth), increased feeding time and lethargy. Further review revealed Resident #1 had used general swallowing techniques/precautions and upright posture during meals 70% (percent) of the time by [DATE], was tolerating the pureed diet while fed by staff, caregiver/staff were educated on safe swallowing strategies including bite/sip, small bites, and positioning. The swallow treatment training included small bites/sips (,[DATE] to ,[DATE] teaspoon) and facilitation of body positioning to increase safety with intake. Resident #1's Swallow Ability was moderately impaired, and had declined since the initial evaluation when he was mildly impaired. Medical record review of the Progress Notes revealed the following: [DATE] at 11:30 PM .No further emesis noted, had earlier after lunch x (times) 1. Afebrile . [DATE] at 2:15 PM .Moderately large emesis noted during activity in dining room. Afebrile . [DATE] at .1:30 PM Res (resident) consumed 100% of meal with asst (assist) with no dysphagia. Res vomited very large amt (amount) of liquid et (and) pureed food. Res entered Cheyne-Stokes (abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing) respirations et was unresponsive. Nurse at this x (time) went to supply closet to obtain suction equipment .at 1:34 PM Re-entered room. Noted absence of pulse, B/P (blood pressure) et respirations. Skin pale/gray et cool to touch. RN (Registered Nurse) #1 Supervisor notified .at 1:40 PM Pronounced deceased . by RN #1 @ (at) this time. Call placed to Hospice nurse) .at 1:45 PM RP (Responsible Party) et son notified of passing of resident .(RP) instructed funeral home to be called .at 3:50 PM Remains released to funeral home . Interviews with Licensed Practical Nurse (LPN) #5 on [DATE] at 2:55 PM and 4:25 PM on the long hall and the conference room, on [DATE] at 11:10 AM in the conference room, on [DATE] at 4:10 PM in the conference room, and on [DATE] 8:30 AM, on the long hall revealed Resident #1 had general decline as time passed including pocketing food, and had ,[DATE] vomiting episodes after eating. Further interview revealed LPN #5 had .fed (Resident #1) Magic Cup (nutritional supplement) and fluids ,[DATE] times by syringe .a couple of months before hospice started .I gave Magic Cup and water by syringe the morning of [DATE] . and Resident #1 .wanted water and could no longer suck on a straw .I didn't want him dehydrated . When questioned about the resident's advanced directive of no artificial feeding, why was a syringe okay to use, the LPN stated .because not able to suck through straw and when you held a cup to the lips the resident could blow into it so I tried a syringe, he knew to swallow once in mouth . When asked why the LPN used the syringe, the LPN stated .I was trying to help the man out, I don't know if Certified Nurse Aide (CNA) #4 was trained to use syringe . When asked what CNA #4 was doing when the LPN entered the resident's room on [DATE] at lunch, the LPN stated the CNA .was spoon feeding the resident lunch and I told her there was a syringe available if she needed it .When asked what the LPN did after she was aware the resident was projectile vomiting on [DATE] immediately after eating lunch, the LPN stated she got called to the resident's room .I was going to try to suction but he had already passed . When asked what happened to the syringe, the LPN stated .I told (CNA #4) to throw it away because there was no doctor's order for it . When asked if the LPN had informed Hospice, her supervisors, the physician, the resident or responsible party/Power of Attorney of the use of the syringe prior to Resident #1's death, the LPN stated No. Interviews with CNA #4 on [DATE] at 9:25 AM and on [DATE] at 10:15 AM and 12:35 PM, in the conference room and the nursing station revealed CNA #4 had been spoon feeding Resident #1 lunch on [DATE] when LPN #5 entered the resident's room and informed the CNA .syringe in drawer and she told me to try use it. I got syringe out, liquefied the pureed food with the fluid on the tray and put a little in his mouth, he swallowed, I asked if he wanted more and he said 'Uh Huh', I took my time feeding him and he ate all the food, 100%, and when I was done feeding he started vomiting. His head of bed was up but I put it up as high as it could go and yelled for help. (CNA #1) came to the room and she yelled for (LPN #5) to come to the room .(LPN #5) and (RN #1) came in the room .resident had thrown up so bad and stopped breathing . When asked when she was spoon feeding the resident lunch how had the resident been accepting the by mouth food, the CNA stated .he wasn't taking it like before . When asked why she used the syringe, CNA #4 stated .(LPN #5) told her the LPN had been using the syringe throughout the day with magic cup and juice and he did fine . When asked what happened to the syringe, CNA #4 stated .(CNA #1) told her that (LPN #5) told (CNA #1) to tell (CNA #4) to get the syringe out of there, I threw it in the trash in the resident's room then, I removed it and took it to the hopper room trash . Interview with CNA #1 on [DATE] at 2:40 PM, in the conference room when asked regarding events of [DATE] at lunch, the CNA stated she heard her name yelled out with urgency and she went next door and saw Resident #1 vomiting and CNA #1 yelled for LPN #5 to come to the room and .by the time (LPN #5) got to there (to room) (the resident) took 2 breaths and nothing. (LPN #5) whispered to me to tell (CNA #4) to get the syringe out of the room, I looked at (LPN #5) but told (CNA #4) what (LPN #5) had said and I went back to finish feeding my resident . Interview with CNA #7 on [DATE] at 9:15 AM, in the conference room revealed CNA #7 was assigned to Resident #1 mostly toward the end of his life and there were times he refused to open his mouth to eat. Further interview revealed CNA #7 had spoon fed Resident #1 on [DATE] for breakfast with approximately 50% intake and .swallowing good and drank a lot of liquids . Telephone interviews with the Hospice Patient Care Coordinator on [DATE] at 8:45 AM and 10:00 AM, and on [DATE] at 10:30 AM, when asked if hospice syringe fed residents stated .we don't push .eating, we educate .this is part of the dying process when they do not want to eat .body shuts down and no need to eat or drink unless they ask for something . The interview revealed hospice had no policy on syringe use and .Always told not to do it .not even a part of equipment provided staff . When asked if the hospice was aware the facility had used a syringe to feed Magic Cup and fluid on ,[DATE] occasions and lunch on [DATE] after which the resident projectile vomited and died stated No, I was not aware. Why would you do that? Interviews with the Speech Therapist on [DATE] at 11:10 AM, and on [DATE] at 8:40 AM, in the therapist office and the conference room revealed Resident #1 was provided speech therapy for swallowing from [DATE] to [DATE] and the texture of the food was downgraded progressively until was totally pureed due to increasing problems with dysphagia and swallowing problems. Further interview revealed the pureed diet was primarily due to pocketing (food getting stuck in mouth), increased time feeding and lethargy. Further interview revealed .he was definitely an aspiration risk when I changed the diet to pureed due to lethargy and there are no circumstances you should use a syringe .such a high risk for everything to go wrong and my biggest fear was for aspiration . Interviews with the Director of Nursing (DON) on [DATE] at 3:40 PM, on [DATE] at 10:50 AM and 4:40 PM, on [DATE] at 12:53 PM, and on [DATE] at 8:35 AM and 1:45 PM, in the conference room revealed the facility did not have a policy on syringe feeding a resident, and did not have a policy on aspiration/aspiration precautions. Further interview revealed the DON was not aware a syringe was being used to feed a resident prior to the event. The DON stated she had been notified by RN #1 of Resident #1's death on [DATE] and of being fed lunch with syringe, vomiting and then the death after the resident was pronounced and had left the building. When asked what the facility did after they were aware of the syringe feeding, the DON stated .interviewed the CNA and LPN, wrote up and suspended the LPN, and did one-on-one training with the CNA with verbal warning and planning to do full staff in-service on inappropriate use of syringe at next staff meeting . Telephone interviews with the Medical Director on [DATE] at 12:17 PM and on [DATE] at 12:50 PM, revealed when asked when he had become aware the facility had used a syringe stated .aware after the fact fluids given by syringe by the nurse . Further interview revealed when asked if he was aware a CNA had fed Resident #1 lunch by syringe with 100% intake, projectile vomited and then died , stated .I didn't know (Resident #1) got pureed food by syringe. Don't recall facility telling me . Further interview revealed, when asked if feeding with a syringe, thereby forcing the food into mouth, could have contributed to the projectile vomiting and death stated .He had significant issues already and reasonable to say aspirated, but with medical issues something else could be going on . Refer to F154 J, F155 J, F157 J, F224 J SQC, F225 J SQC, F226 J SQC, F241 J SQC, F278 J and F282 [NAME]",2019-11-01
5044,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2016-05-25,282,G,1,0,V91S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to provide treatment and services for pressure ulcers per the care plan for one resident (#9) of 3 residents reviewed for pressure ulcers, of 17 sampled residents, resulting in Harm to Resident #9. The findings included: Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) with an assessment date of 11/28/15 revealed the resident had a Brief Interview for Mental Status (BIMS) of 3 (severely impaired cognition) with no behaviors present during the assessment period. The resident was totally dependent on staff for all levels of activities of daily living (ADLs) and the resident had function limitation in range of motion of upper and lower extremity. Medical record review of the facility's admission assessment and interim care plan dated 11/4/15 revealed the resident was a high risk for skin breakdown. On admission the resident was identified as having red area with broken skin on the coccyx, left ankle with a red scab area, and left lateral foot with a dark purple area. Medical record review of the care plan developed 11/4/15 with a revision date of 2/17/16 revealed the resident had impaired skin integrity with skin tear on sacrum, and a dark area on the left lateral foot. The resident had potential for increased skin impairment due to incontinence and decreased mobility. Interventions included the following: administer treatment as ordered, monitor wounds for healing progress, or lack and notify MD/NP (physician or nurse practitioner) as needed. Report onset signs/symptoms of infection (odor, redness, drainage) to MD/NP. Weekly skin assessments. Check for incontinence every 2 hours and more often if needed. Turn and reposition every two (2) hours when in bed; when in Geri-chair provide total assistance to relieve pressure by boosting, shifting weight, and use cushion in Geri-chair. Bunny boots while in bed. Medical record review revealed the resident was sent to the hospital, with the pressure areas, and was discharged from the hospital in (MONTH) (YEAR), after receiving treatment for [REDACTED]. The resident was in the hospital for several days and was assessed as having a stage II sacral ulcer while in the hospital and at discharge. Medical record review of the wound care nursing notes and weekly skin assessments from (MONTH) (YEAR) to (MONTH) (YEAR) revealed the resident's sacral stage II ulcer was slowly healing. Medical record review of the physician reconciliation orders for (MONTH) (YEAR) revealed the resident's wound treatment protocol included cleanse wound with normal saline or wound cleaner and cover with Alginate silver. Medical record review of a nurses' note dated 2/20/16 at 7p-7a revealed the treatment for [REDACTED]. Medical record review of the Weekly Skin Integrity Review dated 2/25/16, revealed the resident was assessed with [REDACTED]. Further review revealed the skin review stated if there was an open area, proceed to appropriate skin condition record. Medical record review revealed the skin condition record was not in the chart and there was no documentation of the stage or characteristics of the wound and no documentation of wound treatment. Medical record review revealed no further documentation regarding the presence of a wound on the sacral area or the condition of the resident's skin after the Weekly Skin Integrity Review note dated 2/25/16. Medical record review of nurses' notes dated 3/3/16 at 10:00 AM, revealed the resident was assessed as having altered mental status, respiratory distress, and an elevated temperature. Further review revealed the resident was transferred to the emergency room . Medical record review of the emergency room records dated 3/3/16 revealed the resident was admitted to the hospital with [REDACTED]. Further review of the emergency room records revealed the stage III decubitus ulcer, which was noted to be present on admission to the emergency room , was a potential source for the [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON) on 5/26/16 at 1:30 PM, revealed the wound nurse was responsible for doing weekly wound assessments on residents with pressure ulcers and writing a summary note in the nursing notes. The DON reviewed the resident's weekly skin inspection review sheets dated 2/25/16 and confirmed the skin inspection review sheet identified the resident had an open area on the sacrum. Further interview confirmed the sheet did not identify the stage of the wound. The DON confirmed the next skin inspection review was dated 3/3/16, when the resident was in the hospital. Medical record review and interview with the DON confirmed there was no documentation of wound care being completed after the treatment was discontinued on 2/20/16. Interview with the Wound Care Nurse on 5/26/16 at 4:00 PM and at 7:00 PM, confirmed the nurse was new to the position and was not in the wound care position during the months of (MONTH) and (MONTH) (YEAR). The nurse confirmed the facility was unable to produce any documentation the care plan was followed and the wounds were monitored for healing, skin assessments were done, and wound treatments were provided between the time the wound treatment was discontinued on 2/20/16, until the resident's discharge to the emergency roiagnom on [DATE]. Refer to F-314",2019-05-01
1651,GRACE HEALTHCARE OF WHITES CREEK,445281,3425 KNIGHT DRIVE,WHITES CREEK,TN,37189,2018-03-02,609,D,1,1,GWBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to report allegations of abuse within the 2 hour time frame as required by the State Agency for 4 residents (#64, #167, #75, #93) of 12 residents reviewed. Findings include: Medical record review revealed Resident #64 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #167 was admitted to the facility on [DATE], readmitted on [DATE], and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nurses' Notes dated 9/28/17 at 6:06 PM revealed Resident #64 was struck by Resident #167 in his chest and arm. Medical record review of the facility investigation revealed the allegation of abuse was reported to the State Agency on 9/29/17 at 1:35 PM. Interview with the Director of Nursing (DON) on 2/1/18 at 3:35 PM in the hallway outside her office confirmed the facility failed to report the allegation of abuse within the 2 hour time frame as required by Federal Regulations for Resident #64 and #167. Review of a facility investigation dated 12/24/17 at 6:57 PM by Registered Nurse (RN) #4 revealed Resident #75 hit Resident #93 on 12/24/17 at 3:30 PM in the dining room and was unwitnessed. Continued review revealed the Physician was notified at 3:35 PM and the family was notified at 3:40 PM. Medical record review of Departmental Notes for Resident #93 dated 12/24/17 at 3:23 PM by Licensed Practical Nurse (LPN) #3 revealed, .Resident has (had) verbal altication (altercation) with another resident . Interview with LPN #3 on 1/30/18 at 3:00 PM in the staff development room when asked what time the altercation occurred, LPN #3 stated, Church service starts at 2:00 PM and goes for an hour or hour and fifteen minutes, so around 3:00 PM or a little after. Review of a Reportable Event Form dated 12/24/17 and completed by the DON revealed Resident #75 hit Resident #93 at 4:00 PM in the dining room. Continued review revealed an X was placed in the box next to Physical Abuse of Patient/Resident. Continued review revealed the form was faxed on 12/24/17 at 18:15 (6:15 PM) to the State Agency. Interview with the DON on 1/30/18 at 3:20 PM in the Staff Development room confirmed the time of the resident to resident altercation between Resident #75 and Resident #93 was closer to 3:00 PM or 3:15 PM. Continued interview with the DON confirmed the facility failed to report allegations of abuse to the SA within the required 2 hour time frame.",2020-09-01
3295,"THE WATERS OF SMYRNA, LLC",445502,202 ENON SPRINGS ROAD EAST,SMYRNA,TN,37167,2017-07-06,225,D,1,0,K8GY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to report an allegation of abuse to the state agency timely for 1 resident (#2) of 3 residents reviewed. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Progress Note dated 6/17/17 at 2:26 PM revealed residents daughter came to nurses station asking if anything hs happened the past few days in her chart. I stated no mam, I have been here today and yesterday and nothing has happen to my knowledge, Daughter also stated thather Mother stated she had been raped outside at night two days ago and the man said bang bang bang. Daughter also texted social services. social services called me, administrator, and DON (Directer of Nursing). Police are here investigating incident and .ambulance service has been called for them to send a truck out here to send residnet to ER to be evaluated. Daughter notified of what's going on. Review of a Nursing Progress Note dated 6/17/2017 at 9:00 PM revealed Pt (patient) returned to facility at 2100 by ambulance with daughter accompanying pt. Daughter reported that the physical exam at teh hospital revealed no brusing or any signs of traums. Therefore, daughter stated that she chose to deny the rape kit at thsi time. Daughter is concerned that the pt's dementia is progressing . Review of physician progress notes [REDACTED]. Today she is non-verbal but smiles socially . Interview with the Director of Nursing (DON) on 7/6/17 at 11:10 AM in the DON's office revealed the incident was reported to the state agency on 6/18/17 at 5:50 PM. Continued interview revealed the incident was reported to the facility staff on 6/17/17 at 3:00 PM. The DON confirmed the facility failed to report the incident within the required 2 hour period to the state agency.",2020-09-01
4141,MT PLEASANT HEALTHCARE AND REHABILITATION,445374,904 HIDDEN ACRES DR,MOUNT PLEASANT,TN,38474,2016-11-03,225,J,1,0,J51L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to report an incident of neglect when a resident with swallowing difficulty and at risk for aspiration was force fed food and liquids by a syringe to the state agency for 1 resident (#1) of 6 residents who were totally dependent on staff for eating. This failure placed all residents at risk for aspiration and requiring total dependence on staff for eating 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 of a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on [DATE] at 3:00 PM in the Administrator's office. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 60 day Minimum (MDS) data set [DATE] revealed Resident #1 had adequate hearing, clear speech, could make self understood, was able to understand others, was severely cognitively impaired per the ,[DATE] score on the Brief Interview for Mental Status, was totally dependent with one person assist for eating, had no swallowing disorder, and received 95 minutes of speech therapy. Interviews with Licensed Practical Nurse (LPN) #5 on [DATE] at 2:55 PM and at 4:25 PM on the long hall and the conference room, on [DATE] at 11:10 AM in the conference room, on [DATE] at 4:10 PM in the conference room, and on [DATE] at 8:30 AM on the long hall revealed Resident #1 had general decline as time passed including pocketing food, and had ,[DATE] vomiting episodes after eating. Further interview revealed LPN #5 had .fed (Resident #1) Magic Cup (nutritional supplement) and fluids ,[DATE] times by syringe .a couple of months before hospice started .I gave Magic Cup and water by syringe the morning of [DATE] . and (Resident #1) .wanted water and could no longer suck on a straw .I didn't want him dehydrated . When questioned about the resident's advanced directive of no artificial feeding, why was a syringe okay to use, the LPN stated .because not able to suck through straw and when you held a cup to the lips the resident could blow into it so I tried a syringe, he knew to swallow once in mouth . When asked why the LPN used the syringe the LPN stated .I was trying to help the man out, I don't know if Certified Nurse Aide (CNA) #4 was trained to use syringe . When asked what CNA #4 was doing when the LPN entered the resident's room on [DATE] at lunch, the LPN stated the CNA .was spoon feeding the resident lunch and I told her there was a syringe available if she needed it . When asked what the LPN did after she was aware the resident was projectile vomiting on [DATE] immediately after eating lunch, the LPN stated she got called to the resident's room .I was going to try to suction but he had already passed . When asked what happened to the syringe, the LPN stated .I told CNA #4 to throw it away because there was no doctor's order for it . When asked if the LPN had informed Hospice, her supervisors, the physician, the resident or responsible party/Power of Attorney of the use of the syringe prior to Resident #1's death, the LPN stated No. Interviews with CNA #4 on [DATE] at 9:25 AM and on [DATE] at 10:15 AM and 12:35 PM, in the conference room and the nursing station revealed CNA #4 had been spoon feeding Resident #1 lunch on [DATE] when LPN #5 entered the resident's room and informed the CNA .syringe in drawer and she told me to try to use it. I got syringe out, liquefied the pureed food with the fluid on the tray and put a little in his mouth, he swallowed, I asked if he wanted more and he said 'Uh Huh', I took my time feeding him and he ate all the food, 100%, and when I was done feeding he started vomiting. His head of bed was up but I put it up as high as it could go and yelled for help. (CNA #1) came to the room and she yelled for (LPN #5) to come to the room .(LPN #5) and (RN #1) came in the room .resident had thrown up so bad and stopped breathing . When asked when she was spoon feeding the resident lunch, how had the resident been accepting the food by mouth, the CNA stated .he wasn't taking it like before . When asked why she used the syringe, CNA #4 stated .(LPN #5) told her the LPN had been using the syringe throughout the day with magic cup and juice and he did fine . When asked what happened to the syringe, CNA #4 stated .(CNA #1) told her that (LPN #5) told (CNA #1) to tell (CNA #4) to get the syringe out of there, I threw it in the trash in the resident's room then I removed it and took it to the hopper room trash . Interviews with the Director of Nursing (DON) on [DATE] at 3:40 PM, [DATE] at 10:50 AM and 4:40 PM, [DATE] at 12:53 PM, and [DATE] at 8:35 AM and 1:45 PM, in the conference room revealed the DON was not aware a syringe was being used to feed a resident prior to the event. The DON stated she had been notified by RN #1 of Resident #1's death on [DATE] and of being fed lunch with a syringe, vomiting and then the death after the resident was pronounced and had left the building. When asked what the facility did after they were aware of the syringe feeding, the DON stated .interviewed the CNA and LPN, wrote up and suspended the LPN, and did one-on-one training with the CNA with verbal warning and planning to do full staff in-service on inappropriate use of a syringe at next staff meeting . Further interview revealed, when asked if the incident was reported to the state agency, the DON stated, as far as I know nothing was reported to the state. Refer to F154 J, F155 J, F157 J, F224 J SQC",2019-11-01
1182,BOULEVARD TERRACE REHABILITATION AND NURSING HOME,445235,1530 MIDDLE TENNESSEE BLVD,MURFREESBORO,TN,37130,2017-05-02,225,D,1,0,E04V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to report and fully investigate an allegation of misappropriation 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 the facility investigation dated 2/14/17 revealed in late 1/2017 CNA #1 beckoned Physical Therapist (PT) #1 into a residents room were she witnessed CNA #1 remove (3) $100 bills from a white envelope inside the wallet of Resident #7 and then placed the envelope back in the wallet and gave it to the PT and told her to give the wallet back to Resident #7. Review of the facility investigation revealed the facility failed to report and fully investigate the allegation of Misappropriation to the State Agency as required. Telephone interview with the Human Resource (HR) coordinator on 4/13/17 at 7:56 AM confirmed the facility failed to report and fully investigate the allegation of Misappropriation to the State Agency as required.",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
1669,GRACE HEALTHCARE OF WHITES CREEK,445281,3425 KNIGHT DRIVE,WHITES CREEK,TN,37189,2019-06-18,657,D,1,0,QRE111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to revise the Comprehensive Care Plan after an incident of verbal and threatened abuse for 1 (Resident #2) of 4 residents reviewed for abuse. 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 scored 9 on the Brief Interview for Mental Status (BIMS) indicating she was moderately cognitively impaired. Continued review of the MDS revealed Resident #2 required extensive assistance of 1 person with transfers, dressing, toileting, grooming, and bathing; and was frequently incontinent of bowel and bladder. Medical record review revealed on 6/5/19 Resident #2 reported to a staff member that nurse (CNA#2) came into the bathroom and was very angry at her. She was fussing at her for getting food on her clothing. The resident reported the employee threatened to spank her. Review of facility investigation of a written statement from CNA #1 dated 6/5/19 revealed .I was in the room with another tech (CNA) when we saw (named Resident #2) was crying. Resident stated (named CNA #2) was mean to her and she changed her pants and she was fussing at her. Resident said that (named CNA #2) was going to whoop her for changing her clothes. As of this date CNA #1 stated (named Resident #2) asks him daily if that nurse is coming back and says I don't want her. Medical record review of the Comprehensive Care Plan revealed it was not updated after the incident to address the resident's fear of the nurse coming back to the facility and the psychosocial harm which occurred to the resident.",2020-09-01
3296,"THE WATERS OF SMYRNA, LLC",445502,202 ENON SPRINGS ROAD EAST,SMYRNA,TN,37167,2017-07-06,280,D,1,0,K8GY11,"**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 (#1) of 5 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Care Plan revised on 5/17/17 revealed .is at risk for falls/injuries related to h/o (history of) falls, requires assistance with transfers, uses wheelchair for mobility .Goal .Risk for major injury related to falls will be reduced through the next review .Interventions .Bolsters to bed .Date initiated 09/04/2016 . Medical record review revealed no documentation the bed bolsters had been used in the care of Resident #1 for the past 3 months. Interview with the Director of Nursing (DON) on 6/7/17 at 11:10 AM in her office, after reviewing the at risk for falls care plan for Resident #1 revised on 5/17/17, revealed the resident had bed bolsters on a previous stay and the care plan was not updated when the resident returned to the facility. Continued interview revealed the resident did not need the bed bolsters for this stay and Bolsters would not have kept her from getting out of the bed. The DON confirmed the facility failed to update the care plan when the resident was readmitted on [DATE] and again when it was revised on 5/17/17.",2020-09-01
4488,CUMBERLAND HEALTH CARE AND REHABILITATION INC,445262,4343 ASHLAND CITY HWY,NASHVILLE,TN,37218,2016-09-21,280,D,1,0,KCHW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to revise the comprehensive care plan for 2 residents (#1, #2) of 8 resident's reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating she was cognitively intact. The resident had no behaviors and used a wheelchair for locomotion. Medical record review of Clinical Notes dated 6/27/16 at 1:25 PM revealed Resident #1 was observed in a male resident's room with his hand close to the side of her breast. The male resident's roommate .stated that he observed them kissing . Continued review revealed a Clinical note dated 7/22/16 at 4:57 PM revealed .noted by CNA (certified nurse aide) with male pt. (patient) outside during designated smoke break touching him in genital area on top of clothes and attempting to kiss him on mouth. CNA asked her to stop and she refused, asked by CNA again to stop and she did not . Clinical note dated 8/22/16 at 8:19 PM revealed, .informed that resident has been displaying behaviors, such as demanding staff to provide care for her at the minute that it is requested. When she doesn't get staff's attention right away, she proceeds to ram her wheelchair into the walls at the nurses's station and yell out 'I want it now.' . Medical record review of the comphrensive care plan for Resident #1 revealed no problem of sexual or verbal behaviors with interventions was present. Interview with the Director of Nursing (DON) on 8/31/16 at 1:30 PM, in the Conference Room confirmed Resident #1's care plan was not revised to include behaviors. Continued interview with the DON confirmed the facility failed to revise the comprehensive care plan related to sexual and verbal behaviors for Resident #1. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of an Admission MDS dated [DATE] revealed the resident scored a 5/15 on the BIMS indicating Resident #2 was severely cognitively impaired. Continued review revealed the resident had physical and verbal behavioral symptoms directed toward others, for 1-3 days of the 7 day look back period. The resident significantly intruded on the privacy of others and was significantly disruptive to the care and living environment. He rejected care and had behaviors of wandering 1-3 days of the 7 day look back period which significantly intruded on the privacy of other residents. Continued review revealed the resident was ambulatory and required supervision of 1 person. Medical record review of Clinical Notes dated 6/2/16 at 12:48 AM revealed, .patient noted to (be) completely naked standing in front of sleeping roommate . Continued medical record review of Clinical notes dated 6/2/16 at 9:04 AM revealed, .pacing, rummaging through other residents belonging especially foods .disrobing in public, wandering, seeking exits .easily agitated high anxiety .resistant at times from redirection . Further medical record review of the Clinical Notes dated 6/2/16 at 10:31 PM revealed .Resident wandering into rooms and was asked to come out. Upon guiding resident out of the room, resident tried to hit at me by balling fist and flexing toward me .Resident can become combative easily when being redirected . Medical record review of Clinical notes dated 6/3/16 at 10:50 PM revealed .resident noted in another residents room sitting on bed eating food from her room . and at 11:04 PM .wandering in several residents room, residents getting upset .Resident noted pulling at furniture and the railing in the hallway. Resident becomes a little agitated when attempting to redirect . Continued medical record review dated 6/5/16 at 5:55 PM revealed, .Resident is wandering in hallway nude; numerous attempt to put clothes on resident but resident resistive. Resident took meds and spit them out saying I am not taking any medication to hell with you .Helping resident only led to agatation/anxiety. Resident went down to hallway door trying to get out .swinging out at staff members . resident returned to same behaviors . Medical record review of Clinical notes dated 7/10/16 at 12:09 AM revealed, .Patient found in his room pulling his roommate by the feet towards the floor .several redirection techniques with no effectiveness .Resident then began to take off his pants and get into bed with roommate . On 7/27/16 at 10:09 PM clinical notes documented .Resident going in and out of other patient's rooms closing doors behind him .resident will not leave the room unless assisted by more than one staff member .During supper resident pulled out penis and urinated on the floor. One hour later resident noted to be urinating on nurses med cart and aiming at another residents head . 7/28/16 at 5:51 PM clinical notes documented .disrobing in public, grabbing items from other resident's .grabbing water pitcher off cart .urinating in hallway in corners .approached female table and started pulling off tablecloth .then he proceeded around the table and pinched a female resident upper right arm .becomes aggressive pulls away aggressive stance acts like he's going to hit staff when he was separated from female resident . On 7/31/16 at 6:27 PM clinical notes revealed .Continues disrobing in public, smearing stool on bed and chair .wandering .continues to urinate in hallway, standing up in center of bed today after approximately 20 minutes came down .reassurance not effective . Medical record review of a comprehensive care plan dated 6/14/16 revealed a problem of verbal behavioral symptoms directed toward others. Openly expresses anger with others. Interventions included .Encourage (resident) to verbalize feelings in an appropriate manner and provide realistic feedback .talk with family .to identify potential sources/reasons . Continued reveiw revealed no further interventions were present on the care plan to address the resident's specific verbal behaviors and anger. Medical record review of the comprehensive care plan dated 6/14/16 revealed a problem of noncompliant with care and presents with acting out behaviors related to [DIAGNOSES REDACTED], and intermittent confusion. Interventions included to offer alternate choices when refusal of care occurs; staff to attempt to redirect resident verbally during episodes of acting out behaviors. Further review revealed no further specific interventions were present on the care plan when redirection of the resident was unsuccessul during multiple episodes of acting out behaviors. Interview with the MDS Coordinator on 8/31/16 at 11:30 AM in the MDS office confirmed the comprehensive care plan did not address Resident #2's behaviors with specific interventions. Interview with the Director of Nursing (DON) on 8/31/16 at 1:30 PM, in the Conference Room confirmed Resident #2's comprehensive care plan had not been updated to reflect his specific behaviors. The DON confirmed the interventions were not specific and were not appropriate. Interview with the DON confirmed the facility failed to revise the comprehensive care plan relating to behaviors for Resident #2.",2019-09-01
3234,THE HIGHLANDS OF DYERSBURG HEALTH & REHAB,445497,350 EAST TICKLE STREET,DYERSBURG,TN,38024,2018-02-07,623,D,1,1,G1QP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to send the Ombudsman a notice of transfer or discharge for 2 of 5 (Resident #45 and 146) sampled residents reviewed for transfer/discharge requirements. The findings included: 1. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The discharge Minimum Data Set ((MDS) dated [DATE] documented .discharge assessment .return anticipated . The facility was unable to provide documentation that the Ombudsman had been notified of the transfer to the hospital on [DATE]. 2. Closed medical record review revealed Resident #146 was admitted to the facility on [DATE] with a readmission on 8/23/17 with [DIAGNOSES REDACTED]. Review of a Social Service note dated 12/4/17 revealed Resident #146 was referred to a behavioral health center due to increased behaviors. Resident #146 was discharged from this facility on 12/1/17. The facility was unable to provide documentation that the Ombudsman had been notified of the transfer to a behavior health center on 12/1/17. Interview with the Administrator on 2/6/18 at 3:30 PM, in the Administrator office, the Administrator was asked if it was acceptable not to contact the Ombudsman with all hospitalization s, discharge and transfers. The Administrator stated, No. Telephone interview with the Ombudsman on 2/8/18 at 9:29 AM, the Ombudsman was asked if she received documentation of the facilitiy's hospitalization s, discharges, and transfers. The Ombudsman stated, We have not received it .I talked to the DON and ADON (Assistant Director of Nursing) .it was on Friday (MONTH) 19th .I had the DON pull it up on her computer .I showed her the forms and how to fill them out .showed her how to send the forms to the Ombudsman .the email was on the web site .they have to be sent in by the 20th of each month as stated on the web site. The Ombudsman was asked if she had received any information from the facility. The Ombudsman stated, I have not received any information from the facility.",2020-09-01
1519,GREEN HILLS CENTER FOR REHABILITATION AND HEALING,445267,3939 HILLSBORO CIRCLE,NASHVILLE,TN,37215,2018-02-14,656,D,1,1,NGHG11,"**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 after 2 resident to resident incidents occurred for 1 resident (#29) of 4 residents reviewed. The findings included: Medical record review revealed Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #29 had a resident to resident incident on 1/8/18. Further review revealed the resident had a second resident to resident incident with a different resident on 1/9/18. Medical record review of the Care Plan dated 1/9/18 revealed no update to capture the resident to resident incidents for Resident #29. Interview with the Director of Nursing on 2/14/18 at 8:30 AM in the conference room confirmed the facility failed to updated the Care Plan after 2 resident to resident incidents for Resident #29.",2020-09-01
5829,CUMBERLAND VILLAGE GENESIS HEALTHCARE,445276,136 DAVIS LANE,LAFOLLETTE,TN,37766,2015-11-17,280,D,1,0,6YVL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to update the care plan for 1 resident (#1) with recurring Urinary Tract Infection [MEDICAL CONDITION] and failed to update the current ambulatory status for 1 resident (#3) with a fall of 11 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Nurse's Notes, laboratory reports and physician's orders [REDACTED]. Medical record review and review of hospital records dated 4/3/15 and 6/4/15, revealed the resident was hospitalized with acute mental status alteration secondary to UTI. Medical record review of the current care plan revealed the care plan did not include identification of the recurring UTIs as a focus or concern and did not define interventions to specifically address recurring UTI. Telephone interview with Registered Nurse (RN)#1/MDS (Minimum Data Set) nurse and review of the current care plan 11/10/15 at 9:45 AM confirmed the care plan had not been updated to include the recurring UTIs. Continued interview confirmed interventions had not been defined on the care plan to reduce the risk of UTI, such as assessment of vital signs and side effects from medications, good peri care, incontinence care every two hours, and monitoring for signs/symptoms of UTI. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the care plan dated 6/24/14 revealed the resident required extensive assistance of 1-2 staff with ambulation. Medical record review of Nurse's Notes dated 5/29/15-6/8/15 revealed Resident #3 frequently wandered on the secured unit, going in and out of other resident's rooms, rummaged through other residents' belongings, transferred and ambulated as desired without assistance, and required verbal cueing and redirection from staff. Medical record review of the annual Minimum Data Set ((MDS) dated [DATE] revealed the resident required no physical help from staff with ambulation in the room or the corridor. Medical record review of the current care plan revealed the care plan had not been updated to reflect the resident's independence with ambulation. Continued review revealed the resident's behaviors of wandering into other residents' rooms and pacing behavior on the secured unit as documented in the above nursing notes had not been updated or included on the care plan. Telephone interview with Licensed Practical Nurse (LPN) #1/Falls Management on 11/5/15 at 10:55 AM confirmed in (MONTH) (YEAR) (prior to a fall on 6/9/15), Resident #1 .walked around unit at will .pacing independently . Continued interview confirmed the wandering and pacing behaviors had not been included on the falls care plan. Telephone interview with Registered Nurse (RN) #1/MDS Coordinator on 11/5/15 at 11:20 AM, and review of the current care plan with RN #1 (via the telephone) confirmed the care plan had not been updated to reflect the resident's independent ambulation with supervision only and continued to reflect the resident required extensive assistance of 1-2 staff with ambulation. Continued interview and review confirmed the resident's wandering and pacing behaviors had not been included on the care plan.",2018-11-01
5326,CREEKSIDE CENTER FOR REHABILITATION AND HEALING,445516,306 W DUE WEST AVENUE,MADISON,TN,37115,2016-04-01,280,D,1,0,2CEQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interview, the facility failed to update the care plan for 1 resident (#210) of 41 residents reviewed. The findings included: Medical record review revealed Resident #210 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 2, indicating severe cognitive impairment. The resident required extensive assistance to total dependence for all ADLS, with extensive physical assistance of 2 person for bed mobility and transfer; and had no impairment of the range of motion for upper and lower extremities. Medical record review of the Physical Therapy Screen dated 10/29/15 revealed, Total assist bed mobility, 2 person transfer .No changes in functional status at this time .per nsg (nursing). Medical record review of Discharge/Aftercare Instructions from the hospital dated 1/15/16 at 10:58 AM revealed, .you have fractured both the tibia and fibula bones .This injury often happens when the ankle is twisted strongly. This tears ankle ligaments. It also causes a break in the bones the ligaments hold together .3. Do not put any weight on the injured ankle .6. SPLINT CARE instructions. Do the following many times throughout the day: Check capillary refill (circulation) in the nail beds .8 .check the skin around the cast every day. Look for red or irritated areas . Medical record review of the Physician's Telephone Orders revealed the ER Discharge instructions to be non-weight bearing for the left lower extremity and to check for circulation and skin condition of the left lower extremity was not written as physician's orders [REDACTED]. Interview with Registered Nurse (RN) #2, the Unit Coordinator, on 1/31/16 at 10:45 AM, at the Capital(NAME)nursing desk, confirmed RN #2 was not able recall if the resident required 1 or 2 persons for physical assistance for transfer after returning to the facility with fractures of the left lower extremity. Interview and review in the Smart Chart, used by the CNA staff as a care guide and for documentation, confirmed the RN could not bring up the resident's CNA care guide for Resident #210. Interview confirmed the CNA caring for the resident on 1/24/16 had recorded transferring Resident #210 to and from the bed on 1/24/16 with the physical assistance of 1 person after the resident had returned non-weight bearing on 1/15/16. Interview with the Director of Nurses (DON) on 3/31/16 at 1:50 PM, in the conference room, confirmed the resident's care plan was not updated to address pain until 1/18/16, three days after the resident had the fractures of the left lower extremity assessed at the ER. Continued interview confirmed the care plan had not been updated to include the ER discharge instructions for SPLINT CARE. Interview with the Administrator on 3/31/16 at 4:00 PM, in the conference room, confirmed Resident #210's Care Plan included Resident requires assistance with .ADLS, Staff to transfer resident with a hoyer lift and two staff. The Administrator stated this intervention was not developed until 1/21/16, 6 days after Resident #210 had returned to the facility from the ER with discharge instructions for the resident to be non-weight bearing.",2019-04-01
4466,BOULEVARD TERRACE REHABILITATION AND NURSING HOME,445235,1530 MIDDLE TENNESSEE BLVD,MURFREESBORO,TN,37130,2016-09-20,241,D,1,0,MZH411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interviews, the facility failed to ensure dignity was maintained for 2 residents (#3 and #8) of 7 residents reviewed. The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #3 was moderately impaired for daily decision making skills, totally dependent for transfers, required assistance with dressing, toileting, and bathing, was occasionally incontinent, and used a wheelchair for mobility. Interview with Resident #3 on 9/15/16 at 3:15PM, in her room, revealed she sometimes had to wait for her call light to be answered and she had accidents while waiting for staff to assist her to the toilet. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #8 was cognitively intact for daily decision making skills. The resident required extensive assistance with all activities of daily living with 1-2 person assist and required the use of a lift for transfers with 2 person assist. Interview with Resident #8 on 9/20/16 at 3:15 PM, in her room, revealed the resident had recently been told on the evening shift she could not be assisted to the bathroom to have a bowel movement and would have to use a bed pan because there was not anyone available to assist with the transfer. Interview with CNA #4 on 9/14/16 at 5:00PM, on the B hall, revealed it was tough sometimes and the residents just have to wait. Interview with CNA #6 on 9/15/16 at 3:50PM, in the Minimum Data Set (MDS) office, revealed the residents are not helped like they should be. Interview with the Administrator on 9/20/16 at 5:45 PM, in the MDS office, confirmed the residents continued to report the call lights were not answered timely and the facility failed to ensure Resident #3 and #7's dignity was maintained.",2019-09-01
4468,BOULEVARD TERRACE REHABILITATION AND NURSING HOME,445235,1530 MIDDLE TENNESSEE BLVD,MURFREESBORO,TN,37130,2016-09-20,353,E,1,0,MZH411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interviews, the facility failed to meet Quality of Care in 2 resident hallways (Hall A and Hall C) of 3 hallways surveyed. The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #3 was moderately impaired for daily decision making skills, totally dependent for transfers, required assistance with dressing, toileting, and bathing, was occasionally incontinent, and used a wheelchair for mobility. Interview with Resident #3 on 9/15/16 at 3:15PM, in her room, revealed she sometimes had to wait for her call light to be answered and she had accidents while waiting for staff to assist her to the toilet. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum (MDS) data set [DATE] revealed the Resident #7 was cognitively intact for daily decision making skills, and was totally dependent for all activities of daily living with 1-2 person assist. Interview with Resident #7 on 9/15/16 at 11:05 AM, in his room, revealed it would take 30 minutes or longer for the staff to answer his call light on the 3-11 shifts and he did not receive much care. Interview with resident #7 on 9/20/16 at 3:25 PM, in his room, revealed he was not sure how long his food was on the cart before staff would bring it to him, but they would always reheat it. Continued interview revealed he was not turned every 2 hours. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #8 was cognitively intact for daily decision making skills. The resident required extensive assistance with all activities of daily living with 1-2 person assist and required the use of a lift for transfers with 2 person assist. Interview with Resident #8 on 9/20/16 at 3:15 PM, in her room, revealed the resident had recently been told on the evening shift she could not be assisted to the bathroom to have a bowel movement and would have to use a bed pan because there was not anyone available to assist with the transfer. Interview with CNA #4 on 9/14/16 at 5:00PM, on the B hall, revealed it was tough sometimes and the residents just have to wait. Interview with CNA #6 on 9/15/16 at 3:50PM, in the Minimum Data Set (MDS) office, revealed the residents are not helped like they should be. Interview with the Administrator on 9/20/16 at 5:45 PM, in the MDS office, confirmed the residents continued to report the call lights were not answered timely.",2019-09-01
4467,BOULEVARD TERRACE REHABILITATION AND NURSING HOME,445235,1530 MIDDLE TENNESSEE BLVD,MURFREESBORO,TN,37130,2016-09-20,312,D,1,0,MZH411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interviews, the facility failed to meet provide daily care to 3 residents (3, #7, and #8) of 7 residents reviewed. The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #3 was moderately impaired for daily decision making skills, totally dependent for transfers, required assistance with dressing, toileting, and bathing, was occasionally incontinent, and used a wheelchair for mobility. Interview with Resident #3 on 9/15/16 at 3:15PM, in her room, revealed she sometimes had to wait for her call light to be answered and she had accidents while waiting for staff to assist her to the toilet. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum (MDS) data set [DATE] revealed the Resident #7 was cognitively intact for daily decision making skills, and was totally dependent for all activities of daily living (ADL) with 1-2 person assist. Interview with Resident #7 on 9/15/16 at 11:05 AM, in his room, revealed it would take 30 minutes or longer for the staff to answer his call light on the 3-11 shifts and he did not receive much care. Interview with resident #7 on 9/20/16 at 3:25 PM, in his room, revealed he was not sure how long his food was on the cart before staff would bring it to him, but they would always reheat it. Continued interview revealed he was not turned every 2 hours. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #8 was cognitively intact for daily decision making skills. The resident required extensive assistance with all activities of daily living with 1-2 person assist and required the use of a lift for transfers with 2 person assist. Interview with Resident #8 on 9/20/16 at 3:15 PM, in her room, revealed the resident had recently been told on the evening shift she could not be assisted to the bathroom to have a bowel movement and would have to use a bed pan because there was not anyone available to assist with the transfer. Interview with CNA #4 on 9/14/16 at 5:00PM, on the B hall, revealed it was tough sometimes and the residents just have to wait. Interview with CNA #6 on 9/15/16 at 3:50PM, in the Minimum Data Set (MDS) office, revealed the residents are not helped like they should be. Interview with the Administrator on 9/20/16 at 5:45 PM, in the MDS office, confirmed the residents continued to report the call lights were not answered timely and the facility failed to provide ADL care to Resident #3, #7, and #8.",2019-09-01
758,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2020-02-05,641,D,1,0,5CUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to accurately assess the fall on the Minimum Data Set for 1 (Resident #1) resident of 5 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].NON-ST ELEVATION [MEDICAL CONDITION] INFARCTION; TYPE 2 DIABETES MELLITUS; MAJOR [MEDICAL CONDITION], RECURRENT, SEVERE WITH PSYCHOTIC SYMPTOMS; UNSPECIFIED CONVULSIONS, [MEDICAL CONDITIONS] DISORDER, [MEDICAL CONDITION] TYPE; [MEDICAL CONDITION] DISEASE OF NERVOUS SYSTEM, and AGE-RELATED [MEDICAL CONDITION] since 2014 . Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 had clear speech, and usually could make her needs known and usually understood others. The resident scored a 4 on the Brief Interview for Mental Status (BIMS), indicating she was severely cognitively impaired (severely impaired range 0 - 7). She was occasionally incontinent of bowel and bladder. She required limited 1 person assistance for bed mobility, transferring, walking in the room, locomotion on and off the unit, eating and toileting for her activities of daily living (ADL). Resident #1 was assessed as having no falls during the review period. Medical record review of the Nursing Progress Note, written by Licensed Practical Nurse (LPN) #1, dated 12/4/2019 at 7:00 PM, revealed .Resident (#1) was found on the floor of the room across the hall from her own room, (named Certified Nurse Aide (CNA) #1) went down the hall to start her round and saw the resident sitting on her bottom, in the floor, with blood in her hair and on the floor around her, the CNA called for a nurse, this nurse assessed the resident, discovered she had two bleeding wounds, quickly forming lumps, on her head, one on the back, right side, and one on her left side . Review of the facility investigation included the Supervisor Investigation of Fall, written by LPN #1, dated 12/4/2019, revealed Resident #1 had an unwitnessed fall on 12/4/2019 at 7:00 PM, in another resident's room. Further review revealed the resident's head hurt, and she had 2 hematomas to the head and was bleeding. Review of the Resident Event Report Worksheet, written by LPN #1, with the event date and time of 12/4/2019 at 6:55 PM, revealed Resident #1 had an unwitnessed fall with a significant injury while in another resident's room. Further review revealed the resident sustained [REDACTED]. Medical record review of the Quarterly MDS dated [DATE], revealed the MDS did not address the fall with injury which occurred on 12/4/2019. Interview with the Registered Nurse MDS Coordinator on 2/5/2020 at 9:20 AM in the conference room confirmed the MDS dated [DATE] failed to include the fall of 12/4/2019 by Resident #1.",2020-09-01
3347,LIFE CARE CENTER OF OLD HICKORY VILLAGE,445509,1250 ROBINSON ROAD,OLD HICKORY,TN,37138,2018-12-19,760,D,1,0,E35X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, Blood Glucose Monitoring Record, and interview, the facility failed to administer the correct dose of Sliding Scale Insulin to 1 (Resident #2) of 4 residents reviewed for administration of Sliding Scale insulin. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5 Day Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 scored 6 on the Brief Interview for Mental Status indicating she was severely cognitively impaired. Medical record review of physician's orders [REDACTED].#2 was ordered Sliding Scale Insulin [MEDICATION NAME] R ac (before meals) and hs (at bedtime): glucose 151 - 200 2 units insulin glucose 201 - 250 4 units insulin glucose 251 - 300 6 units insulin glucose 301 - 350 8 units insulin glucose 351 - 400 10 units insulin glucose greater than 400 Call MD Medical record review of the Medication Administration Record [REDACTED]. Continued review revealed on 12/12/18 at 7:30 AM the resident's blood glucose result was 255 and it is documented she received 2 units of insulin when she should have received 6 units of insulin. Interview with the Administrator and DON on 12/19/18 at 3:15 PM in the conference room confirmed the incorrect dose of Sliding Scale Insulin was administered.",2020-09-01
2231,NORTHSIDE HEALTH CARE NURSING AND REHABILITATION C,445373,202 EAST MTCS ROAD,MURFREESBORO,TN,37130,2017-09-27,502,D,1,0,O5S911,"**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 had been completed for 1 (#2) resident of 20 residents reviewed. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].BMP (Basic Metabolic Panel) . Medical record review of the laboratory results dated [DATE] revealed .Potassium 4.0 .Reference Range 3.5-5.5 . Medical record review of a physician's orders [REDACTED]. starting 3/16/17 .Order date: 3/10/17 . Medical record review revealed no laboratory results for the BMP on 3/16/17. Interview with the Director of Nursing (DON) on 9/27/17 at 7:40 AM, in the DON's office confirmed the lab for the BMP ordered on [DATE] had not been completed.",2020-09-01
678,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2018-07-12,690,D,1,0,MQID11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, and interview, the facility failed to ensure laboratory services were provided as ordered by the physician for 1 of 3 (Resident #5) residents reviewed for urinary tract infection. The findings included: Medical record review revealed Resident #5 was admitted to the facility on [DATE] with a readmission date of [DATE] with the [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 04, which indicated severe cognitive impairment and the presence of an indwelling urinary catheter. The physician's orders [REDACTED].UA (urinalysis) & (and) Culture . Interview with the Director of Nursing (DON) on 7/5/18 at 11:37 AM, in the administrator's office, the DON was asked if the urinalysis was collected for Resident #5. The DON stated, No .we were unable to find the labs (laboratory test results) ordered by the physician on 1/31/18 . The DON was asked if it was acceptable to not follow doctor orders for labs. The DON stated, No.",2020-09-01
4888,ALLENBROOKE NURSING AND REHABILITATION CENTER,445485,3933 ALLENBROOKE COVE,MEMPHIS,TN,38118,2016-07-27,309,D,1,0,Z2RM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, and interview, the facility failed to provide care and treatment of [REDACTED].#6) sampled residents receiving [MEDICAL TREATMENT]. The findings included: Medical record review revealed Resident #6 was admitted to the facility on [DATE], readmitted on [DATE] and discharged home on[DATE]. The resident had the [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #6 had moderate cognitive deficits, relied on total dependence for her activities of daily living and received [MEDICAL TREATMENT] while in the facility. The Care Plan dated 9/4/15 and updated on 6/16/16 revealed Resident #6 had the potential for complications related to [MEDICAL TREATMENT] as evidenced by bleeding, decreased blood pressure, weakness, and fluid overload related to End Stage [MEDICAL CONDITION] with interventions to observe the resident's vascular catheter (vas cath) access site daily for redness, bruises, discoloration, swelling and drainage. Resident #6 also had a care plan for risk for bruising or bleeding tendencies related to the use of anticoagulants. The facility was not able to provide physician orders [REDACTED]. The facility did not provide documentation that Resident #6's access site had been assessed for bleeding, signs or symptoms of infection and in accordance with the care plan for the month of April, May, and (MONTH) (YEAR). Interview with the Director of Nursing (DON) on 7/27/16 at 11:00 AM, in the conference room, the DON was asked what were her expectation for documentation from the nursing staff regarding a [MEDICAL TREATMENT] resident. The DON stated, .I would expect that the resident's access site be assessed . The DON was asked where did she expect the assessments of the access sites to be found. The DON stated, .On the MAR (Medication Administration Record) or in their nursing notes . The DON was shown Resident MARs and nursing notes and asked if there had been any documentation that Resident #6's access had been assessed. The DON stated, .No, I don ' t see any . The DON was asked if it would be appropriate for the nursing staff to document the presence of a bruit or thrill. The DON stated, Yes. The DON was asked if Resident #6 should have physician orders [REDACTED].Looks like I need to add that one to my list of things to do . The DON was asked what the facility's policy stated in regards to resident assessments. The DON stated, .the [MEDICAL TREATMENT] transfer policy is the only policy that we have .",2019-07-01
1773,CONCORDIA NURSING AND REHABILITATION-NORTHHAVEN,445297,3300 BROADWAY NE,KNOXVILLE,TN,37917,2018-01-22,658,D,1,0,5M9L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, and interview, the facility failed to provide surgical wound care as ordered by the physician for one resident (# 3) of 3 residents reviewed for wound care of 4 sampled residents. The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician's recapitulation order dated 9/1/17 revealed .Dakins Solution 1/4 strength (bleach based wound care solution) .apply topically two times a day for wound care, clean abd (abdominal) wound with NS (normal saline) fill wound with Dakins Solution wet to dry packing, and cover BID (twice daily) and PRN (as needed). Review of the Treatment Administration Records (TAR) dated 10/1/17 through 1/19/18 revealed there was no documentation wound care was performed on Friday 10/13/17 on the evening shift; on Wednesday 10/18/17 on the evening shift; Thursday 11/16/17 on the evening shift; Tuesday 11/28/17 on the day shift; Thursday 12/14/17 on the day shift; and on 12/29/17 on the day shift. Interview with Resident #3 on 1/19/18 at 12:38 PM, in the resident's room, revealed the resident was alert and oriented. Continued interview revealed during the months of October, (MONTH) and (MONTH) of (YEAR), the facility neglected to perform surgical wound care twice daily as directed by the physician. Further interview revealed Resident #3 documented dates and times her wound care was performed in a notebook she kept in her room and she had advised nursing staff when wound care was not done. Interview with the Director of Nursing (DON) on 1/22/18 at 12:15 PM, in the activity office, confirmed the facility failed to perform wound care for Resident #3 as directed by the Physician.",2020-09-01
481,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-09-13,677,D,1,0,9GQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility documentation review, and interview, the facility failed to provide assistance with bathing to maintain personal hygiene for 1 resident (#1) of 3 residents reviewed. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] and discharged on [DATE], with [DIAGNOSES REDACTED]. Review of an Admission Minimum (MDS) data set [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Continued review revealed the resident required extensive assistance with toileting, and personal hygiene. Review of a facility document, Bathing Report, dated 7/20/18 through 8/6/18, revealed no documentation Resident #1 received scheduled showers on 7/19/18, 7/23/18, 7/28/18, or 8/4/18. Interview with the Director of Nursing on 9/11/18 at 4:21 PM, in the conference room confirmed the facility failed to provide assistance with bathing for 4 of 7 scheduled showers.",2020-09-01
1949,WOOD PRESBYTERIAN HOME,445322,520 OLD HIGHWAY 68,SWEETWATER,TN,37874,2018-05-22,609,D,1,1,RJHM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility documentation review, incident report review, and interview the facility failed to ensure all allegations involving abuse are reported immediately, but not later than 2 hours after the allegation is made to the Administrator of the facility and other officials in accordance with State Law through established procedures for 1 resident (#4) of 4 residents reviewed for abuse, of 33 sampled residents. The findings included: Medical record review revealed Resident #4 was admitted to the facilityon 2/12/16 with [DIAGNOSES REDACTED]. Medical record review of Resident #4's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) of 99 indicating the resident was unable to complete the interview for cognition. Continued review revealed the resident had [MEDICAL CONDITION] and exhibited hallucinations and delusions. Medical record review revealed Resident #18 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #18's Annual MDS dated [DATE] revealed the resident had a BIMS of 8 indicating the resident was moderately cognitively impaired. Medical record review revealed Resident #53 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #53's Quarterly MDS dated [DATE] revealed the resident had a BIMS of 12 indicating the resident was moderately cognitively impaired. Review of the Complete Facility Investigation dated 7/15/17 revealed Certified Nursing Assistant (CNA) #3 noted a resident's door was closed. Continued review revealed CNA #3 and CNA #4's entered the room and observed Resident #53 in female Resident's #4 and #18's room. Continued review revealed Resident #53 backed away from Resident #4's bed when the CNAs entered the room. Further review revealed when CNA #3 asked Resident #4 if Resident #53 had touched her she stated yes and patted her private area. Continued review revealed CNA #3 asked Resident #18 what Resident #53 was doing in the room and Resident #18 informed the CNA he had tried to kiss her (Resident #4). Review of the Incident Report dated 7/17/17 revealed the alleged allegation of abuse occurred on 7/15/17 and was not received and reported to the state agency until 7/17/17. Further review revealed the state agency was not notified of the allegation of abuse until 2 days after the alleged incident.",2020-09-01
1353,HARTSVILLE CONVALESCENT CENTER,445256,649 MCMURRY BLVD,HARTSVILLE,TN,37074,2019-09-19,580,D,1,0,2T6811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility incident investigation and interview, the facility failed to notify the physician and the resident representative of an incident and subsequent pain and [MEDICAL CONDITION] after a fall for 1 resident (#10) of 13 residents reviewed. The findings include: Medical record review revealed Resident #10 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum (MDS) data set [DATE] revealed Resident #10 was cognitively intact with a score of 14 on the Brief Interview for Mental Status. Further review revealed the resident required limited 1 person assistance for transferring and extensive 1 person assistance for toileting. Further review revealed the resident had a fall with no injury during the review period. Review of the facility investigation documentation, written by Licensed Practical Nurse (LPN) #7, revealed the incident occurred on 5/21/19 at 3:40 PM in Resident #10's bathroom. Further review revealed the resident pushed the alert button in the bathroom and was .found hanging off the w/c (wheelchair)/commode, almost falling Further review revealed LPN #7 told the resident she was going to sit the resident on the floor and get help. Further review revealed the LPN and noncertified Nurse Aide (a noncertified Nurse Aide (NA) is an employee performing direct resident care without completing the certification and competency evaluation) #2 put the resident into the wheelchair, provided incontinence care and no injury was identified. Further review revealed the resident .mentioned no pain . Further review revealed the physician and the resident representative had not been notified of the fall. Medical record review of the Nurse's Notes, written by LPN #5, dated 5/21/19 at 10:00 PM, over 6 hours after the fall, revealed Resident #10 was .complaining of RLE (right lower extremity) pain, right knee and right ankle [MEDICAL CONDITION] (swollen) . Further review revealed the resident stated she had fallen .yesterday . Continued review revealed the nurse .noted [MEDICAL CONDITION] to (right) ankle and elevated . Further review revealed no notification to the physician or the resident representative of the development of the pain or [MEDICAL CONDITION] after the fall. Telephone interview with LPN #5, on 9/19/19 at 9:30 AM, confirmed the LPN failed to notify the physician or the resident representative of the resident's complaint of pain and the [MEDICAL CONDITION] after a fall. Interview with the Director of Nursing and the Assistant Director of Nursing on 9/12/19 at 2:05 PM in the conference room revealed the physician and resident representative were to be notified of all falls. Further interview confirmed the physician and resident representative were not notified of the fall on 5/21/19 at 3:40 PM and were not notified at 10:00 PM when the resident complained of pain and had [MEDICAL CONDITION] of the right ankle.",2020-09-01
1357,HARTSVILLE CONVALESCENT CENTER,445256,649 MCMURRY BLVD,HARTSVILLE,TN,37074,2019-09-19,658,D,1,0,2T6811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility incident investigation documentation review, facility staffing review and interview, the facility failed to provide timely treatment for 1 resident (#10) of 13 residents reviewed. The findings include: Medical record review revealed Resident #10 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum (MDS) data set [DATE] revealed Resident #10 was cognitively intact with a score of 14 on the Brief Interview for Mental Status. Further review revealed the resident required limited 1 person assistance for transferring and extensive 1 person assistance for toileting. Further review revealed the resident had a fall with no injury during the review period. Medical record review of the comprehensive care plan dated 4/7/19 revealed Resident #10 was .alert and oriented .forgetful .required assistance with ADLS (activities of daily living) .limiting endurance, resulting in varying levels of ADL dependence day to day .Risk for falls . Further review revealed the interventions included .Usually requires Lim. (limited) to ext (extensive) assist of 1-2 staff for .transfers .toileting .Encourage resident to allow staff to assist her with transfers for safety . Medical record review of the Nurse's Notes, written by Licensed Practical Nurse (LPN) #7, dated 5/21/19 revealed Resident #10 pushed the call light in the bathroom and was found by the LPN on the side of the wheelchair and commode .about to fall off . The LPN told the resident the LPN was going to sit the resident on the ground and get a .technician to assist getting the resident in the wheelchair . Noncertified Nurse Aide (a noncertified Nurse Aide (NA) is an employee performing direct resident care without completing the certification and competency evaluation) #2 assisted the LPN with providing direct patient care and transferring the resident into the wheelchair. Further review revealed the resident had no signs or symptoms of distress or pain and the resident stated she .was fine . Review of the Incident/Accident Report, written by LPN #7, revealed the incident occurred on 5/21/19 at 3:40 PM in Resident #10's bathroom. Further review revealed the resident pushed the alert button in the bathroom and was found hanging off the wheelchair/commode, almost falling. The LPN told the resident the LPN was going to sit the resident on the floor and get a technician to help. The technician (was NA #2) and the LPN put the resident into the wheelchair and provided direct care. Further review revealed the resident did not mention she was in pain. Review of the facility investigation documentation dated 5/21/19 revealed Resident #10 was alert, confused, did not complain of pain and was in the restroom trying to transfer from toilet to wheelchair or wheelchair to toilet. Further review revealed the new intervention implemented was .advised the resident to call for help before transferring self . Review of the facility staffing on 5/21/19 on the 3:00 PM to 11:00 PM shift revealed NA #2 and LPN #7 were assigned to Resident #10 at the time of the fall. Medical record review of the Nurse's Notes, written by LPN #5, dated 5/21/19 at 10:00 PM, over 6 hours after the fall, revealed Resident #10 was complaining of pain of the right lower extremity, right knee and right ankle was [MEDICAL CONDITION] (swollen). The resident stated she had fallen .yesterday . The nurse elevated the right ankle due to the [MEDICAL CONDITION]. Medical record review of the 5/2019 Physician order [REDACTED]. Further review revealed .Pain Scale: Use Numerical Scale .(1-10) . every shift. Medical record review of the 5/2019 Medication Administration Record [REDACTED]. Medical record review of the Nurse's Notes, written by Registered Nurse (RN) #3, dated 5/22/19 at 9:30 (AM) revealed Resident #10 complained of pain in the right ankle and a multi-colored bruise was noted. Medical record review of the 5/2019 MAR indicated [REDACTED]. Medical record review of the telephone order, signature of RN #3 receiving the order, dated 5/22/19 at 11:35 AM revealed .x-ray of R (right) foot and ankle (2 views) . Medical record review of the Nurse's Notes dated 5/22/19 at 1:30 PM, over 21 hours after the fall, revealed .X-ray of foot done . Medical record review of the Radiology Report signed by the Radiologist on 5/22/19 at 4:06 PM revealed .Right Ankle .Conclusion: Acute distal fibula (lower leg bone) fracture . Further review revealed the radiology report was faxed on 5/22/19 at 4:10 PM, over 24 hours after the fall. Medical record review of the Nurse's Notes dated 5/22/19 at 9:30 PM, over 29 hours after the fall, revealed the radiology fax had been received and the resident had a distal fibula fracture. The physician was notified and an order was was received to send the resident to the hospital. Further review revealed at 9:45 PM the facility Administrator, Assistant Director of Nursing (ADON) and the resident's responsible party were notified of the x-ray results. Further review revealed at 10:00 PM, over 30 hours after the fall, Emergency Management Services arrived to take the resident to the hospital. Telephone interview with NA #2 on 8/12/19 at 5:28 PM and on 8/13/19 at 11:06 AM when asked about the duties the NA performed, NA #2 revealed .I could do all of it, incontinence care, bathing, dressing, toileting, whatever care was needed by myself. Since I was hired I did all care, sometimes a Certified Nurse Aide or nurse there but I've been on hall by myself and did all the care by myself . Interview with the Director of Nursing (DON) and ADON on 9/12/19 at 2:05 PM in the conference room revealed the DON worked on Resident #10's unit as a Certified Nurse Aide on 5/21/19 on the 11:00 PM-7:00 AM shift. Further interview revealed the nurse on duty had told the DON Resident #10 had a bruised ankle and complained of pain. Further interview revealed the DON then instructed the nurse to call the physician to let him know and ask if he wanted an x-ray. Further interview confirmed the x-ray was ordered at 5/22/19 at 11:35 AM; at 1:30 PM the x-ray services were at the facility; at 4:06 PM the radiologist read x-ray; at 4:10 PM the radiology report was faxed to the facility; at 9:30 PM, over 29 hours after the fall, the facility informed the physician and obtained the order to send the resident to the emergency room ; and at 10:00 PM the emergency services were at the facility. Further interview confirmed the facility failed to provide timely treatment.",2020-09-01
1356,HARTSVILLE CONVALESCENT CENTER,445256,649 MCMURRY BLVD,HARTSVILLE,TN,37074,2019-09-19,656,D,1,0,2T6811,"**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 1 resident (#1) of 9 residents reviewed for falls. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Nursing assessment dated [DATE] revealed Resident #1 had a score of 20 on the Fall Risk Assessment indicating the resident was at high risk for falls. Medical record review of the Admission Physician order [REDACTED].#1 was to have .Bed pad (pressure) alarm (alarm alerts care giver with audio alarm when the resident gets out of the bed or chair) on bed @ (at) all times for safety, tab alarm (A pull string attached to the secured alarming device and to the resident. When the pull string contact is disrupted the alarm alerts care giver with audio alarm when the resident gets out of the bed or chair) @ all times when up in w/c (wheelchair) for safety .Bed in lowest position @ all times . Medical record review of Resident #1's Admission/Interim Plan of Care (baseline care plan) dated 4/29/19 revealed .ADL (activities of daily living) Impaired mobility and/or self-care abilities . The interventions included .Required staff assistance for Bed mobility, Transfers, locomotion . Further care plan review revealed the area of concern .Falls/Safety Risk/Elopement: falls hx (history) . The interventions included .Personal alarm if indicated: chair/pad alarms, tab alarm .Requires staff supervision/assistance for safe transfers/ambulation . Further review revealed the admission care plan was updated on 5/2/19 with the intervention .When OOB (out of bed) keep @ (at) nurses station when not involved in activities for direct supervision by staff . Medical record review of the 5/17/19 comprehensive care plan for Resident #1 revealed .Fall risk with H/O (history of) recurring falls (due to) no safety awareness and ataxic gait (abnormal, uncoordinated movement) . Further review revealed the interventions included extensive to totally dependent on 1-2 staff for all transfers, bed mobility, ambulation, locomotion and toileting; bed pad alarm on resident at all times when in bed; tab alarm on resident at all times when in wheelchair as .resident repeatedly attempts to stand and ambulate unassisted . Medical record review of the Incident/Accident report, written by LPN #6, dated 6/3/19 at 9:00 PM revealed Resident #1 was .laying on the floor on right side next to bed, in front of w/c (wheelchair) .with no apparent injuries . Review of the POS [REDACTED].check alarm functionality q (every) shift, to ensure proper working order . Medical record review of the 6/2019 Medication Administration Report and Treatment Administration Report (MAR/TAR) for Resident #1 revealed no documentation of the alarm functionality monitoring every shift to ensure proper functioning per the 6/3/19 fall intervention. Review of the Incident/Accident Report, written by RN #1, dated 7/9/19 at 6:45 PM revealed Resident #1 .Upon arriving to room resident was in floor bleeding from forehead on right side of bed (with) back to wall next to window . Medical record review of Resident #1's Nurse's Notes, written by Registered Nurse (RN) #1, dated 7/9/19 at 6:45 PM revealed .Patient had fallen from bed. Alarm upon investigation sounding intermittently .Patient transported to .ER (emergency room ) for eval (evaluation) + treat (treatment) . Interview with the Assistant Director of Nursing (ADON) on 8/13/19 at 10:35 AM in the ADON's office revealed .The (bed pad) alarm on the bed was malfunctioning. (named MDS nurse) tested it and sometimes it was working and other times was not working so we replaced the (bed) pad (alarm) . Medical record review of the MAR/TAR for Resident #1 dated 7/1/19 - 7/31/19 revealed there was no documentation of the alarm functionality monitoring every shift to ensure proper functioning per the 6/3/19 fall intervention. Review of the hospital emergency room documentation dated 7/9/19 revealed Resident #1 had a .Laceration: Wound Repair of 8cm (centimeters) (3.1in (inch)), subcutaneous (under the skin), laceration to the forehead .Skin closed with 10 .sutures . Interview with the Administrator, Director of Nursing (DON) and ADON on 8/13/19 at 1:50 PM in the conference room when asked how the DON expected the alarm functionality to be monitored every shift, the DON revealed .to document on the MAR/TAR .should expect to see functionality checked after the 6/3/19 fall, I hope . Continued interview confirmed the facility failed to monitor the alarm functionality from 6/3/19 through 7/31/19 for Resident #1 as care planned.",2020-09-01
4590,THE WATERS OF SPRINGFIELD LLC,445480,704 5TH AVENUE EAST,SPRINGFIELD,TN,37172,2016-09-21,323,D,1,0,0MPG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility investigation review and interview, the facility failed to supervise 1 Resident (#5) with prior sexual inhibitions from making sexual advances toward 1 Resident (#4) of 2 residents reviewed for abuse. The findings included: Medical record review revealed Resident #4 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #4 had impaired short and long term memory, was moderately impaired in daily decision making, was totally dependent on 1 to 2 or more staff for all Activities of Daily Living, had adequate hearing, was unclear of speech, could usually make self understood, and could usually understand others. Medical record review revealed Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #5 was moderately cognitively impaired, per the 6 out of 15 score on the Brief Interview of Mental Status, had no episodes of delirium, no change in mental status, no evidence of psychosis or behaviors, had little interest or pleasure in doing things in past 2-6 days of the review period, had trouble falling or staying asleep or slept too much for past 7-11 days of the review period, was feeling tired or had little energy for past 12-14 days of the review period, required supervision with set-up assistance for ambulation, no wandering episodes, had adequate hearing, could make self understood and understood others, and received anti-depressant and anti-hypnotic medication for 7 days of the review period. Medical record review of the care plan problem with the original date of 3/18/15 revealed Resident #5 had .recently expressed frustration regarding her inability to have sexual relationships and confusion as to why men in the facility are unable to make their own decisions due to their cognition. This is a private problem and the patient feels that she does not need anything else at this time; however she will inform the nursing staff and social services if she needs further assistance with this in the future . The care plan problem was updated on 2/25/16 to include .with hx (history) of flirting with other male residents as reported per 2 sons . The care plan was updated on 5/26/16 with no changes. The care plan problem was updated on 8/11/16 with .Care Plan Reviewed No change at this time r/t (related to) Geri-Psych placement . The approaches included .SS (Social Services) will visit as needed and will be the only one to discuss this issue with (Resident #5) unless she requests otherwise. Refer to psych (psychiatric) services for counseling services and medication management if needed . On 2/25/16 the approaches were updated to include .Redirect resident as indicated for verbally responding with improper conduct/words toward men in facility prn (as needed) . On 8/11/16 the approaches were updated to include One-on-one supervision. Medical record review of the care plan with the original date of 7/15/16 revealed the problem of Disturbed Thought Processes r/t .a [DIAGNOSES REDACTED]. The care plan approaches revealed .Monitor for s/s ((signs or symptoms) of delirium or any s/s of acting out with sexual inhibitions and notify charge nurse, Director of Nursing and/or Administrator . Medical record review of the Physician order [REDACTED]. 1.) Telephone order dated 5/25/16 for .DC (discontinue) Temazepam (sedative) 7.5 mg (milligrams) q HS (every bedtime) .Start Temazepam 7.5 mg by mouth (po) @ (at) HS PRN (as needed) insomnia . 2.) Telephone order dated 7/30/16 to .Increase Paxil (anti-depressant) 30 mg po HS .DC 20 mg Paxil . 3.) The 8/2016 Recapitulation Physician order [REDACTED].Temazepam 7.5 mg po at bedtime as needed insomnia .Paroxetine (Paxil) 30 mg po at bedtime .Rivastigmine (also goes by Exelon-for Dementia/Alzheimer's Disease) 4.6mg/24 (hour) apply transdermal patch topically to back daily . Medical record review of the (MONTH) and (MONTH) (YEAR) Medication Administration Records (MAR) revealed the Temazepam, Paxil and Rivastigmine were administered as ordered. Medical record review of the Psychotherapy Services provided to Resident #5 revealed the following: 1.) The Assessment/Progress Note-Psychiatric dated 6/22/16 .Nursing report GDR (Gradual Dose Reduction) of Temazepam done 5/25/16 per recommendation. Staff report ongoing episodic sexual advances towards males in the facility. Resident reports (I don't feel good.) Resident reports her mood as (OK) Resident reports she is eating and sleeping as (OK) .Current Psychotropic Medications .Paroxetine 20 mg by mouth bedtime .Temazepam 7.5 mg by mouth at bedtime PRN started 2/8/16 .GDR #1 on 5/8/15 successful .GDR 9/23/15 failed .GDR 5/25/16 successful .Exelon (Rivastigmine) 4.6mg/24 hours patch transdermal daily .New Orders/Recommendations 1. Continue current orders and treatment plan . 2.) The Progress Note-Psychotherapy dated 7/5/16 .Specific Problems of Focus .Confusion, grief, depression .Plan/Staff Recommendations .Continue supportive therapy-pt (patient) responds well . 3.) The Assessment/Progress Note-Psychiatric dated 7/27/16 .Staff request visit for resident with increased sexual advances toward males in facility. Follow up for Alzheimer's disease with inappropriate sexual behaviors, impulse control disorders, depression, insomnia and behavioral disturbances. Resident is awake and alert. Resident reports (I'm feeling good) Resident reports she is eating and sleeping as (OK) .Current Psychotropic Medications .Paroxetine 20 mg by mouth bedtime .Temazepam 7.5 mg by mouth at bedtime PRN started 2/8/16 .GDR #1 on 5/8/15 successful .GDR 9/23/15 failed .GDR 5/25/16 successful .Exelon (Rivastigmine) 4.6mg/24 hours patch transdermal daily .New Orders/Recommendations .1. Paroxetine 30 mg by mouth bedtime .2. DC Paroxetine 20 mg po bedtime for dose increase .3. Recommendation that resident not have male caregivers, to avoid increased behavioral disturbances . 4.) The Progress Note-Psychotherapy dated 8/2/16 .Specific Problems of Focus .Confusion, Depression .Plan/Staff Recommendations .Continue supportive therapy pt responds well . 5.) The Progress Note-Psychotherapy dated 8/9/16 .Specific Problems of Focus .Confusion, Depression, grief .Plan/Staff Recommendations .Continue supportive therapy pt responds well . Medical record review of the Monthly Flow Record to monitor behaviors and side effects of psychotropic medication for 8/2016 revealed insomnia was the behavior monitored and the episodes documented matched the 8/2016 MAR for Temazepam administration. Medical record review of the Nurse's Notes revealed no documentation of Resident #5 wandering. Review of the facility investigation revealed the incident dated 8/11/16 at 5:00 PM was reported by Certified Nurse Aide (CNA) #1 who reported the incident to Licensed Practical Nurse (LPN) #1. The investigation included witness statements from CNA #1 and LPN #1. The CNA #1 witness statement revealed Resident #5 was leaning over Resident #4 .with .hand on .penis. Further review of the CNA #1's statement revealed the CNA's story changed from hand on penis to at point of arousal. The LPN #1 witness statement revealed Resident #5 was .leaning over (Resident #4) bed kissing .face and trying to pull .brief back down . The investigation revealed Resident #4 was interviewed and stated Resident #5 did not make contact. Interview with Resident #4 on 9/19/16 at 3:30 PM in his room when asked if he recalled a female in his room about a month ago touching him stated No. When asked if he recalled staff coming in and removing a woman from his room he stated No. When asked if he recalled a woman in his room trying to kiss him he stated No. Interview with the Administrator on 9/21/16 at 4:55 PM confirmed the Administrator understood the facility failed to supervise the resident to prevent abuse.",2019-09-01
4983,FAYETTEVILLE HEALTH AND REHABILITATION CENTER,445320,4081 THORNTON TAYLOR PARKWAY,FAYETTEVILLE,TN,37334,2016-06-23,282,D,1,0,QLLM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility investigation review, and interview the facility failed to follow approaches on the comprehensive care plan to prevent further bruising for 1 (Resident #3) resident of 7 resident's reviewed. The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of a 60 day Minimum Data Set ((MDS) dated [DATE] revealed the resident had short and long term memory loss and was severely cognitively impaired. She had behaviors of pacing, wandering, and delusions. She was independently ambulatory with supervision. Medical record review of a comprehensive care plan dated 3/18/16 revealed a problem of bruise to (left) eyebrow. Approaches included observe resident for putting self in floor; observe for resident lying head on hard object and redirect as necessary. Continued review revealed approaches of .observe for bruises and bleeding; notify MD (Medical Doctor) undated; Monitor bruise to (left) eye undated; 4/17/16 offer pillow when resident is noted to be laying her head down in other areas instead of her bed; 5/12/16 Monitor resident activities and note actions and how resident ambulates around hall & station; 5/13 DC ASA (discontinue aspirin) . Medical record review of a 72 hour Event Follow-up Documention note dated 4/17/16 at 6:00 AM revealed, Resident ambulating around nurses station when this nurse noted resident with bruise to left eye. Purple over eyelid, black to lateral corner, dark purple to medial corner descending down face . Medical record review of the Interdisciplinary (IDT) Progress Notes dated 4/18/16 at 10:00 AM revealed, .on 4/17/16 resident was observed (with) bruise to (left) eye .patient lays her head down on tables counters, handrails etc. at times forcefully. Staff will offer a pillow when resident is noted to be lying head down in area other than her bed . Medical record review of a 72 hour Event Follow-up Documentation note dated 5/12/16 at 11:45 PM revealed, CNA bathing resident and reported to charge nurse discoloration on skin, nurse noted several bruises on resident .resident had one bruise on right shoulder yellow in color 2 x (by) 1 (inch), left underside of breast, red in color 4 x 7, 2 small bruises to right lower abdomen 1/2 x 1/2 and 1/2 x 1/2, and one on left inner thigh measures 2 x 7 . Medical record review of an IDT note dated 5/13/16 at 10:00 AM revealed, .staff noted bruising to (right) shoulder .under left breast . (right lower quadrant) abdomen .(left) thigh .cause is not certain however pt (patient) is known to walk into walls, chairs, & other objects. Also noted to lean on chairs & gate @ (nurses) station. Takes ASA (aspirin) 81 mg (milligrams) PO (by mouth) QD (every day). Pt will be monitored to determine if cause can be identified . Medical record review of Nurse's Notes from 3/19/16 through 5/15/16 revealed no documentation of the resident laying in the floor, or laying her head on hard objects, redirected, or if a pillow was offered and accepted by the resident. Medical record review of a Consultant Pharmacist Communication to the Physician for the review period of 5/2016 revealed, .A Medication Regimen Review (MRR) was performed due to bruising .currently receiving Aspirin 81 mg daily. No other medications noted that I consider contributory to bruising . The response to the Pharmacist's recommendation revealed, order to dc ASA 81 mg received from MD . and was dated 5/17/16. Medical record review of a physician's orders [REDACTED].late entry D/C ASA 81 mg daily on 5/13/16 R/T (related to) bruising . Review of the Medication Administration Record [REDACTED]. Interview with the DON on 6/22/16 at 2:15 PM in the Admissions office confirmed the facility was aware of the resident's behavior that put her at increased risk for bruising. Continued interview revealed the DON confirmed the facility failed to obtain information regarding Resident #3's activities and actions to prevent the resident from further bruising, and failed to discontinue the ASA 81 mg on 5/17/16 as per the care plan. The DON confirmed the facility failed to follow approaches on the comprehensive care plan to protect Resident #3 from further bruising.",2019-06-01
1473,AHC CUMBERLAND,445262,4343 ASHLAND CITY HIGHWAY,NASHVILLE,TN,37218,2018-09-27,580,D,1,0,DU8211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility investigation review, and interview, the facility failed to contact a resident's wife when he requested and he developed medical issues for 1(Resident #3) of 25 residents reviewed. The findings include: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 scored 8 on the Brief Interview for Mental Status indicating he was moderately cognitively impaired. Continued review of the MDS revealed Resident #3 was dependent on 2 people for transfers and toileting; was dependent on 1 person for bathing and grooming; required extensive assistance of 1 person for dressing; and was always incontinent of bowel and bladder. Medical record review of Nursing Notes dated 8/31/18 revealed .pt (patient) c/o (complained of) nausea - vomited x10 between 2000 (8:00 PM) and 0100 (1:00 AM). Emesis noted brown some red. Nurse called on care provider and left voice mail. Due to emesis, increased confusion, and agitation nurse called EMS (Emergency Medical Services) to take pt to hospital . The resident returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of facility investigation of a Social Services Note dated 9/4/18 revealed .Resident's wife visited SW this date. She reported on 8/30/18 around 7:30 PM resident was placed in bed. Resident's wife stated resident is never put to bed that early and his food needs to digest before being put to bed. Stated resident requested to staff to call his wife and they didn't do so. Resident's wife stated that is why resident was so upset. SW validated her feelings and asked if she thought any foul play had taken place and resident's wife replied No, he was upset because they didn't call me and he didn't want to go to bed that early. Wife visits facility daily and is very involved with resident's care. Telephone interview with CNA #1 on 10/3/18 at 10:05 AM revealed she recalled the night in question (8/30/18) and stated Resident #3 was vomiting all over. Continued interview revealed he did not tell her he wanted his wife called but asked where she was. Further interview revealed the nurse asked him if he wanted to call his wife and he said yes. Telephone interview with LPN #2 on 10/4/18 at 10:15 AM revealed Resident #3 had a tendency to vomit but had been vomiting excessively that evening. Continued interview revealed he was inconsolably upset and she had never seen him in that state before. Further interview revealed he wanted to go to the hospital and wanted his wife. Continued interview revealed LPN #2 felt the CNA put the resident to bed too soon after eating and his reflux acted up. Further interview revealed CNA #1 was very good with the resident and vary caring. Continued review revealed LPN #2 called the resident's wife to let her know of his vomiting and they were sending him out to the hospital at the point they were ready to send him but she did not call the wife at any other time. Interview with the Administrator on 10/3/18 at 11:30 AM in the conference room confirmed the resident's wife was not called when the resident requested it, possible contributing to his increased anxiety.",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
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
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
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
4985,FAYETTEVILLE HEALTH AND REHABILITATION CENTER,445320,4081 THORNTON TAYLOR PARKWAY,FAYETTEVILLE,TN,37334,2016-06-23,514,D,1,0,QLLM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility investigation review, and interview, the facility failed to provide accurate documentation of a fall for 1 (Resident #2) resident and failed to provide accurate documentation of bruises for 1 (Resident #3) resident of 7 resident's reviewed. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Discharge Minimum Data Set (MD'S) dated 3/20/16 revealed Resident #2 was severely impaired cognitively. Continued review of the MD'S revealed Resident #2 required extensive assist of two people with transfers, dressing, and grooming; was dependent on one person for bathing; required extensive assist of one person for eating; and was always incontinent of bowel and bladder. Further review of the MD'S revealed Resident #2 exhibited behaviors of screaming at others and wandering. Medical record review of nurses' notes dated 3/20/16 at 1:05 AM, revealed .Resident notes to be on floor on ort (right) side of bed on ort (right) side. Upon assessment wide area of discoloration to anterior of hip. c/o (complaining of) severe leg and hip pain. MD (physician) notified and ordered to send to ER (emergency room ) to eval (evaluate) and TX (treat). Called (named son) and (named daughter) but no answer; no voice mail set up; and no call back. Resident left facility at 1:25 AM via ambulance service . Review of the facility investigation dated 3/20/16 revealed Resident #2 was found by Certified Nursing Aides (CNAs) in another room with her knees on the floor and her torso on the bed. Continued review revealed the resident was unable to weight bear and had a large area of bruising on her anterior right hip. Further review revealed an investigation was started at that time. Continued review revealed the nurse documented Resident #2 rolled out of bed onto the floor and the CNAs put the resident into bed before the nurse arrived. Further review revealed no one knew how the fracture occurred. Continued review revealed the camera system was checked and showed the CNAs taking Resident #2 in a wheelchair from another room into her own room. Further review revealed the statements of the CNAs did not match the video tapes. Review of the incident report in the facility investigation packet dated 3/20/16 revealed the narrative stated .Resident noted to be on the floor to the right side of the bed (window side) on right side. Upon assessment large area of bruising noted to anterior hip. Resident indicated pain to the touch and pain with movement . Continued review of the packet revealed no updated/revised incident report with the corrected details of the incident, i.e. Resident #2 found kneeling on the floor with her torso on the bed of another resident in another room. Interview with the DON on 6/22/16 at 2:30 PM in the Admissions Office confirmed the Incident Report had not been updated to reflect the actual circumstances of the incident resulting in inaccurate documentation. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of a 72 Hour Event Follow-up Documentation form dated 4/17/16 for Resident #3 documented the resident had a dark purple and black bruise to her left eye. Continued review revealed documentation of the bruise through 4/20/16. Medical record review of an Assessment Template dated 4/24/16 at 3:21 AM revealed bruising to the left eye was blue, green and yellow in color. 4/25/16 at 9:36 AM revealed the left eye was purplish and yellow in color. 4/26/16 at 1:03 AM revealed no skin issues. 4/26/16 at 9:48 AM revealed, bruising was fading, and discoloration continued. 4/27/16 at 1:37 AM revealed no skin issues. 4/27/16 at 9:22 AM revealed a bruise to the left eye was fading, and discoloration continued. 4/28/16 at 2:50 AM revealed no skin issues. 4/28/16 at 9:59 AM revealed a skin issue of a left eye bruise. 4/29/16 at 1:42 AM revealed no skin issues. 4/30/16 12:50 AM revealed no skin issues. 4/30/16 at 12:45 PM revealed a skin issue of bruising. 5/1/16 at 1:21 PM revealed left eye bruising improving, light in color and smaller surface area affected. 5/2/16 at 1:29 AM revealed no skin issues. 5/4/16 at 9:40 AM revealed bruising to left eye continued to fade. Record review of a Resident Incident Report form dated 5/12/16 at 8:00 PM revealed Resident #3 had a 2 x (by) 7 (inch) bruise to her right shoulder; a 4 x 7 bruise under her left breast; 2 small bruises to her right lower abdomen measuring 1/2 x 1/2 each; and a 2 x 7 bruise to her left inner thigh. Medical record review of an Assessment Template dated 5/16/16 at 12:39 AM revealed no skin issues. 5/16/16 at 10:25 AM documented a skin issue of bruising and .bruising noted to left inner upper thigh .under right (breast) to the outer side .another bruise under right breast to median aspect of chest .a large dark bruise to entire bottom portion of left breast . Continued review revealed documentation on 5/17/16 at 3:16 AM of no skin issues. Interview with the Director of Nursing (DON) on 6/21/16 at 10:00 AM in the Admissions office stated, There is inconsistent and inaccurate nursing documentation when shown documentation contained in the resident's medical record. The DON confirmed the facility failed to maintain an accurate clinical record for Resident #3.",2019-06-01
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
4981,FAYETTEVILLE HEALTH AND REHABILITATION CENTER,445320,4081 THORNTON TAYLOR PARKWAY,FAYETTEVILLE,TN,37334,2016-06-23,280,D,1,0,QLLM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility investigation review, and interview, the facility failed to update the care plan to address care for and observations of a resident with fractured fingers for 1 (Resident #1) and failed to update the care plan to reflect interventions to prevent further bruising for 1 (Resident #3) of 7 residents reviewed. The findings included: Medical record review revealed Resident #1 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 #1 was severely impaired cognitively. Continued review of the MDS revealed Resident #1 required extensive assistance with transfers, dressing, eating, and grooming; was dependent for bathing; was always incontinent of bowel and bladder; and ambulated with supervision. Review of the investigation of the fall which occurred on 6/2/16 revealed the resident was in the dining room; noted something on the floor; reached to pick it up; and fell from the chair. Continued review revealed the resident did not sustain any injury. Further review of the investigation revealed the cause of the accident was clutter on the floor so those items were removed from the area. Review of the investigation of the fall which occurred on 6/3/16 revealed Resident #1 was found lying face down on another room beside Bed B and had sustained a laceration to the left side of the head measuring 2.2 centimeters. Continued review revealed the cause of the incident was .Resident becomes tired after being up for extended period of time, refused to rest . Further review of the incident revealed immediate intervention included placing Resident #1 in a wheelchair with alarm to provide supervised rest periods. Medical record review of nursing notes dated 6/5/16 revealed the nurse was called to the room by the Certified Nursing Aide (CNA) to look at the resident's hand. Continued review revealed the resident's left hand was blue and swollen from the wrist to the middle of the fingers. Further review revealed Resident #1 was transferred to the hospital for x-rays of the hand. Review of the Emergency Department (ED) record dated 6/5/16 revealed the resident .sustained another fall and he was found to have metacarpal (hand) fractures of the fingers 3, 4, and 5 on the left hand. Continued review revealed the resident had a soft splint on the left forearm and hand with an ace type wrap. Further review of the ED record revealed an x-ray of the resident's left hand which showed third through fifth obliquely oriented metacarpal fractures. Continued review of the ED record revealed the physician's statement .Consult SS (Social Services) to eval (evaluate) incident report on injury to (L) (left) hand multiple suspicious fractures . Medical record review of the care plan revealed interventions were listed for each fall Resident #1 had sustained. Continued review of the care plan revealed no mention of the [MEDICAL CONDITION]; the splint on his hand; observations to be made of the fingers; and care of the splint and resident's hand. Observation of Resident #1 on 6/22/16 at 9:40 AM revealed him lying on his back, asleep, mouth breathing with oxygen cannula in place. Continued observation revealed the resident's face was very red and he had a large (5 inches by 2 inches) dark brown bruise to the back of the hand and wrist of the right hand. Further observation revealed a splint to the left hand which was wrapped with an ace bandage. Continued observation revealed the fingers of the left hand were dark blue on the back and the fingers of both hands were bent at a 90 degree angle at the knuckles. Interview with the DON on 6/22/16 at 2:55 PM in the Admissions Office confirmed the care plan for Resident #1 did not address the [MEDICAL CONDITION] to include observations to be made of the splint; care of the skin under the splint; and observations of the fingers. Continued interview confirmed the CNA care card did not include the fractures of the fingers including observations to be made of the splint and fingers as well as when to notify the nurse. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of a 60 day Minimum Data Set ((MDS) dated [DATE] revealed the resident had short and long term memory loss and was severely cognitively impaired. She had behaviors of pacing, wandering, and delusions. She was independently ambulatory with supervision. Medical record review of a comprehensive care plan dated 3/21/16 revealed no problem of a left black eye identified on 4/17/16, or bruises identified to the resident's right shoulder, below the left and right breast or the left inner thigh identified on 5/12/16. Continued review revealed the care plan was not updated to reflect problems of injury related to lying the head on the table or counter, leaning on walls, or use of Aspirin. The comprehensive care plan included an undated problem of signs and symptoms of [DIAGNOSES REDACTED] (sleep disorder that causes overwhelming daytime drowsiness) with no approaches included. Interview with the Director of Nursing (DON) on 6/21/16 at 10:00 AM in the Admissions office confirmed the comprehensive care plan did not reflect Resident #3's problem of bruising when identified on 4/17/16 and 5/12/16, nor provide approaches for a problem of [DIAGNOSES REDACTED]. Continued interview with the DON confirmed the facility failed to prevent future bruising to the resident by not updating the care plan with approaches to protect the resident after behaviors of stumbling into walls, leaning over the gate at the nurse station, laying her head on tables or counters, or hitting her leg on the leg of tables was identified by the facility.",2019-06-01
3709,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2017-03-22,323,D,1,0,4VOH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility investigation review, and interviews, the facility failed to ensure adequate supervision for 1 resident (#1) of 3 residents reviewed for risk of elopement. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the initial Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 6/15 (severely cognitive impaired) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required limited assistance for transfer, dressing, and hygiene/bathing with supervision required for ambulation and eating. Medical record review of a nurses' note dated 3/10/17 at 6:28 AM revealed .A/O (alert and oriented) x (times) 2 to person .place .with confusion noted . Medical record review a nurses' note dated 3/10/17 at 2:24 PM revealed .at Approx. (approximately) 10:10am (AM) the social worker approached the nursing desk .said the resident (Resident #1) stated he wanted to leave .spoke to the resident about leaving .asking him why .telling him the dangers of leaving .He (Resident #1) cont. (continued) to state that he did not want to stay any longer .asked him if he would wait on his brother to come and he said no .proceeded to tell him how dangerous the road was in front of the facility .he stated that he was used to walking on such roads .asked him to please wait on his brother and he finally said yes .During this time the social worker was interacting with resident .he was verbally aggressive and cursing the social worker .Resident went and had a seat in chair in front of elevator .resident went to dining room with staff. He then returned to chair in front of elevator .nurse reports at about 11:20 that resident pushed button and got on elevator and she was unable to stop him .notified front desk receptionist and supervisor . Medical record review of a Social Services (SW) dated 3/10/17 at 4:09 PM revealed .this sw director was gotten by 1st floor sw approx. 11:15 (AM) .requested my assistance to come to the floor bc (because) he had a res (resident) that wanted to leave and he couldn't get him (Resident #1) redirected .said the res was very adimit (adamant) that he was leaving to go home .went to the floor .nursing staff notified us that he had got on the elevator and left .sw called 911 (police) approx. 11:25 (AM) bc we were concerned bc he was headed out the .busy highway and could not be redirected . Review of the facility's investigation dated 3/10/17 revealed a witness statement completed by front desk receptionist/switchboard operator. Continued review revealed the receptionist was notified by staff Resident #1 was on the elevator. Further review revealed .when he stepped off the elevator I asked him his name .I advised (resident)the nurses were looking for him .he said 'well that's too bad cuz (because) I'm leaving, I'm out of here' .a few minutes later the switchboard received a phone call from an outside person stating they saw him (Resident #1) .asked if we had a person leave the building . Continued review of a witness statement dated 3/10/17 and completed by Licensed Practical Nurse (LPN) #2 revealed .caught up (with) resident .asked him what was wrong .resident repeat (repeated) 'I'm going home' .then turns and walks away from me .I continued to try redirecting resident asking him to come back to facility .unable to redirect .resident confused repeating 'I'm going home' .I then returned to the facility .he then continued down (named street) after first subdivision . Further review of a witness statement dated 3/10/17 and completed by the Director of Nursing (DON) revealed .at 1154 am (11:54 AM) (named police officer) called me .stated they had picked resident up (approximately) 1 mile from facility . Interview with the DON on 3/22/17 at 12:10 PM, in the conference room, revealed the resident was advised of the dangers of leaving prior to exiting the building. Interview with Registered Nurse (RN) #1 on 3/22/17 at 12:15 PM, in the conference room, revealed the resident was advised of the dangers of the road. Telephone interview with LPN #2 on 3/22/17 at 12:30 PM revealed the resident left the building. Further interview revealed .I was there and he told me he was leaving .there was no redirecting the resident . Continued interview confirmed the LPN returned to the facility and the resident was left unsupervised. Interview with the DON and the Regional Director of Clinical Services on 3/22/17 at 1:15 PM, in the DON's office, confirmed Resident #1 was left unsupervised while outside the facility.",2020-03-01
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
2570,BETHESDA HEALTH CARE CENTER,445427,444 ONE ELEVEN PLACE,COOKEVILLE,TN,38501,2018-06-27,656,D,1,1,V97211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility investigation review, observation and interview, the facility failed to follow the plan of care during personal care for 1 resident (#4) of 2 residents reviewed for Activities of Daily Living and failed to follow the plan of care for activities for 1 resident (#67) of 2 residents reviewed for activities, of 27 residents reviewed. The findings include: Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE], revealed a Brief Interview For Mental Status score of 14, indicating the resident was cognitively intact Medical record review of the resident's care plan dated 3/22/18 revealed .Needs assist with ADL's (activity of daily living) D/T (due to) Left AKA (Above Knee Amputation), Generalized Weakness, is unable to take care of herself, refuses to wear gait belt during ADL (activities of daily living) care/transfers .Assist x (times) 2 for transfers . Further review revealed .Patient has history of falsifying info (information) that she relays to staff, refuses to allow staff to use gait belt during ADL care/transfers .During times of miscommunication information to staff, reorient and redirect her, address her concerns appropriately . Review of facility's investigation revealed a statement by CNA (certified nurse assistant) #1 dated 6/14/18 at 9:00 AM revealed Resident #4 informed her approximately 2 weeks ago that CNA #2 threw her around and threw her head against the wall during a shower. The resident was provided care by 1 CNA and not 2 CNAs as per the resident's care plan. Review of a facility investigation revealed a statement by Resident #4 dated 6/14/18 at 9:35 AM .She (CNA #2) bumps my head into wall. 2 person assist, (CNA #2) attempted 1 assist. It happened maybe 2 weeks ago. Maybe - I don't recall when . Continued review of the facility's investigation revealed a statement by CNA #2 dated 6/14/18 .I do not remember pt (patient) in the last 2 weeks complaining of pain due to hitting her head on bathroom wall. Pt daily has pain during transfers . Medical record review of Nurse's Event Note dated 6/14/18 at 3:21 PM revealed .head to toe assessment completed, no redness, bruising or swelling noted that would indicate abuse .Pt stated a couple weeks ago pt and a staff member were in the shower room and while transferring pt hit head on the wall . Review of CNA #2's Personnel Action form dated 6/15/18 revealed .Re-educated on proper transfer with adequate staff . Review of inservice training for employees dated 6/15/18 revealed CNA #2 underwent inservice on the 2 person transfers. Interview with CNA #2 on 6/26/18 at 8:15 AM, at the nurse's station, revealed Resident #4 complained about bumping her foot or toe. Stated the resident can stand up holding onto rail and does assist with transfers. Stated the resident was a 2 person transfer and she did not ask for help the last time she provided care to Resident #4. Stated she could not remember the last date she provided care to the resident. She stated she received a reprimand for not providing appropriate 2 person transfer assist for Resident #4. Interview with the DON (Director of Nurses) on 6/27/18 at 8:00 AM, in the DON's office, revealed the 2 person transfer on the care plan was put into place due to the resident's frequent false allegations. Further interview confirmed CNA #2 did not follow the care plan regarding the 2 person transfer. Medical record review revealed Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of annual MDS (Minimal Data Set) dated 12/7/17 revealed news and music was somewhat important to the resident. Further review revealed animals, going outside, religious services were very important to the resident. Medical record review of care plan dated 6/7/18 revealed .Resident is Baptist and likes to read the Bible .Resident likes to go outside on sunny warm days to sit or watch birds. She likes birds .Resident keeps up with the news by watching TV .Resident likes large print materials .Resident likes religious music on radio or CD .Resident likes to watch TV . Observation of the resident on 6/25/18 at 10:00 AM, in the resident's room, revealed the resident lying in bed, positioned on the left side. No music or television was on. Observation of the resident on 6/25/18 at 12:30 PM, in the resident's room, revealed the resident lying in bed, positioned on the right side. No music or television was on. Observation of the resident on 6/25/18 at 3:30 PM in the resident's room, revealed no music or television was on. Observation of the resident on 6/26/18 at 7:30 AM, in the resident's room, revealed the resident lying in bed, No music or television on. Observation of the resident on 6/26/18 at 2:30 PM, in the resident's room, revealed the resident lying in bed and no music or television was on. Observation of the resident on 6/27/18 at 7:10 AM, in the resident's room, revealed the resident was sitting in a chair. The resident was dressed, hair combed, eyes open, talking to self. No music or television on. Interview with the Activity Director on 6/27/18 at 10:30 AM, in the conference room, revealed only 1 activity was provided to the resident (between (MONTH) (YEAR) to (MONTH) (YEAR)) which was Pet Therapy on 6/22/18. No other activity was documented. Further interview revealed the Activity Director confirmed the resident only attended 1 activity (Pet Therapy) and the plan of care was not followed.",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
1766,HOLSTON MANOR,445295,3641 MEMORIAL BLVD,KINGSPORT,TN,37664,2017-10-04,272,D,1,0,RHUI11,"**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 notification of care plan meetings for one resident (#3) of 5 residents reviewed. The findings included: Medical record review revealed resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility policy Care Planning-Interdisciplinary Team not dated revealed .1. A comprehensive care plan for each resident is developed within (7) days of completion of the resident assessment (MDS) .The resident, the resident's family .are encouraged to participate in the development of and revisions to the resident's care plan . Interview with the social worker on 10/3/17 at 10:12 AM, in the conference room, revealed the social worker stated an 8/15/17 and 9/5/17 meeting was canceled by the resident family, no other care plan meetings were held with family while at facility and it was typical to meet 7 days after admission with family of resident. Interview with the residents family member on 10/4/17 at 8:59 AM, by phone, revealed the resident family member stated the facility never attempted a Care Plan meeting prior to the 9/15/17 Care Plan meeting with the State Ombudsman. Interview with the Administrator and Director of Nursing on 10/4/17 at 10:49 AM, in the conference room, confirmed there was no documentation an 8/15/17 and 9/5/17 care plan meeting was planned. Interview confirmed the facility policy to encourage family participation with Care planning was not followed.",2020-09-01
1474,AHC CUMBERLAND,445262,4343 ASHLAND CITY HIGHWAY,NASHVILLE,TN,37218,2019-10-24,600,D,1,0,K2ER11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility policy review, facility investigation review, and interviews the facility failed to keep residents free from abuse for 1 (#7) of 5 residents. The findings include: Resident #7 was admitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status of 15 indicating no cognitive impairment. Continued review revealed extensive to total assistance of 1 staff member was required for transfers, dressing, toileting, personal hygiene, and bathing. Further review revealed bladder and bowel status was always incontinent. Medical record review of a Comprehensive Care Plan revised 9/4/19 revealed Resident #7 was assessed and monitored for smoking and safety from smoking hazards. Review of facility policy, Abuse Prohibition Plan revised 5/2019 revealed .this facility has a zero-tolerance for abuse .the resident will not be subjected to mistreatment . Review of the facility investigation dated 9/11/19 revealed Resident #7 reported to Licensed Practical Nurse (LPN) #7 that during a smoke break Certified Nurse Aide (CNA) #13 deliberately and spontaneously stated how ungrateful and unappreciative the patients were for the care they receive. Continued review revealed CNA #13 then spoke directly to Resident #7 calling him an inappropriate name and saying that she would jerk him out of his wheelchair. Further review revealed CNA #13 also spoke in a derogatory way about Resident #7's mother and sister. Written statements were taken from interviews with Resident #6, Resident #8, Resident #9, and Resident #11 on 9/11/19 by Social Services. Continued interview revealed the statements from the residents were consistent with the statement made by Resident #7. Interview with Resident #7 on 10/21/19 at 11:35 AM in the resident's room revealed a recount of the incident with CNA #13 during the smoke break on 9/10/19. Continued interview with Resident #7 confirmed CNA #13 called the resident and his family members derogatory names and threatened to jerk Resident #7 from his wheel chair. Interview with Licensed Practical Nurse (LPN) #1 and LPN #7, unit manager on 10/23/19 at 11:20 AM and 12:30 PM respectively at the nurse's station revealed the same consistent report from Resident #7. Continued interview revealed Resident #7 stated he had talked back to CNA #13 when she started speaking in a derogatory manner about his family. Interview with Resident #6, Resident #8, Resident #9, and Resident #11 on 10/21/19 and 10/22/19 confirmed the written statements provided about the incident on 9/10/19 involving Resident #7 and CNA #13 during a smoke break.",2020-09-01
5773,BLOUNT MEMORIAL TRANS CARE CTR,445404,2320 EAST LAMAR ALEXANDER PKWY,MARYVILLE,TN,37804,2015-12-02,333,D,1,1,TFV511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility policy review, review of facility investigation, observation, and interview, the facility failed to prevent significant medication errors for 2 residents (#357, #44) of 13 residents reviewed for medications of 29 sampled residents. The findings included: Medical record review revealed Resident #357 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Review of facility policy, Medication Administration, revealed .New and urgent medications, except for emergency .medications are ordered as follows .Use the Pyxis (medication dispensing system) when the resident needs a medication prior to pharmacy delivery .Medication Administration .Take med cart to doorway .and pull medications scheduled from drawer while reviewing the MAR (Medication Administration Record). This is the (first) safety check .The (second) safety check is done at the bedside identify the resident using name and date of birth .the (third) and final safety check is done prior to administration with a final verification of each medication and with MAR ensuring accuracy of 5 'rights' (right resident, medication, dose, route, time) . Review of the facility investigation dated 2/26/15 revealed .Event date: 2/26/15 .orders were written for (resident) in room .for potassium now and repeat in 4 hours. LPN (Licensed Practical Nurse) took from pyxis and administered to (resident #357) .had 2 patients with same last name. I was told I needed to give a now order of 40 meq (milliequivalent) of (potassium) to (resident #357) .the (potassium) was supposed to be given to (resident #358) .when I went to give the (second) dose I did not have the MAR because (second) shift had started med pass. Recognized when I went to sign for (potassium) that it was (resident #358) . Interview with LPN #1 on 12/1/15 at 4:15 PM, by telephone confirmed .was told by the RN (Registered Nurse) to give a now dose to Ms. (resident), had two female residents with the same last name, gave two doses of Potassium to (resident #357), did not review the MAR for the first or second dose, when signed for the potassium after the second dose realized the error. Continued interview confirmed LPN #1 failed to review the MAR prior to the medication administration and did not sign the MAR immediately after administration of the medication. Interview with the Director of Nursing (DON) on 12/2/15 at 8:00 AM, in the conference room confirmed a significant medication error had occurred. Medical record review revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Hospital Discharge Summary dated 10/30/15 revealed .At this time she is ready for discharge to skilled nursing facility for rehabilitation and antibiotics. She'll be on IV [MEDICATION NAME] (antibiotic) through (MONTH) 4 . Medical record review of the Physician Telephone Order dated 11/9/15 revealed .decrease vanco ([MEDICATION NAME]) to 1250mg (milligram) Q (every) 12 IV (Intravenous) via (route) PICC (Peripherally Inserted Central Catheter) . Medical record review of a Physician Telephone Order dated 11/10/15 revealed .Hold tonight's dose of [MEDICATION NAME]. Resume Q12 on 11/11/15. Same dose (1250mg) . Medical record review of a Medication Dosing Worksheet dated 11/12/15 revealed .They gave patient a 1500mg dose of vanco on 11/11/15 (PM Dose) instead of the 1250mg . Medical record review of the Medication Occurrence Report dated 11/12/15 revealed .Wrong dose of [MEDICATION NAME] hung- Five Rights not done I suppose . Observation on 12/02/15 at 10:33 AM revealed the resident sitting in her recliner and smiling. She stated she should be going back to another facility soon. Interview with the Director of Nursing on 12/02/15 at 8:02 AM, in the conference room confirmed, The [MEDICATION NAME] dose of 1500mg given was a significant med (medication) error. Interview with Registered Nurse (RN) #2 on 12/02/15 at 2:25 PM, by telephone in the conference room confirmed I hung the wrong dose.",2018-12-01
5278,SIGNATURE HEALTHCARE OF GREENEVILLE,445351,106 HOLT COURT,GREENEVILLE,TN,37743,2016-04-25,225,D,1,0,LII611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility policy review, review of the facility investigation and interview, the facility failed to notify the State Survey Agency within 24 hours of an alleged assault for one resident (#3) of 12 residents reviewed. The findings included: Resident #3 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 7 day Minimum Data Set ((MDS) dated [DATE] revealed the resident had severely impaired decision-making skills and inattention; had physical and verbal behaviors directed towards others and other behavioral symptoms not directed towards others (hitting or scratching self, pacing, or vocal symptoms like screaming or disruptive sounds); required extensive assistance with all activities of daily living (ADL); and received antipsychotic medication in the prior 7 days. Medical record review of a nursing assessment dated [DATE] at 4:45 PM revealed, CNA (Certified Nursing Assistant #1) observed the agency sitter striking resident three times in the head area. CNA immediately notified charge nurse and insured residents safety .Agency sitters were immediately removed from resident's room and first aid was applied by the wound care nurse .Perpetrator alleges that the resident was in a behavior and had calmed down and was on the floor when he began to hit his head on the metal frame of the bedside table .alleges that they were trying to shield resident from hitting his shunt on the tables sharp edge and used hands to put in front of residents head to prevent any injury to shunt . The resident stated, He hit me. Review of the facility's policy for abuse and neglect dated 3/2013 revealed, .If the facility believes that a crime has been committed the Elder Justice Act guideline will be followed . Review of facility policy, Elder Justice Act Policy and Procedure, revealed, .It is the intent of the facility to uphold The Elder Justice Act as established under the Social Security Act .which requires covered individuals to report reasonable suspicion of a crime to their state regulatory agency and to local law enforcement within specific time frames . Continued review revealed serious bodily injuries included extreme pain; substantial risk of death or loss of function of a bodily member; sexual abuse or aggravated sexual abuse or the need for medical intervention such as surgery or hospitalization . Continued review revealed, If the events that cause the reasonable suspicion do not result in serious bodily injury to a resident, the covered individual shall report the suspicion not later than 24 hours after forming the suspicion . Review of a written statement by CNA #1 dated 10/16/15 revealed, .heard a loud sound .entered the room from the bathroom and saw the larger man punch the resident (#3) in the head. He had his knuckle out when he was punching him . Review of a written statement by Licensed Practical Nurse (LPN #2) (Wound Care Nurse) dated 10/16/15 revealed the resident had .laceration to the crown of his head .another laceration to his Rt (right) eyebrow .abrasion to his forehead and .left eyebrow .several small abrasions all over his face and a couple . on the left shoulder that appeared as scratches. Review of a written statement by LPN #1 dated 10/16/15 revealed the resident stated to LPN #1 on 10/16/15, He hit me in the head. He hit me in the head. Review of a typed interview by the Administrator with Sitter #1 (the sitter accused of hitting the resident in the head) dated 10/16/15 revealed Sitter #1 reported the resident .starting banging his head on the bottom of the bedside table .(Sitter #1) grabbed head or rather blocked head from hitting his head from hitting the table . Review of a typed interview by the Administrator with Sitter #2 (who was in the room at the time of the alleged assault) dated 10/16/15 revealed Sitter #2 reported the resident started head-butting the floor .then head-butted the table and (Sitter #1) blocked his head with his hand out-the palm of his hand . Interview with the Director of Nursing (DON) on 4/11/16 at 1:55 PM, in the conference room revealed the State Survey Agency was not notified of the alleged assault by the Administrator until 10/19/15 at 3:08 PM (3 days after the alleged assault). Interview with LPN #2 on 4/12/16 at 6:15 AM, in the conference room confirmed her written assessment findings dated 10/16/15. Continued interview revealed the resident had abrasions when admitted to the facility and he thrashed around a lot. Continued interview confirmed LPN #2 assessed the resident with a new laceration to the right eyebrow and top of the head and forehead. Continued interview revealed the wound on the forehead had been smaller and scabbed over .but was reopened and bigger after the alleged incident. Continued interview revealed the Wound Care Nurse sat with the resident for a while after the incident. Continued interview revealed the resident told the Wound Care Nurse, Those guys were mean to me .bad guys. Telephone interview with Sitter #2 on 4/12/16 at 10:10 AM revealed Sitter #1 was trying to block head-butt against the table .Hit table once on top back side of head .Did not see (Sitter #1) strike him . Telephone interview with CNA #1 on 4/12/16 at 11:00 AM confirmed her written statement after the statement was read to her. Continued interview revealed the CNA stated, It looked like his knuckles were out .hit (resident) 3 times. He drew back the first time and came forward and hit the (resident). He didn't draw back as far the next 2 times. Continued interview revealed the resident was on the knees in front of the bathroom door (in the resident's room). Continued interview revealed, I didn't see anything on (resident) at the time, but saw blood in the floor .never saw head-banging .really believe he (Sitter #1) was hitting him (resident). Interview with LPN #1 on 4/12/16 at 11:30 AM, in the conference room revealed the LPN confirmed her written statement dated 10/16/15. Continued interview confirmed LPN #1 entered the resident's room after the incident, and the resident stated, He hit me in the head twice. Continued interview revealed the resident had attention-seeking behavior and wasn't being cooperative. I think the two sitters were stressed. We tried to help them calm him (resident) down .EMS came .tried to encourage him to settle down so he could go to the hospital .was going to get him checked out because of the shunt (VP Shunt) .was bleeding from wound on the forehead . Telephone interview with the accused sitter (Sitter #1) on 4/12/16 at 11:40 AM revealed the resident had a habit of grabbing the sitter's private parts. Continued interview revealed the sitter got the resident's hand removed and then the resident attempted to grab the sitter's hand. Got hand released .He hit his head on the sharp frame (of the bedside table). Continued interview revealed Sitter #1 slammed the table against the wall to keep him (resident) from hitting the table .had my hand on his head to keep him from hitting his head on the wall. I don't know what she (CNA #1) saw. The only thing I did was try to prevent further injury .Did not hit (resident) in the head .Did what I thought was the best thing to prevent him from self-harm. Continued interview revealed Sitter #1 was interviewed by law enforcement, and no charges were ever filed. Telephone interview with the Administrator of the facility (at the time of the incident) on 4/12/16 at 12:40 PM revealed the Administrator was waiting to get all the facts before reporting to the State agency. Continued interview confirmed the alleged assault was reported the State agency on 10/19/15 (3 days after the alleged incident) and was not reported to the State agency within 24 hours per facility policy and the Elder Justice Act.",2019-04-01
5365,SUMMIT VIEW OF ROCKY TOP,445259,204 INDUSTRIAL PARK RD,ROCKY TOP,TN,37769,2016-03-22,225,D,1,0,5X0U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, facility policy review, review of the facility investigation, observation and interview, the facility failed to immediately report to the Administrator an allegation of abuse and failed to report the alleged violation to the State agency for 1 resident (#2) with Dementia (loss of mental ability severe enough to interfere with normal activities of daily living) of 28 residents reviewed. The findings included: Resident #2 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 4/15 on the Brief Interview for Mental Status (BIMS) with severe cognitive impairment; had inattention, Delusions and disorganized thinking; and required extensive assistance with all ADL. Medical record review of the comprehensive care plan revealed the resident had physical behaviors toward others including spitting, cursing and hitting at staff during care. Continued review of the care plan revealed when the resident was showing physical behaviors, staff were to attempt refocus to positive behaviors and, if appropriate, stop care and attempt care at a later time with the same or different staff. Medical record review of nurse's notes dated 1/2/16-2/29/16 revealed no documentation of behaviors or of any incidents involving the resident. Review of facility policy, Reporting Abuse to Facility Management, revealed, It is the responsibility of our employees .to promptly report any incident or suspected incident of .resident abuse .to facility management .Employees .must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services. In the absence of the Director of Nursing Services such reports may be made to the Nurse Supervisor on duty .The Administrator must immediately be notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and Director of Nursing Services must be called at home or must be paged and informed of such incident .When an alleged or suspected case of mistreatment .or abuse is reported, the Administrator, or his designee, will immediately (within twenty-four hours of the alleged incident) notify the following persons or agencies of such incident .State licensing/certification agency responsible for surveying/licensing the facility .local/State Ombudsman .Adult Protective Services .Law Enforcement Officials .Attending Physician .Facility Medical Director . Review of an undated written statement by the Certified Nursing Assistant (CNA) #7 who witnessed the alleged incident revealed the incident occurred on 2/3/16. Continued review revealed CNA #7 and CNA #12 were in the resident's room dressing and preparing her for the lunch meal. Continued review revealed the resident was agitated and hollering which was normal behavior for the resident. Further review revealed CNA #7 was placing the resident's shoes on when she .looked up and (CNA #12) had both hands on (resident's) mouth and stated in a stern voice .'what did I tell you yesterday .If you wouldn't holler and cooperate we wouldn't have to do this.' (CNA #12) removed her hands and (the resident) said (ok .Why are you so mean to me). Continued review revealed the CNAs completed dressing the resident; placed the resident in a geri chair; and took her to the dining room for lunch. Review of a typed document by the Administrator dated 2/18/16 (15 days after the alleged incident) revealed Adult Protective Services (APS) entered the facility on 2/17/16 regarding the alleged incident. Continued review revealed the Administrator re-interviewed CNA #7, CNA #12 and the Licensed Practical Nurse (LPN) Supervisor #1 after APS left the facility. Continued review revealed CNA #7 told the Administrator, Oh this wasn't abuse .definitely inappropriate but she didn't do anything abusive to her. Review of the documented interview with LPN #1 revealed the LPN said that they both called the situation inappropriate but weren't saying it was abuse. Review of the documented interview with CNA #12 revealed the CNA denied the alleged incident and reported she may have put her hand up to stop her (resident) from spitting on her because (the resident) was known to do this. Observation of the resident on 3/7/16 at 1:30 AM in the resident's room with CNA #1 and #2 revealed the resident lying on the bed. Observation revealed when the CNAs attempted to reposition the resident and provide incontinence care, the resident became agitated; made garbled and nonsensical sounds; but did say repeatedly and rapidly, gonna tell my Daddy, gonna tell my Daddy, gonna tell my Daddy. Interview with CNA #7 (witness to allegation) on 3/8/16 at 10:25 AM and 3/9/16 at 12:15 AM, in the conference room revealed the CNA read her written statement and confirmed she documented in the statement what she observed on 2/3/16. Continued interview revealed she and CNA #12 were working with the resident to get her up and dressed before her spouse arrived for the lunch meal. The CNA reported she had placed one sleeve on the resident, and while she was attempting to place shoes on the resident, CNA #12 was attempting to place the other sleeve on the resident. CNA #7 heard (CNA #12) say the resident's name and then say, 'You need to cooperate.' CNA #7 looked up at the resident who was being uncooperative and observed CNA #12 with both hands crossed and on the resident's mouth .had hands on the mouth long enough to say to the resident, 'I told you yesterday if you will cooperate we won't have to go through this if you will cooperate' . Continued interview revealed the resident's reaction was like a small child, scared like when they get in trouble. Continued interview with CNA #7 revealed, It was absolutely unacceptable .to me it was abuse .If you were talking and I put my hands on your mouth and said to hush, that's abuse. CNA #7 confirmed again that CNA #12 had both hands on the resident's mouth. Continued interview confirmed the CNA did not report the incident to anyone until Friday 2/5/16 when she reported the incident to the LPN Supervisor (#1). Continued interview confirmed after the incident, during interviews with Registered Nurse (RN) Supervisor (#1) and the Administrator, the CNA reported to them that CNA #12 had both hands on the resident's mouth. Interview with the LPN Supervisor (#1) on 3/8/16 at 11:05 AM in the conference room confirmed she was not informed of the incident until Friday (2/5/16). The LPN Supervisor was informed by CNA #7 that she was assisting CNA #12 with the resident; heard the CNA raise her voice; and put her hands on or toward the mouth. Continued interview confirmed the alleged incident was not reported to anyone until Monday 2/8/16 when the LPN reported the alleged incident to the (Registered Nurse) RN Supervisor (#1). Interview with the accused CNA (#12) on 3/8/16 at 11:25 AM in the conference room revealed the CNA stated, I don't remember that day. I never covered her (resident #2) mouth .no way I had my hands crossed on her mouth. Interview with the RN Supervisor (#1) on 3/8/16 at 1:30 PM in the conference room revealed she was informed by CNA #7 that CNA #12 had her hands over the resident's mouth. Continued interview confirmed she was not informed of the alleged incident until Monday 2/8/16 (5 days after the alleged incident). Interview with the Director of Nursing (DON) on 3/15/16 at 2:00 PM, in the conference room confirmed she was not informed of the incident until Monday 2/8/16 (5 days after the incident). Continued interview revealed the RN Supervisor (#1) informed the DON on Monday morning of the incident and provided the written statement (by CNA #7) to the DON. The DON asked the RN Supervisor, This happened last week. Why am I just now hearing about it? Continued interview revealed the written statement was given to the Administrator on Monday morning (2/8/16) and the Administrator asked, Why am I just now learning about it .told him I had just found out. Continued interview revealed, after the DON read the written statement by CNA #7, the DON thought Oh my gosh and went to assess the resident. The DON reported she assessed teh resident's mouth, neck and head and found no signs of injury or bruising. Review of the facility's abuse policies with the DON confirmed the notification policies were not followed. The DON had no knowledge if notification was provided to Adult Protective Service (APS), the Ombudsman, local law enforcement, the facility's Medical Director or the resident's family. Continued interview revealed the Administrator was the Abuse Coordinator for the facility. Interview with the Administrator on 3/10/16 at 3:00 PM, in the conference room confirmed the allegation had not been reported to the State survey agency or any agency.",2019-03-01
2190,HARRIMAN CARE & REHAB CENTER,445368,240 HANNAH ROAD,HARRIMAN,TN,37748,2020-01-15,626,D,1,0,JJIZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, hospital documentation review, and interview, the facility failed to permit a resident to return to the facility after a hospitalization for 1 of 5 (Resident #3) reviewed for hospitalization . The findings include: Review of the medical record, showed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly Minimum Data Set ((MDS) dated [DATE], showed the resident had a Brief Interview of Mental Status Score (BIMS) of 15 indicating the resident was cognitively intact. Continued review showed the resident was on oxygen therapy. Review of a General order dated 11/24/2019, showed the facility transferred Resident #3 to a local hospital for evaluation and treatment. Resident #3 was evaluated in the emergency department and admitted to the hospital for further treatment for [REDACTED]. Record review of the Discharge MDS dated [DATE], showed the resident's readmission to the facility after hospitalization was anticipated. Review of electronic communication between the facility and the local hospital showed on 12/2/2019 the facility communicated to the hospital Resident #3 would not be able to return to the facility upon discharge from the hospital due to unable to meet needs. Review of the Hospital Discharge Summary dated 12/23/2019, showed .Patient's long-term center (Name of Nursing Home) refused to take her back .So case management looking for a different facility .Discharge pending to accepting facility with a bed for long term care .Will also need BI PAP .Patient has been at her usual baseline for several days now and has no new issues or concerns .Stable treated for [REDACTED]. During an interview on 1/14/2020 at 4:10 PM, Resident #3's family confirmed the facility refused to allow (Resident #3) to return after they transferred her to the hospital. Family stated the hospital had to find another placement for Resident #3. During an interview on 1/15/2020 at 9:48 AM, the MDS Coordinator confirmed Resident #3 was discharged on [DATE] to the hospital and her readmission to the nursing home after hospitalization was anticipated. During an interview on 1/15/2020 at 10:45 AM, the Social Service Director confirmed Resident #3 was initially expected to return to the facility after hospitalization . During an interview on 1/15/2020 at 11:27 AM, the Admissions Director confirmed she sent a referral to the admitting hospital on [DATE] informing them the facility would accept Resident #3 back to the facility. Continued interview confirmed she instructed the hospital Case Manager unless the Resident's respiratory status changed the facility could not meet the resident's needs and she could not return to the facility after being discharged . The Admissions Director was unsure of the date she notified the hospital the resident would not be accepted back to the facility. During an interview on 1/15/2020 at 3:12 PM, the Director of Nursing (DON) confirmed the facility failed to allow Resident #3 to return to the facility after being transferred to the hospital for urgent care on 11/24/2019.",2020-09-01
5358,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2016-03-28,309,D,1,0,PQUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, hospital record review, and interview, the facility failed to ensure a resident attained the highest potential of well-being for 1 (Resident #2) of 5 residents reviewed. The facility's failure to follow up with and intervene with Resident #2, who had not had a bowel movement in several days, necessitated a trip to the hospital. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set ((MDS) dated [DATE], revealed Resident #2 was moderately impaired cognitively; required extensive assistance with transfers, dressing, and grooming. Continued review of the MDS revealed Resident #2 was dependent upon staff for bathing; ate a mechanical soft diet with nectar thick liquids; and was incontinent of bowel and bladder. Medical record review of nursing notes dated 2/5/16 revealed Resident #2's speech was slightly slurred and she complained of severe achy and burning pain in bilateral lower extremities, Continued review of nursing notes dated 2/9/16 revealed Resident #2 complained of generalized weakness after her appointment with the neurologist and required the maxi-lift to transfer her to the chair. Further medical record review of nursing notes dated 2/16/16 revealed Resident #2 complained of upper left chest pain as if someone was sitting on it as well as abdominal pain. Continued review revealed the resident was not short of breath or diaphoretic, but was transferred to the Emergency Department (ED). Medical record review of the Bowel Report for the month of (MONTH) (YEAR), revealed Resident #2 had no checked on the form indicating no bowel movement from 2/4/16 - 2/10/16 and 2/11/16 - 2/16/16. Medical record review of the Medication Administration Record [REDACTED]. Continued review revealed the resident received Milk of Magnesia and [MEDICATION NAME] on 2/15/16 with no results. Further review revealed no documentation the physician was notified of this situation and no additional interventions were documented. Review of the Discharge Summary from the hospital dated 2/17/16 revealed Resident #2 .presented to the ED with chest pain and abdominal pain. Her workup included an EKG and three sets of cardiac enzymes which were negative. On abdominal plain film she was noted to have significant burden of stool. She reported no stool in approximately one week. She was given an enema and magnesium [MEDICATION NAME] and last night had a significant stool output .I think the most likely cause of her chest and abdominal discomfort was her constipation . Interview with the Administrator on 3/16/16 at 5:50 PM in the conference room, revealed the facility does not have a policy on bowel movements. Continued interview revealed the Administrator stated they followed the standard protocol of nothing happening in three days then you do something.",2019-03-01
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
1857,SIGNATURE HEALTH OF PORTLAND REHAB & WELLNESS CENT,445306,215 HIGHLAND CIRCLE DRIVE,PORTLAND,TN,37148,2017-09-21,353,E,1,0,DUCD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, interview and observation, the facility failed to provide adequate staffing to ensure services, as bathing and shaving, for 6 residents (#3, #4, #5, #6, #22, #23) of 8 residents reviewed for requiring assistance. The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident expired on [DATE]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 required extensive 1 person assistance with hygiene, and was total dependence with 1 person assistance for bathing. Review of the Quarterly MDS dated [DATE] revealed Resident #3 was total dependence with 1 person assistance for hygiene and bathing. Review of the Station 1 Shower List revealed Resident #3 was scheduled on Tuesdays and Fridays for a shower. Review of the ,[DATE] Bathing Report revealed Resident #3 failed to receive a shower on Tuesday, [DATE]; on Friday, [DATE]; and on Tuesday, [DATE] as scheduled. Further review revealed the resident failed to receive any form of bathing on [DATE], [DATE], [DATE], [DATE] and [DATE]. Interview with the Director of Nursing (DON ) on [DATE] at 2:35 PM in the conference room and on [DATE] at 2:25 PM in the conference room confirmed Resident #3 was scheduled to receive showers every Tuesday and Friday. Further interview confirmed the facility staff failed to provide a shower as scheduled to the resident. When asked if the failure for staff to bath a resident was an acceptable practice the DON stated No. 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 required extensive 1 person assistance for hygiene and bathing. Review of the Station 1 Shower List revealed Resident #4 was scheduled on Tuesdays and Fridays for a shower. Review of the ,[DATE] Bathing Report revealed from [DATE]-[DATE] Resident #4 failed to receive a shower on Tuesday, [DATE]; on Friday, [DATE]; and on Tuesday, [DATE] as scheduled. Further review revealed the resident failed to receiving any form of bathing on [DATE], [DATE], [DATE], [DATE], and [DATE]. Interview with DON on [DATE] at 7:30 AM in her office and at 2:25 PM in the conference room confirmed Resident #4 was scheduled to receive a shower every Tuesday and Friday. Further interview confirmed the facility staff failed to provide a shower as scheduled to a resident. When asked if the failure for staff to bath a resident was an acceptable practice the DON stated No. 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 Resident #5 required extensive 1 person assistance for hygiene and bathing. Observation on [DATE] at 10:53 AM, 11:25 AM, 12:00 PM, 3:10 PM, and 4:40 PM revealed Resident #5 in various locations in the facility with long facial hair. Interview with Resident #5 on [DATE] at 10:53 AM in his room revealed he liked to be clean shaven and had not had a shave in ,[DATE] days. Interview with direct care Certified Nurse Aide (CNA) #8, on [DATE] from 8:30 AM to 8:55 AM on the Station 1 unit revealed she was assigned to the resident last Thursday and came back Monday to find .my men on (resident's) hall need a shave . Review of the Station 1 Shower List revealed Resident #5 was to have a shower on Tuesdays and Fridays. Review of the Bathing Report for Resident #5 revealed he received 1 shower in ,[DATE] and all other bathing was a half bath. Interview with the DON on [DATE] at 7:30 AM in her office confirmed Resident #5 received 1 shower the entire month of ,[DATE] and there was no documentation of the resident refusing a shower. Further interview confirmed residents were to be shaved as requested, scheduled, or as needed. When asked if the failure for staff to bath and shave a resident was an acceptable practice the DON stated No. Medical record review of Quarterly MDS dated [DATE] revealed Resident #6's Brief Interview of Mental Status (BIMS) score 8 out of 15, indicating moderate cognitive impairment. Further review revealed Resident #6 required extensive assistance from one staff to complete personal hygiene, which included shaving. Medical record review of the Care Plan dated [DATE] and updated [DATE], revealed Resident #6 would be clean, dressed, and groomed. Observation on [DATE] at 11:10 AM, revealed Resident #6 in her bedroom seated in a wheelchair with white hairs visible on her chin. Observation on [DATE] at 8:40 AM revealed Resident #6 in her bed eating breakfast on her over-bed table and multiple white whiskers, approximately 1/2 inch long, were visible on her chin. Interview with Resident #6 on [DATE] at 8:40 AM in her room revealed the (CNAs) shaved her chin, and that she wanted the whiskers shaved off. Resident #6 was unable to recall the last time the (CNA) had shaved her chin whiskers. Review of Resident #6's Bathing Schedule revealed she should have received a bath or shower every Wednesday and Saturday. Review of Resident #6's Bathing Reports and C.N.[NAME] Skin Care Alert sheets from (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) revealed: December, she should have received a bath or shower 9 times. There were 2 baths or showers documented. January, she should have received a bath or shower 8 times. There were 2 baths or showers documented. August, she should have received a bath or shower 9 times. There were 5 baths or showers documented. September, she should have received 5 baths or showers to-date for the month. There were 2 baths or showers documented. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #22 had a BIMS score of 8 indicating she was moderately cognitively impaired. She was totally dependent and required assistance of one person for personal hygiene like shaving, applying makeup, and brushing teeth. Review of Resident #22's C.N.[NAME] Skin Care Alert sheets, from (MONTH) (YEAR) and to-date in (MONTH) (YEAR) revealed he most recent date she was documented as being shaved was [DATE]. Review of her bathing schedule revealed she should have received a bath or shower every Monday and Thursday. Review of her Bathing Reports and C.N.[NAME] Skin Care Alert sheets from (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) revealed: December, she should have received a bath or shower 9 times. There were 2 bed baths documented. January, she should have received a bath or shower 9 times. There was 1 bed bath documented. August, she should have received a bath or shower 9 times. There were 3 full baths or showers documented. September, she should have had 5 baths or showers to-date for the month. There were 2 full baths or showers documented. Observations on [DATE] at 8:40 AM during the initial tour revealed Resident #22 had long whiskers, approximately one-quarter inch or longer, on her chin. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #23 had a BIMS score of 15, indicating she was cognitively intact. She required extensive assistance of one person for personal hygiene. Review of Resident #23's C.N.[NAME] Skin Care Alert sheets from (MONTH) (YEAR) to-date in (MONTH) (YEAR) revealed the most recent date she was marked as receiving a shave was [DATE]. Review of her Bathing Schedule revealed she should have received a bath or shower every Tuesday and Friday. Review of her Bathing Reports and C.N.[NAME] Skin Care Alert sheets from (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) revealed: December, she should have received a bath or shower 9 times. There were 4 showers documented. January, she should have received a bath or shower 9 times. There were 2 showers documented. August, she should have received a bath or shower 9 times. There were 5 showers documented. September, she should have received 5 baths or showers to-date for the month. There was 1 shower documented. Observations on [DATE] at 8:40 AM of Resident #23 during the initial tour revealed she had long whiskers, approximately one-quarter inch or longer, on her chin. Interview with CNA #8 on [DATE] at 3:00 PM at the main nurses' station revealed residents were usually shaved on their bath or shower days, if needed, and documented on the C.N.[NAME] Skin Care Alert sheets. If staff noticed facial hair they typically shaved it. Those sheets should have been filled out every time a bath or shower was given, or if the resident refused. Interview with the DON on [DATE] at 3:15 PM in her office revealed residents should have been shaved as they requested or wanted. Most female residents did not want to have any facial hair. C.N.[NAME] Skin Care Alert sheets should have been filled out every time a resident was given a bath or shower. If the resident refused, refused should have been documented on one of the alert sheets. If Bathing Reports had documented a half type of bathing, that could mean peri care after an incontinence episode or a bed bath. There was no way to tell which it was unless there was a C.N.[NAME] Skin Care Alert sheet with a matching date to the bath report. Review of staff training In-Services dated [DATE] revealed, .We understand staff issues but do your best to complete showers as much as possible. If families ask about showers don't become defensive, just simply say I haven't gotten to it yet but I will before the day is over. Then try your best to complete that shower .",2020-09-01
1850,SIGNATURE HEALTH OF PORTLAND REHAB & WELLNESS CENT,445306,215 HIGHLAND CIRCLE DRIVE,PORTLAND,TN,37148,2017-09-21,242,D,1,0,DUCD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, interview, observation, review of the Station 1 Shower List, and review of the Bathing Report, the facility failed to honor the shaving and bathing preferences of 1 resident (#5) of 8 residents reviewed for shaving and bathing. The findings included: Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #5 was moderately cognitively impaired; had no [MEDICAL CONDITION], moods, [MEDICAL CONDITION]; was verbally abusive for 1-3 days during the review period; could hear adequately, had clear speech, made self understood and understood others; required supervision after set-up assistance for bed mobility, transfers, and eating; and required extensive 1 person assistance for hygiene and bathing. Interview with Resident #5 on 9/18/17 at 10:53 AM in his room revealed he liked to be clean shaven and had not had a shave in 3-4 days. Observation on 9/18/17 at 10:53 AM, 11:25 AM, 12:00 PM, 3:10 PM, and 4:40 PM revealed Resident #5 in various locations in the facility with long facial hair. Observation and interview with Resident #5 on 9/19/17 at 7:45 AM and 9:20 AM in the dining room revealed he was clean shaven and he said he .wanted a shave and shower 2 times a week at least . Interview with direct care Certified Nurse Aide (CNA) #8, on 9/21/17 from 8:30 AM to 8:55 AM on the Station 1 unit revealed she was assigned to the resident last Thursday and came back Monday to find .my men on (resident's) hall need a shave . Review of the Station 1 Shower List revealed Resident #5 was to have a shower on Tuesdays and Fridays. Review of the Bathing Report for Resident #5 revealed he received 1 shower in 12/2016 and all other bathing was a half bath. Interview with the Director of Nursing on 9/21/17 at 7:30 AM in her office confirmed Resident #5 received 1 shower the entire month of 12/2016 and there was no documentation of the resident refusing a shower. Further interview confirmed residents were to be shaved as preferred. When asked if the staffs failure to bath and shave Resident #5 per his specified preference was an acceptable practice the DON stated No.",2020-09-01
5327,CREEKSIDE CENTER FOR REHABILITATION AND HEALING,445516,306 W DUE WEST AVENUE,MADISON,TN,37115,2016-04-01,323,G,1,0,2CEQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, interview, review of facility incident report and investigation, and observation, the facility failed to provide supervision for safe transfers for 1 resident (#210); and failed to maintain a bed alarm intervention to address falls for 1 resident (#182) of 41 residents reviewed. The facility's failure to provide supervision resulted in harm for Resident #210. The findings included: Medical record review revealed Resident #210 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Risk assessment dated [DATE] revealed, under the section Transfer Needs Assessment, Registered Nurse (RN) #2 chose Dependent. Continued review revealed the Risk Assessment defined dependent as requires staff to lift more than 35 lbs. (pounds) of the resident's weight or resident is unpredictable in the amount of assistance needed. In this case assistive devices should be used. Further review revealed the next section required the Unit Coordinator to assess Weight-bearing capability - Full, Partial, or None. Review revealed the weight-bearing assessment was not done. Continued review revealed a section titled, Appropriate lift/transfer devices needed: (answer based on appropriate Transfer Need Algorithm (a guided decisionmaking tool)). Continued review revealed 10 options were available and RN #2 chose Stand and Pivot with gait belt (although the weight bearing ability of the resident had not been assessed). Medical record review of the Admission/Interim Care Plan dated 7/7/15, revealed Complete .Lift Program Lift/Transfer Assessment Form and report findings to ADON (Assistant Director of Nurses) as per instructions of appropriate use - communicate findings to CNA (Certified Nurse Aide). Continued medical record review revealed the assessment was not completed. Medical record review of the Occupational Therapy Screen dated 7/7/15 revealed, Pt (patient) is dependent for all functional ADL and does not present with recent change in functional status . Medical record review of the Physical Therapy Screen dated 7/8/15 revealed, Pt is dependent for all moving. Medical record review of the Physical Therapy Screen dated 10/29/15 revealed, Total assist bed mobility, 2 person transfer .No changes in functional status at this time .per nsg (nursing). Medical record review of the Quarterly MDS dated [DATE], revealed the resident had a BIMS score of 2, indicating severe cognitive impairment, required extensive assistance to total dependence for ADLS, with extensive physical assistance of 2 persons for bed mobility and transfer, had no impairment of the range of motion for upper and lower extremities, no falls since admission in (MONTH) (YEAR), and was not being treated for [REDACTED]. Medical record review of the Quarterly Physical Therapy Screen dated 1/13/16 revealed Resident #210 required Extensive assistance for bed mobility and transfers and Occupational Therapy assessed Total care related to Limited UE (upper extremity) Joint Motion. Interview with the Administrator and review of the resident's electronic medical record on 3/31/16 at 4:20 PM, in the conference room, revealed the Administrator had a screen shot (a picture of part of the electronic medical record) dated 7/6/15 showing Approaches .Assist me with all transfers. Interview confirmed there was no other intervention care planned to address the resident's assessed need for extensive to total dependence for transfer with the physical assistance of two persons. Medical record review of a night shift Licensed Practical Nurse (LPN #2) entry in Departmental Notes dated 1/15/16 revealed, Received report from resident's care giver (CNA) of c/o (complaint of) pain .guarding her left leg/foot .follow-up assessment .+2 edema (swelling) to left ankle region (more notable to lateral aspect), trace redness noted .pain only notable with position change .NP (Nurse Practitioner) called .stat (as soon as possible) xray (mobile) ordered. Medical record review of the stat mobile xray report dated 1/15/16 at 5:01 AM, revealed, SIGNIFICANT FINDINGS .Acute spiral mildly displaced fractures of the distal diaphysis and metadiaphysical junctions of the tibia and fibula. Overlying soft tissue edema and swelling .Impression: Acute mildly displaced fractures of the distal diaphysis and metadiaphyseal junctions of the tibia and fibula (fractures of the 2 bones in the lower leg) . Medical record review of the Physician's Telephone Orders dated 1/15/16 at 6:15 AM, revealed 1. Send to the ER (emergency room ) .for ortho (orthopedic) evaluation and treatment of [REDACTED]. Medical record review of the ER xrays, dated 1/15/16 at 8:41 AM, revealed, Impression 1. Comminuted spiral fracture distal tibia metadiaphysical. No significant angulation or displacement. 2. Spiral fracture of the fibula diaphysis extending to the distal metaphysis. Medical record review of the ER Physician's History and Physical dated 1/15/16 revealed, History of Present Illness .severely demented .has contractures of her left knee and left hip .from nursing home with left tibia and fibula fracture. There is no real documentation when she suffered her fall. Per daughter she is non-ambulatory and in a wheelchair .Physical Examination .Noted contracture of her left lower extremity with flexion contracture of her knee of approximately 90 degrees and a flexion contracture of the left hip .Assessment and Plan .suffered an unfortunate event that was not witnessed, resulting in a left minimally displaced comminuted spiral pattern mid shaft tibia fracture, which extends intraarticularly with a posterior malleolus (ankle) fracture as well as minimally displaced comminuted fracture of her left distal fibular shaft . Medical record review of the Discharge/Aftercare Instructions dated 1/15/16 at 10:58 AM revealed, .you have fractured both the tibia and fibula bones .This injury often happens when the ankle is twisted strongly . Review of the facility's Resident Incident Report for Resident #210, dated 1/15/16, revealed, .Incident Type: Other, Type of Injury: Fracture, Location: Resident's room, Associate Involved: (CNA #5), Incident Reported by: Certified Tech, Report Prepared by: (LPN #2) . Review of the first written statement that accompanied the Incident Report revealed it was recorded on a Fall Scene Investigation Report not dated or timed with the following: Upon arrival at 11:00 pm I checked on (Resident #210) and she was dry so there was no need to change her so on the next round at 1:00 AM she was wet and I go to change her she complains of pain in her left leg screaming 'it hurts' I finished changing her and immediately got the nurse to examine her (signed by CNA #5, assigned to the resident's care on the night of 1/15/16). Review of the written statement of the second CNA (#3) assigned to Resident #210's unit revealed, While doing my first rounds I was in room 114. I heard screaming. I peeped in the hall to see where it was coming from. As I was walking towards the screams (CNA #5) yelled out to go get the nurse because (Resident #210) was not acting like herself while she attempted to change her. I got (LPN #2). We all entered the room to assess the situation. She yelled and cried the whole time. Review of the written statement made by LPN #2, signed and dated 1/15/16 revealed, Writer assessed resident (#210) at 0145 (AM) for c/o (complaint) of pain to L (left) (lower) ext (extremity) with findings of +1-+2 edema of Left lower extremity. Trace pink color noted to left foot-with guarding of left foot with movement . Review of the fourth written statement revealed it had been obtained from CNA #4, the CNA assigned to care for the resident on 1/14/16 on the evening shift, I had pt. (Resident #210) on 1/14/16 on the 3-11 shift pt. was put to bed by me and she was normal just the no, no, stop like she always does. Medical record review of a Progress Note dated 1/17/16, by the Medical Director, revealed, .seen for readmission H&P (history and physical) .has returned to the facility .fracture sustained . Interview with the DON on 3/30/16 at 9:35 AM, in the conference room, revealed, I investigated the incident .the fracture occurred because the resident had osteoporosis . Interview confirmed the DON had not completed a root cause analysis to determine the cause of the incident that lead to the spiral fracture of the tibia and fibula bones of the lower left leg. Interview with the Director of Nurses (DON) on 3/30/16 at 3:35 PM, in the conference room, confirmed the staff nurse completing the Interim Care Plan did include the intervention Complete .Lift Program Lift/Transfer Assessment Form and report findings to ADON as per instructions of appropriate use - communicate findings to CNA but the mechanical lift assessment was not done. Interview by telephone on 3/30/16 at 9:40 PM, with evening shift CNA #4, caring for the resident on the evening of 1/14/16, revealed CNA #4 did not usually care for the resident. Interview confirmed the CNA had transferred the resident to the bed from the wheelchair without assistance, .she has always been transferred with one person. Further interview revealed the resident went to bed between 8:00-9:00 PM and was dried one time before I went off and she didn't complain of any pain . Interview with the Administrator on 3/30/16 at 4:25 PM, in the conference room, revealed the Administrator stated she had completed the investigation of Resident #210's left lower leg fractures. Interview confirmed she had not conducted a root cause analysis. The Administrator stated the resident's osteoporosis had led to the fractures. Further interview revealed, I'm not saying the fracture was spontaneous .when you are changing someone they have to be turned .it happened as care was being given, because of the osteoporosis. The Administrator was asked if her statement meant the fractures were pathological and she said no. Interview confirmed physical therapy staff and nursing staff had assessed Resident #210 as needing physical assistance of two for transfers in (MONTH) (YEAR) and again in (MONTH) (YEAR) and this need for 2 persons for safe transfer was not included in the care plan. Interview by telephone with LPN #2 on 3/31/16 at 4:26 PM, revealed the LPN came on duty at 7:00 PM the evening of 1/14/16. Interview revealed the LPN stated Resident #210 was already in the bed when he arrived. Interview included the question of the number of persons required to safely transfer the resident and the LPN stated, Not sure .in the bed normally when I come on at 7:00 PM. Interview revealed LPN #2 became aware of the resident's pain when the 2 techs (CNAs) came down the hall to get me . Interview with Resident #62 on 3/31/16 at 10:05 AM, in the resident's room, revealed the resident was alert and oriented to person, place, and time and was the roommate of Resident #210 from 7/5/15 through 1/20/16 and from 1/26-1/29/16. Interview revealed Resident #62 stated her roommate, Resident #210, was put to bed by 1 CNA with a stand and pivot on the evening of 1/14/16, .around 8:00 (PM) . Interview confirmed the observed transfer was how she normally saw Resident #210 transferred. Continued interview revealed, I am a night owl and I was awake when (the CNA) began to turn (Resident #210) .took hold behind her knee like they do when they turn me and (Resident #210) screamed like I had never heard her scream .no, didn't act like she was in any pain before that .went right to sleep . Resident #62 was asked if anything unusuaI happened with Resident #210 when the CNA first began to change her, and Resident #62 answered, No .she didn't yell until she began to be turned .I think it happened when she was transferred to bed .I never saw a lift used to transfer her .they never brought a lift in here to get her out of bed, that is what they have to use to get me out of the bed. Interview with RN #2, the Unit Coordinator, on 1/31/16 at 10:45 AM, at the Capital Hill nursing desk, confirmed Resident #210 resided on her unit during the 7 months of the resident's stay and revealed RN #2 was not able recall if the resident required 1 or 2 persons for physical assistance for transfer. Interview and review in the Smart Chart used by the CNA staff as a care guide, confirmed the RN could not bring up the resident's CNA care guide. Interview confirmed the CNAs had recorded transferring Resident #210 to and from the bed with the assistance of 1 or 2 persons on different dates. Interview confirmed RN #2 did not know if Resident #210 had the mechanical lift care planned. Interview by telephone with the Medical Director (MD) on 3/31/16 at 11:45 AM, revealed the MD stated he had received a phone call from Nursing Administration and had replied to inquiries about the cause of Resident #210's fractures, .osteoporosis is beside the point, how did the fractures happen? Further interview confirmed the spiral fractures (of the tibia and fibula) indicated the ankle was twisted. The MD stated the fractures could have occurred as the resident was transferred to bed and the pain didn't happen until the care during the night .if the fractures possibly displaced at that time. Interview with the Administrator on 3/31/16 at 4:00 PM, in the conference room, confirmed Resident #210's Care Plan included Staff to transfer resident with a hoyer lift and two staff. The Administrator stated this intervention was not developed until 1/21/16, 6 days after Resident #210 had returned to the facility from the ER with discharge instructions for the resident to be non-weight bearing for the left lower extremity. Interview revealed the Administrator could not provide an intervention that was care planned to address the resident's assessed need for extensive to total dependence for transfer with the physical assistance of two persons prior to 1/21/16. Medical record review revealed Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Post-Incident Actions dated 3/9/16 revealed .Immediate Post-Incident Action: Bed Alarm (alarm) . Further review of the Resident Incident Followup revealed .Pressure pad alarm to bed to alert staff to unassisted transfer attempts . Medical record review of the care plan revised 3/9/16 revealed .FYI (for your information) Immediate Post-Incident Action: Bed alarm Pressure pad alarm . Observation on 3/30/16 at 9:23 AM, in the resident's room, revealed the resident lying on his back on the bed with no bed alarm pressure pad in place. Observation on 3/30/16 at 2:00 PM, in the resident's room, revealed the bed alarm pressure pad was not on the bed and the resident was seated in a chair. Observation on 3/30/16 at 2:08 PM, in Resident #128's room, revealed CNA #1 opened a new bed pressure pad alarm package and placed the alarm on the bed. Interview with the resident's wife on 3/30/16 at 2:00 PM, in the resident's room, confirmed the resident had an alarm but she had not seen it lately, possibly since he got his new mattress. Interview with CNA #1 on 3/30/16 at 2:05 PM, in the resident's room, confirmed there was no alarm on the resident's bed. Continued interview confirmed CNA #1 was not certain if the resident had an alarm; and it was not on the electronic Smart Charting (electronic charting for the CNAs) to acknowledge the alarm was in place. Interview with the Assistant Director of Nursing on 3/30/16 at 2:10 PM, at the Heritage Nurses Station, confirmed the resident did not have the alarm on the bed.",2019-04-01
2678,GALLAWAY HEALTH AND REHAB,445440,435 OLD BROWNSVILLE RD,GALLAWAY,TN,38036,2017-09-21,282,G,1,1,XHU311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, kardex review and interview, the facility failed to implement care plan interventions to prevent falls and injury for 1 of 18 (Resident #3) sampled residents reviewed of 32 residents included in the stage 2 review. The failure to provide two person assist with care resulted in actual harm when Resident #3 sustained a fall which resulted in an [MEDICATION NAME] hemorrhage (an emergency condition in which a ruptured blood vessel caused bleeding inside the brain) that formed a subdural hematoma (a blood clot) on the brain and a left clavicular fracture (broken collar bone). The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] revealed Resident #3 was severely cognitively impaired, required extensive assistance with 2 person physical assist with bed mobility, transfer and was total dependent for bathing with two person assist. The care plan dated 7/11/17 documented, Focus .has an ADL (activity of daily living) Self Care Performance Deficit r/t (related to) Stroke, Dementia .Interventions .BED MOBILITY: requires, extensive assist of 2 with turning and repositioning in bed .BATHING: Requires extensive to total assist with bathing .TRANSFERS: Requires ext (extensive) to total assist with all transfers, hoyer lift . The Visual/Bedside Kardex Report documented, .Bathing: Requires extensive to total assist with bathing .Transferring .Two-person assist with transfer and positioning .Mobility: requires, extensive assist of 2 with turning and repositioning in bed . The Progress Notes dated 9/16/17 at 0600 (AM) documented, .called to resident's room at approx. (approximately) 0540 (5:40 AM) by CNA (Certified Nursing Assistant) who stated resident had fallen out of her bed while CNA was providing care .resident noted to be laying supine, in her bed, with bed at waist high. Resident was assessed by this nurse .Resident guarding R (right) side of body, specifically R upper arm and R hip . The computerized tomography (CT) report dated 9/16/17 documented, .[MEDICATION NAME] Hemorrhage (an emergency condition in which a ruptured blood vessel causes bleeding inside the brain) . The comparative CT dated 9/16/17 documented, .There is .small bilateral posterior Subdural hematomas measuring a maximum of 3 mm (millimeters) in thickness on the right and 5 mm on the left .These are non significant change compared to the prior study . The Radiology report dated 9/16/17 documented, .Left arm pain post fall .AP (anterior and posterior) .lateral views of the left humerus were obtained .IMPRESSION: Acute left clavicular fracture . Interview with CNA #2 on 9/19/17 at 11:22 AM, in the conference room, CNA #2 was asked what happened that morning when Resident #3 fell . CNA #2 stated, .I went in to give her a bed bath .I turned her over to wash her .I had reached back with one hand and had one hand on her (I) was reaching back to get the diaper and I kind of loose (loosened) the hand I had on her .her legs was positioned off the bed when I turned her .I didn't have her tight .she flipped off the bed on to the floor . CNA #2 was asked if Resident #3 was a one or two person assist for her baths. CNA #2 stated, She is a two (two persons assist) for anything. CNA #2 was asked if anyone was helping her give Resident #3 a bath that morning. CNA #2 stated, No, ma'am. CNA #2 was asked if she had given Resident #3 a bath by herself before. CNA #2 stated, Yes. CNA #2 was asked how the facility lets the staff know if a resident is a one or two person assist. CNA #2 stated, It's in the ADLs we have to do . CNA #2 was asked if Resident #3 was mobile or could she turn herself. CNA #2 stated, No, ma'am . Interview with the Director of Nursing (DON) on 9/20/17 at 8:33 AM, in the DON's office, the DON was shown Resident #3's care plan and was asked if Resident #3 was a one or two person assist with bathing, transfer and turning. The DON stated, She is an assist of two. The DON was asked if on the morning of the fall, did Resident #3 have one or two people assisting her with her bath. The DON stated, It was just (named CNA #2) .she was alone . The DON was asked if CNA #2 followed the care plan. The DON stated, No. The failure to provide two person assist with care resulted in actual harm when Resident #3 sustained a fall which resulted in an [MEDICATION NAME] hemorrhage that formed a subdural hematoma on the brain and a left clavicular fracture.",2020-09-01
3367,NASHVILLE CENTER FOR REHABILITATION AND HEALING LL,445512,832 WEDGEWOOD AVENUE,NASHVILLE,TN,37203,2020-02-20,759,D,1,0,QJU311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, medication occurrence reporting review, and interviews the facility failed to administer the correct intravenous (IV) medication to 1 of 8 sample residents (Resident #2) reviewed for medication administration. The findings include: Resident #2 was admitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum (MDS) data set [DATE] showed a Brief Interview for Mental Status score of 15 indicating no cognitive impairment. Continue review showed the resident could understand and could be understood. Further review showed IV antibiotics were routinely administered. Medical record review of the Physician orders [REDACTED]. Use 0.45 g IV 3 times a day for infection for 53 days; order started 12/18/19. Review of the medication occurrence reporting form dated 1/23/2020 showed Licensed Practical Nurse (LPN) #6 administered certriaxone (brand name [MEDICATION NAME], antibiotic given to fight infection in the body) IV instead of ceftolozane-tazobactam IV to Resident #2. Interview with the Director of Nursing (DON) on 2/19/2020 at 2:50 PM in the conference room confirmed the wrong IV medication was given to Resident #2 on 1/23/2020 at approximately 9:05 AM. Continued interview confirmed before LPN #6 left the resident's room, the resident stated the IV medication bag had another resident's name on it. Interview with the NP on 2/20/2020 at 9:00 AM in the conference room confirmed she was called by LPN #6 and the DON and informed of the medication error on Resident #2. Telephone interview with LPN #6 on 2/20/2020 at 11:00 AM confirmed she did hang the wrong IV medication for Resident #2 on 1/23/2020.",2020-09-01
741,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2019-06-26,755,D,1,0,UMZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, narcotic log review, and interview the facility failed to provide a system of medication records that enables periodic accurate reconciliation and accounting for controlled substances for 2 residents (#1 and #2) of 7 residents reviewed. The findings include: Medical record review revealed Resident #1 was admitted [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Review of the narcotic log sheets dated 2/2019 and 5/14/19 revealed [MEDICATION NAME] (an orally administered narcotic controlled substance for severe pain) was signed out 41 times. Continued review revealed 32 narcotic log sign-outs for [MEDICATION NAME] were not reflected on the MAR indicated [REDACTED] Medical record review revealed Resident #2 was admitted [DATE] and discharged [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Review of the narcotic log sheets dated 4/2019 and 5/15/19 revealed [MEDICATION NAME] was signed out 17 times. Continued review revealed 10 narcotic log sign-outs for [MEDICATION NAME] were not reflected on the MAR indicated [REDACTED] Telephone interview with the Pharmacist on 6/25/19 at 10:23 AM confirmed an audit done by the Pharmacist, the DON, and the ADON revealed some nurses were sporadic in making entries appropriately and timely to the MAR. Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 6/26/19 at 2:30 PM in the chapel confirmed the narcotics logs and MARs dated 2/2019 to 5/15/19 for Resident #1 and Resident #2 had inconsistencies. Continued interview revealed the DON confirmed the MARs for Resident #1 and Resident #2 had omissions on the MARs dated 2/2019 to 5/15/19.",2020-09-01
740,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2019-06-26,726,D,1,0,UMZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, narcotic log review, and interview the facility failed to show nursing competency in medication administration documentation for 2 residents (#1 and #2) of 7 residents reviewed. The findings include: Medical record review revealed Resident #1 was admitted [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Review of the narcotic log sheets dated 2/2019 and 5/14/19 revealed [MEDICATION NAME] (an orally administered narcotic controlled substance for severe pain) was signed out 41 times. Continued review revealed 32 narcotic log sign-outs for [MEDICATION NAME] were not reflected on the MAR indicated [REDACTED] Medical record review revealed Resident #2 was admitted [DATE] and discharged [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Review of the narcotic log sheets dated 4/2019 and 5/15/19 revealed [MEDICATION NAME] was signed out 17 times. Continued review revealed 10 narcotic log sign-outs for [MEDICATION NAME] were not reflected on the MAR indicated [REDACTED] Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 6/26/19 at 2:30 PM in the chapel confirmed the narcotics logs and MARs dated 2/2019 to 5/15/19 for Resident #1 and Resident #2 had inconsistencies. Continued interview revealed the DON confirmed the MARs for Resident #1 and Resident #2 had omissions on the MARs dated 2/2019 to 5/15/19.",2020-09-01
1992,AHC COVINGTON CARE,445330,765 BERT JOHNSTON AVENUE,COVINGTON,TN,38019,2017-10-19,282,D,1,0,Inf,"**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 and provide personal hygiene care for 1 of 3 (Resident #1) sampled residents to ensure the resident's skin was properly cleansed during 1 of 2 observations of incontinence care. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set significant change assessment dated [DATE] revealed the resident was cognitively severely impaired, non-ambulatory, dependent to extensive assist of staff for: bed mobility, transfer, dressing, eating, hygiene and bathing, and always incontinent of bowel and bladder. The plan of care (P[NAME]) dated 8/15/17 documented, .(Named Resident #1) is always incontinent of bladder .change if wet/soiled. Clean skin with mild soap and water . The Care Area assessment dated [DATE] documented, .Will continue with P[NAME] to meet toileting needs and keep resident clean, dry, and odorfree . Observations in Resident #1's room on 10/18/17 beginning at 9:25 AM, revealed Certified Nursing Assistant (CNA) #1 provided incontinence care for the resident during which time the incontinence pad under the resident was noted to be wet with urine. The CNA did not wash the resident's back where it had come in contact with the wet incontinence pad. Interview on 10/18/17 in Resident #1's room at 9:45 AM with CNA #1, when asked who's responsibility it was to make sure the resident didn't have urine left on her skin, stated, .It's mine . Interview on 10/18/17 in the Administrator's office at 12:45 PM, the Minimum Data Set nurse, Registered Nurse (RN) #1, confirmed the resident's incontinence and toileting plan of care which was to be followed by facility staff.",2020-09-01
4464,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2016-09-22,325,D,1,0,4LJL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation and interview the facility failed to provide an appropriate therapeutic diet for 1 of 27 ( Resident #182) sampled residents. The findings included: Medical record review for Resident #182 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Back Pain and Enlarged Prostate. The Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status score assessed as moderately impaired cognition. The MDS revealed the resident was totally dependent on 1 staff for eating. The MDS revealed the resident required a mechanically altered and therapeutic diet. A physician's orders [REDACTED]. Special instructions: Supervision for all meals; standard aspiration precautions. The Altered Nutritional Status care plan dated 3/18/16 and revised 9/13/16 revealed the intervention of, Provide diet as ordered: Puree, nectar thick liquids (NTL), no straws. The Potential for Aspiration care plan dated 3/28/16 and revised 7/5/16 revealed the intervention Special instructions: Supervision for all meals; standard aspiration precautions. Monitor for cough, dyspnea, and changes in respiratory rate and pattern and lung sounds. Out of bed for all meals and/or elevate head of bed 90 degrees. Review of the entire care plan revealed there was no resident non-compliance care plan. The Registered Dietician (RD) notes revealed the following: 3/30/16, .Communication received from SLP (Speech Language Pathologist). Diet downgraded to puree NTL (no straw). Tray card updated 4/14/16, .Now (the resident) requires assistance with all meals . 6/20/16, .Resident has Pringles in his room. States his friend brought them to him. Nursing made aware . 9/14/16, .Resident continues to be non-compliant with diet orders and consumes Pringles, thin water, and other snacks brought by friends . The medical record did not contain a waiver from the physician-ordered diet, and there was no documented education provided for the resident from the Dietician, Nursing, the Physician or Speech Therapists. The Nursing notes lacked any documentation of education provided to the resident or the visitors regarding eating potato chips and ice cream on a pureed diet. Observation on 9/19/16 at 3:57 PM revealed the Resident #182 lying in a flat bed with a bowl of Pringles potato chips and a cup with a straw on the bedside table. The fluid in the cup appeared to be thin liquid. The resident revealed people from his church bring chips, and bring lemonade, not thickened, and pour it for him when they visit. Observation on 9/20/16 at 2:44 PM and 3:47 PM and on 9/22/16 at 9:38 AM revealed the resident lying flat on his bed, with the chips next to the bed in a bowl, and a cup with a built-in straw on the table. Observation on 9/22/16 at 2:33 PM, revealed the resident lying flat on his bed, with the chips next to the bed in a bowl, and a cup with a built-in straw on the table, with a small amount of thin fluid in it. The resident revealed he can eat the chips himself, and demonstrated picking up a chip. He stated he lays flat to eat them and does not roll up the bed. In an interview on the 300 Unit hall on 9/21/2016 at 4:03 PM, Certified Nursing Technician (CNT) #7 stated the resident required care for basically everything, and staff had to feed the resident. CNT #7 stated the resident was on a Pureed diet he loves Pringles, and eats them, but he is not supposed to have them. CNT #7 stated the last time she took care of the resident was several days ago and she had reported to the nurse that the resident was eating Pringles, But she already knows. In an interview on the 300 Unit hall on 9/22/16 at 10:15 AM, Licensed Nurse (LPN) #10 stated she was aware the resident had potato chips on his bedside table, but not aware he had thin liquids or a straw. LPN #10 stated the chips have not been reported to her by the staff. I've seen them there, and he (the resident) needs feeding, so maybe they (staff) are feeding them to him, I really don't know how he consumes them. I do not do anything with the information, I don't know what to tell you, I started a month ago and he always has them (chips). It should be noted in his record. In an interview in the Unit Manager Office on 9/22/16 at 10:22 AM, The Unit Manager (UM) #8 stated she was not aware the resident had chips, thin liquids and a straw in his room. UM #8 stated staff should report this to the charge nurse and herself. In an interview on 9/22/16 at 1:30 PM, the Director of Nursing (DON) stated she did not know about (Named Resident #182) consuming the chips and thin liquids. The DON stated staff should remove the items and follow the diet as ordered. Staff should have reported it and removed the items from the room and reported to the supervisor. The DON verified there was no documentation in the record for education with the resident or his Power of Attorney (POA). The DON stated the facility has a dietary waiver , but Resident #182 waiver was not filled out, and education was not done by the Physician, Nursing and Speech Therapy, for the resident and his POA.",2019-09-01
1993,AHC COVINGTON CARE,445330,765 BERT JOHNSTON AVENUE,COVINGTON,TN,38019,2017-10-19,312,D,1,0,Inf,"**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 care for 1 of 3 (Resident #1) sampled residents to ensure the resident's skin was properly cleansed during incontinence care. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set significant change assessment dated [DATE] revealed the resident was cognitively severely impaired, non-ambulatory, dependent to extensive assist of staff for: bed mobility, transfer, dressing, eating, hygiene and bathing, and always incontinent of bowel and bladder. Observations in Resident #1's room on 10/18/17 beginning at 9:25 AM, revealed Certified Nursing Assistant (CNA) #1 provided incontinence care for the resident during which time the incontinence pad under the resident was noted to be wet with urine. The CNA did not wash the resident's back where it had come in contact with the wet incontinence pad. Interview on 10/18/17 in Resident #1's room at 9:45 AM with CNA #1, when asked who's responsibility it was to make sure the resident didn't have urine left on her skin, stated, .It's mine .",2020-09-01
3742,"COLLIERVILLE NURSING AND REHABILITATION, LLC",445495,490 WEST POPLAR AVENUE,COLLIERVILLE,TN,38017,2017-03-02,280,D,1,0,4B1111,"**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 the resident's current code status and to be transferred by total lift for 2 of 23 (Resident #27 and 106) sampled residents of the 47 residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #27 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented no terminal prognosis, and no hospice services received while a resident. The significant change MDS dated [DATE] documented yes to terminal prognosis, and received hospice care while a resident. The physician's orders [REDACTED].pt (patient) is a DNR (Do Not Resuscitate) Post form was revised signed (and) placed on the chart . The Tennessee Physician order [REDACTED].Do Not Resuscitation (DNR / no CPR (Cardiopulmonary Resuscitation)) (Allow Natural Death) . The physician's orders [REDACTED].Consult (Named) Hospice Services R/T (related to) Dx (diagnosis) [MEDICAL CONDITION]. The physician's orders [REDACTED].Admit to (Named) Hospice for [MEDICAL CONDITION] . The care plan dated [DATE] and reviewed [DATE] documented, .I have chosen FULL CODE STATUS . Observations in Resident #27's room on [DATE] at 2:44 PM and on [DATE] at 10:10 AM, revealed Resident #27 lying in the the bed on his right side. Interview with MDS Coordinator #1 on [DATE] at 2:00 PM, in the MDS office, he was asked about the care plan which stated the resident was a full code. MDS Coordinator #1 stated, Yea, apparently did not update it . 2. Medical record review revealed Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed Resident #106 was totally depended with two person assist for all activities of daily living. The care plan dated [DATE] documented, .Problem .at risk for falls .Approaches .2 person assist with all transfers and ambulation attempts .Problem .require assistance with ADL (activity of daily living) .approaches .2 person assist with pivot transfers and ambulation . The LIFT EVALUATION FORM dated [DATE] documented, .Full Lift Transfer .Weight-bearing ability .None .Does Resident have upper body strength .No .Lift recommendations .Total body lift .Special considerations .Non-weight bearing . The NURSE AIDE'S INFORMATION SHEET documented, .Lift to chair .With 2 assist . Interview with the Director of Nursing (DON) on [DATE] at 2:20 PM, in the Theater Room, the DON was asked is this a no lift facility. The DON stated, Yes, you should not lift a resident alone . The DON was asked how the staff was supposed to lift Resident #106. The DON stated, Lift .two people assist .lift to the chair .lift to the bed . The DON was shown Resident #106's care plan that says two persons assist with pivot transfers. The DON stated, .No . The DON was asked is the care plan correct. The DON stated, No The DON was asked how the staff would know how to transfer Resident #106. The DON stated, .care card . The DON was asked how should Resident #106 been transferred. The DON stated, .by the lift .",2020-03-01
2903,DYER NURSING AND REHABILITATION CENTER,445468,1124 NORTH MAIN,DYER,TN,38330,2017-11-07,328,D,1,0,RKY711,"**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 oxygen (O2) filters were properly cleaned for 1 of 3 (Resident #3) sampled residents receiving O2. The findings included: Medical record review revealed Resident #3 was admitted [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].OXYGEN AT 2L (liter)/MIN (per minute) . Review of the 11 to 7 Shift job description for Nurses revealed, .Mondays .Clean O2 Filters, wipe canisters down . Observation on 11/6/17 at 7:13 AM and 8:03 AM in Resident #3's room revealed Resident #3 was receiving O2 at 2 liters a minute through her [MEDICAL CONDITION]. The filters on each side of the oxygen machine were covered in dust. During an interview with the Assistant Director of Nursing (ADON) on 11/6/17 at 8:09 AM in Resident #3's room the ADON was asked if there should be dust on the O2 machine-filters in use for Resident #3. The ADON stated, No ma'am .the 11 to 7 night shift are responsible for cleaning them .",2020-09-01
2230,NORTHSIDE HEALTH CARE NURSING AND REHABILITATION C,445373,202 EAST MTCS ROAD,MURFREESBORO,TN,37130,2017-09-27,323,D,1,0,O5S911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation and interview, the facility failed to ensure a door alarm was functioning for 1 Resident (#1) of 3 residents reviewed for falls of 20 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident scored a 2 on the Brief Interview for Mental Status indicating severe impairment in cognitive skills for daily decision making, and normally used a wheelchair for mobility. Medical record review revealed an Elopement Risk assessment dated [DATE] indicating the resident was a high risk for elopement. Medical record review of the (MONTH) (YEAR) Physician order [REDACTED].Wander Guard .Order Date: 8/25/15 . Medical record review of the Nursing Note dated 12/8/16 revealed .Another resident looking out 200 hall exit door, asked 'What is that gentlemen doing sitting in the yard. 'CNA (Certified Nursing Assistant) looked out window and noted resident sitting in the grass next to the building and his w/c (wheelchair) tipped over. Asked how he got outside stated 'out the door'. Noted the green light on the control panel next to the door and door was unsecure. CNA and myself assessed resident good ROM (Range of Motion) all extremities, neuro checks WNL (Within Normal Limits) for this resident. Assisted resident to w/c and brought inside. Noted small round abrasion on the outside of left knee, and a medium bruise and abrasion on the left shoulder . Observation of Resident #1 on 9/25/17 at 10:40 AM revealed the resident seated in a wc in the hall with a wander guard bracelet on the right ankle. Interview with Certified Nursing Assistant #1 (CNA) on 9/25/17 at 10:35 AM in the conference room revealed Resident #1 had left the dining room around lunch, approximately 11 minutes later another resident said a man was outside. Continued interview revealed Resident #1 had fallen out of his wheelchair and was sitting up against the building. Interview with the former Maintenance Director on 9/25/17 at 12:45 PM by telephone revealed someone may have opened the door and when the door went to rearm it didn't rearm. Interview with the Administrator on 9/25/17 at 9:50 AM in the conference room confirmed the door was not functioning properly allowing the resident to exit the building.",2020-09-01
4808,RAINTREE MANOR,445216,415 PACE STREET,MC MINNVILLE,TN,37110,2016-07-15,246,D,1,0,HCFE11,"**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 5 residents (#1, #6, #7, #8, #9) and water was within reach for 3 (#1 #6, #7) residents with functional ability to use the call light and water pitcher on one hall of 4 halls observed. The findings included: Medical record review revealed Resident #4 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, had severely impaired cognitive skills, and required extensive assistance for eating. Medical record review of the care plan dated 2/26/16 realed the resident was at risk for nutritional concerns included Resident uses 2 handled cup with spout with meals and fluids. Observation with Licensed Practical Nurse (LPN) #1 in the resident's room on 7/12/16 at 3:40 PM revealed the resident was sitting in a recliner, the call light was on the bed out of reach, and the 2 handled cup was on the over bed table to the left of the resident out of the resident's reach. Continued observation revealed the nurse moved the table closer, inquired if the resident would like something to drink, and was handed the cup. Continued observation revealed the resident held the cup without assistance and drank 120 cubic centimeters of sweet tea before placing the cup back on the table. Continued observation revealed the nurse secured the call light within the resident's reach. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE] revealed the resident had short and long term memory problems, had severely impaired cognitive skills, and required supervision for eating. Review of the care plan revised 7/7/16 revealed the resident was at risk for weight loss and prefers to eat in the resident's room. Observation with LPN #1 in the resident's room on 7/12/16 at 3:44 PM revealed the resident was lying in bed, the call light was on the floor out of reach, and the water pitcher was on the over bed table out the resident's reach. Continued observation revealed the nurse inquired if the resident would like something to drink and the resident declined. Continued observation revealed the nurse secured the call light within the resident's reach. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE] revealed the resident had short and long term memory problems, had severely impaired cognitive skills, and required supervision for eating. Review of the care plan revised 5/20/16 revealed the resident will throw the call light on the floor and say 'I don't need that.' Observation with LPN #1 in the resident's room on 7/12/16, at 3:45 PM revealed the resident was in the Geri chair, the call light was on the bed behind the resident, out of reach, and the water pitcher was on the over bed table out of the resident's reach. Observation revealed the nurse inquired if the resident would like something to drink and the resident declined. Continued observation revealed the nurse secured the call light to the resident's Geri chair without the resident's resistance within the resident's reach. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11 of 15 indicating intact cognition, and required supervision for eating. Observation with LPN #1 in the resident's room on 7/12/16 at 3:48 PM revealed the resident was lying in bed, and the call light was on the floor out of reach. Continued interview revealed the nurse secured the call light within the resident's reach. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE] revealed the resident had short and long term memory problems, had severely impaired cognitive skills, and required extensive assistance for eating. Observation with LPN #1 in the resident's room on 7/12/16 at 3:48 PM revealed the resident was in the Geri chair and the call light was on the bed out of the resident's reach. Continued observation revealed the nurse secured the call light within the resident's reach. Interview with LPN #1 in the entrance to the hallway on 7/12/16 at 3:50 PM, confirmed the findings and confirmed the call lights and water pitchers were not within reach of the residents and the residents were capable of using the call light and obtaining a drink if within reach. Interview with the Director of Nursing (DON) in the conference room on 7/12/16 at 5:25 PM included review of the findings of the tour of the 100 hall with LPN #1. Interview with the DON confirmed the facility failed to ensure the call light and water pitchers were within reach of the residents.",2019-07-01
4936,COUNTRYSIDE HEALTHCARE AND REHABILITATION,445280,3051 BUFFALO ROAD,LAWRENCEBURG,TN,38464,2016-06-26,282,D,1,0,MKNE11,"**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 related to falls and bruising for 1 of 4 (Resident#1) sampled residents. The findings included: Medical record review revealed Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan documented, .Problem onset: 12/08/2015 .Bruise L (left) hip consistent with pinching skin between chair and cushion application of hip protector .observe effectiveness of unisex hip protector and chair cushion .Resident is at risk for falls d/t impaired mobility .Dycem to w/c (wheelchair) for safety .2/12/16 Bruise to left hand .sheepskin to metal parts of gerichair/WC . Observations in the hallway on the East Wing on 6/25/16 at 11:10 AM, revealed resident #1 was seated in a wheelchair, leaning to her right side. There was a large piece of sheepskin fabric hanging from underneath Resident #1's right thigh and touching the floor. Observations at the Nurses' Station on the East Wing on 6/25/16 at 1:35 PM, revealed Resident #1 seated in a wheelchair with a large piece of sheepskin across her lap and laying on top of the lapbuddy device. The resident was not wearing a hipster protector garment. Observations in the Common Area on the East Wing on 6/26/16 at 3:00 PM, revealed Resident #1 was seated in a wheelchair, stood upright from the wheelchair leaning forward. There was no nonslip item (Dycem) in the wheelchair to prevent slipping from the seat of the chair. Interview with CNA #1 and LPN #3 at the Nurses's Station on 6/25/16 at 3:30 PM, CNA #! and LPN #3 was asked if Resident #1 was wearing a hipster protector garment. CNA #1 stated, I didn't know she was supposed to. LPN #3 stated, I guess it's (hipster protector) is in the laundry. We only have one, so when it's dirty she doesn't have one to wear.",2019-06-01
5830,CUMBERLAND VILLAGE GENESIS HEALTHCARE,445276,136 DAVIS LANE,LAFOLLETTE,TN,37766,2015-11-17,309,D,1,0,6YVL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation and interview, the facility failed to follow physician's orders for a Urologist consult for 1 resident (#1) with recurring Urinary Tract Infections [MEDICAL CONDITION] of 11 residents reviewed. The finding included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Nurse's Notes, laboratory reports and Physician's orders dated 3/11/15-10/6/15 revealed the resident had recurring UTIs (3/11/15, 4/23/15, 6/18/15, 8/19/15, 9/6/15 and 10/6/15) and required treatment with antibiotics. Medical record review and review of hospital records dated 4/3/15 and 6/4/15 revealed the resident was hospitalized with acute mental status alteration secondary to urinary tract infection. Medical record review of a computerized Physician's order dated 9/7/15 revealed, Consult urology (named physician) for recurrent UTI. Medical record review of Nurse's Notes dated 9/7/15 through 10/8/15, and review of the facility's transport log for (MONTH) (YEAR) revealed the Physician's order was not followed in securing the appointment with the Urologist. Medical record review of a Physician's order dated 10/8/15 revealed, Please make sure that appointment has been made with .(urology) ordered 9/6/15 for recurrent UTI. Observation on 10/27/15 at 3:50 PM revealed the resident sitting in a wheelchair at the nurse's station. Speech somewhat garbled. Observation revealed the resident was drinking fluids from a small, clear plastic cup. Interview with Certified Nursing Assistant (CNA) #3/Transporter and review of the (MONTH) (YEAR) transport calendar on 11/2/15 at 10:05 AM, in the conference room confirmed the resident did not leave the facility during (MONTH) (YEAR) for a consult with a Urologist. Continued interview revealed the Transporter received a Transportation and Appointment Request Form from the nursing staff when a resident required scheduling of a physician's appointment. Continued interview revealed the Transporter contacted the physicians' offices to schedule appointments and log the appointments on the calendar. Continued interview confirmed the Transporter did not receive a referral in (MONTH) (YEAR) and did not receive a referral to schedule the Urologist's appointment until 10/8/15. The Transporter provided a copy of the request form dated 10/8/15, for Resident #1 to see a Urologist (one month after the initial order). The visit was scheduled for 10/29/15. Interview with the Assistant Director of Nursing (ADON) on 11/2/15 at 11:00 AM, in the conference room confirmed the ADON could find no evidence a Transportation and Appointment Request Form was completed for the order dated 9/6/15, for the Urologist's appointment.",2018-11-01
526,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2018-07-19,684,D,1,0,0VM311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation and interview, the facility failed to follow physician's treatment orders for 1 of 3 (Resident #3) sampled residents reviewed for wound care and treatment. The findings included: Medical record review revealed Resident#3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED].Cleanse lt (left) lower leg with wound cleaner, pat dry, apply dry 4x4's . and wrap with [MEDICATION NAME] qd (every day)/prn (as needed) one time a day for arterial/venous ulcers (.) (MONTH) reapply if dressing becomes soiled or dislodged as needed . Review of physician's orders [REDACTED].Cleanse rt (right) lower leg with wound cleaner, pat dry, apply dry 4x4's . and wrap with [MEDICATION NAME] qd/prn. one time a day for venous/arterial ulcers (.) (MONTH) reapply if dressing becomes soiled or dislodged as needed . Observation in Resident #3's room on 7/16/18 at 3:00 PM revealed the dressings on Resident #3's bilateral lower extremities were dated 7/13/18. The dressings were not changed and treatments were not provided on 7/14/18 or 7/15/18 as ordered by the physician. Interview with Licensed Practical Nurse (LPN) #1 on 7/16/18 at 3:30 PM in Resident #3's room, LPN #1 confirmed Resident #3's bilateral lower extremities dressings were dated 7/13/18. The facility failed to ensure wound treatments were changed according to physician's orders [REDACTED].",2020-09-01
1638,COUNTRYSIDE HEALTHCARE AND REHABILITATION,445280,3051 BUFFALO ROAD,LAWRENCEBURG,TN,38464,2017-07-20,282,D,1,0,4V9N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation and interview, the facility failed to implement the care plan for 2 of 4 (Residents #4, and 10) sampled residents reviewed for nutritional supplements. The findings included: 1. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 4/27/17 documented, .Supplements as ordered . A physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED] a. On 5/2/17, 5/6/17, 5/17/17, 6/29/17, and 6/30/17 at 8 am and 2 pm. On 7/6/17, 7/15/17, and 7/18/17 at 8 pm. Interview with the Director of Nursing (DON) on 7/19/17 at 2:37 PM, in the conference room, the DON was asked if a resident with a significant weight loss and he is refusing his supplements and some are not being documented is it acceptable to not update or revise your care plan for supplement. The DON stated, No .If he is refusing it and not take it .yes .you should let your doctor know . 2. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 1/25/17 and revised on 7/7/17 documented, .Problem .Resident is at nutritional risk .Approaches .supplements as ordered . A physician's orders [REDACTED].pureed diet with regular liquids .mighty shake @ (at) q (every) meal . Observations in the secure unit dining room on 7/19/17 at 12:00 PM, revealed Resident #10 seated at the table in a wheelchair. Resident #10's tray was delivered with a pureed diet and no mighty shake on the tray. Interview with Certified Nursing Assistant (CNA) #5 on 7/20/17 at 9:30 AM, at the West Nursing Desk, CNA #5 was asked if she had seen any mighty shakes on Resident #10's meal tray. CNA #5 stated, No, I haven't seen any, I fed him yesterday and there wasn't one then. Interview with Licensed Practical Nurse (LPN) #4 on 7/20/17 at 9:31 AM, at the West Nursing Desk, LPN #4 was asked if she had seen a mighty shake on Resident #10's meal trays or given him a mighty shake in the last week. LPN #4 stated, I give him Med Pass (liquid supplement) but not a mighty shake . Interview CNA #6 on 7/20/17 at 9:35 AM, at the West Nursing Desk, she was asked if she had given Resident #10 a mighty shake at any time. CNA #6 stated, No, and there was not a mighty shake on his tray this morning .",2020-09-01
3393,NASHVILLE CENTER FOR REHABILITATION AND HEALING LL,445512,832 WEDGEWOOD AVENUE,NASHVILLE,TN,37203,2018-12-20,584,F,1,0,E5NC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation and interview, the facility failed to maintain a clean and sanitary environment by ensuring tube feeding pumps were free of a dried and sticky, cream-colored substance, for 1 resident (#2) of 2 residents reviewed for gastrostomy tube (GT) feedings (a tube inserted into the abdomen for nutritional feedings) and failed to ensure Residents' linens were clean and in good condition for residents residing on 2 of 3 halls (100 and 300). The findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was severely impaired and obtained 51% or more of his nutrition from tube feedings. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. Observation on 12/17/18 at 11:30 AM in Resident #2's room revealed the resident had tube feeding infusing via a pump attached to a metal pole. In examining the pump screen for verification of infusion rate, observation revealed the pump, screen and the pole were dirty with a dried and sticky cream-colored substance. Observation on 12/18/18 at 5:30 AM in Resident #2's room revealed the tube feeding pump and pole next to the bed, was dirty with a dried and sticky cream-colored substance. Interview with Licensed Practical Nurse (LPN) #32 on 12/18/18 at 6:00 AM in the hallway of the 500 Unit revealed LPN #32 stated, .all staff had the responsibility for cleaning resident equipment. Interview with Director of Nursing (DON) #1 on 12/19/18 at 8:50 AM revealed all nursing staff were responsible for cleaning resident equipment. Continued interview revealed housekeeping cleans the equipment when a resident is discharged and prior to another resident needing it. Further interview with DON #1 revealed she was not aware of Resident #2's tube feeding pump and pole being dirty. Observation and interview with Certified Nursing Technician (CNT) #105 on 12/17/18 at 11:23 AM, revealed CNT #105 was observed providing incontinence care. When questioned about the towel that she was using, she stated, This one is a bit brown looking. She then picked up another towel and unfolded it. There were multiple brown stains observed on it. CNT #105 confirmed there were brown stains on the towel and then stated, Wow, that one isn't a good example of what they normally look like. She then stated some of the facility's towels were dingy looking. Interview with Resident #5's family member during the initial tour on 12/17/18 at 10:50 AM, revealed sometimes the towels appeared nasty and stained. Observation of linen carts on 12/17/18 at 12:12 PM, revealed there were 4 towels noted on the cart on the 300 Hall with 2 of the towels dingy with stains. Observation on the 100 Hall cart revealed 2 towels that appeared dingy and 1 had brown stains on it. Observation and interview with Laundry Aid #181 on 12/17/18 at 12:20 PM, revealed she had been employed at the facility since (MONTH) (YEAR). Continued observation with Laundry Aid #181 in the clean linen area revealed there was a linen cart in the clean linen room with linens that had just been folded and placed on the cart. Some towels were still warm. There were multiple towels and a fitted sheet on the linen cart with brown stains. A bath cloth was torn. Laundry Aid #181 confirmed the stains on the linens. Laundry Aid #181 confirmed whenever they find linens with stains, they are supposed to place them in the stained linen hamper to be re-washed. The stains should have come out in the wash when they were bleached. Stained linens after washing had been an issue and management was aware. It was observed that another laundry aid had been overstuffing the washing machine and management was aware. She indicated in her experience she had found if the washing machine was overloaded, the linens do not get clean. When questioned how they know the appropriate load size, Laundry Aid #181 stated after loading the machine, they should still be able to see over the top of the load of laundry through the machine's glass door. During observation of the current load in the washing machine, Laundry Aid #181 removed the current load from the machine, which was mostly blankets, and stated, This is too much. Interview with Laundry Aid #182 on 12/17/18 at 12:35 PM revealed when questioned how she would know how much linen was appropriate to load in the washing machine, she stated, I just know. Continued interview revealed .whenever stains are found on the linens, they were supposed to place them in the stained laundry bin to be re-washed. Interview with the Housekeeping Director #166 on 12/20/18 at 10:28 AM, revealed he stated .stained linens after washing had been brought to his attention .there had been an issue in the past with the staff overloading the laundry machine, but he had addressed it with the staff and he didn't know why the linens had stains now. If the staff are overstuffing the washing machine, then the linens would not get cleaned .",2020-09-01
4456,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2016-09-06,241,D,1,0,T33N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation and interview, the facility failed to maintain the dignity for 2 Resident's (#6 and 7) of 9 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 the Quarterly Minimum (MDS) data set [DATE] revealed Resident #6 was able to make self understood and understood others, was moderately cognitively impaired per the Brief Interview for Mental Status of 12 out of 15, no [MEDICAL CONDITION], no change in mental status from baseline, no exhibition of moods, no [MEDICAL CONDITION] demonstrated, no behaviors exhibited, required supervision with set-up assistance for transfers and toileting, and was always continent of bowel and bladder. Observation on 8/22/16 at 9:23 AM, in the hallway outside Resident #6's room revealed a very strong urine odor. Further observation revealed upon entering the room, the room was very warm, the heater was on and the heater fan was set to high. Further observation revealed Resident #6 seated on the side of the bed closest to the heater unit, the bed had no sheets, and he was facing the activated heater unit. Further observation revealed pajama bottoms, with a wet crotch area, secured to the heater unit blowing upward toward Resident #6 seated on the side of the bed. Further observation revealed wet soiled sheets on the floor against the wall at the foot of the bed. Interview with Resident #6 on 8/22/16 at 9:25 AM, in the resident's room, revealed when asked why the pajama bottoms were blowing in the air with the heater on stated .I have weak kidneys and had an accident so I'm drying them . Interview with the Director of Nursing on 8/22/16 at 9:35 AM, in Resident #6's room confirmed the room smelled strongly of urine and wet soiled pajama bottoms were blowing upward from the heater fan set on high toward Resident #6 seated on the side of the bed closest to the heater unit. Further interview confirmed the facility failed to maintain the dignity of the resident. Medical record review for Resident #7 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #7 had absence of useful hearing, absence of speech, no vision, required extensive assistance for transfers and toileting, and was always incontinent of bowel and bladder. Observation on 8/22/16 at 9:20 AM, in the hallway outside Resident #7's room revealed a very strong urine odor. Further observation upon entering Resident #7's room, revealed Resident #7 seated in a chair with 75% (percent) consumed breakfast plate on the over-bed table in front of his chair. Further observation revealed in front of the over-bed table with the breakfast tray, was the resident's bed with wet saturated sheets and a wet and brown streaked incontinence pad with a very strong odor of urine. Interview with the Director of Nursing on 8/22/16 at 9:30 AM, in Resident #7's room confirmed the urine odor was present, the bed sheets were soiled and wet while Resident #7's breakfast meal was consumed in the room. Continued interview confirmed Resident #7's dignity was not maintained.",2019-09-01
785,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2018-01-24,677,D,1,0,9MDX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation and interview, the facility failed to provide incontinence care for 1 resident (#1) of 5 residents reviewed for incontinence care. The findings included: Medical record review revealed Resident #1, was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged from the facility on 1/12/18. Review of the Minimum Data Set with a reference date of 10/14/17 revealed Resident # 1 was rarely or never understood. Continued review revealed he required total dependence on nursing staff for toilet use and personal hygiene. Medical record review of Resident #1's Bladder Evaluation dated 10/26/17 revealed the resident was incontinent of bowel and bladder at times. Continued review revealed he also went to the bathroom to void at times. Medical record review of the Care Plan dated 11/1/17 revealed Resident #1revealed the resident was to be toileted every 2 hours and as needed and his clothing was to be changed after each incontinent episode. Continued review revealed the resident required assistance with hygiene and showering. Interview with LPN #1 (regarding the 1/11/18 allegation by the caregiver) on 1/22/18 at 6:00 PM in the front conference room, confirmed .His brief was very very wet .Looked like he had voided more than once .His brief was really very wet. Telephone interview with Resident #1's caregiver on 1/23/18 at 4:18 PM confirmed the resident was saturated with urine on 1/9/18 and 1/11/18, when she visited the resident in the facility. Telephone interview with Resident #1's wife on 1/23/18 at 4:50 PM confirmed the resident was saturated with urine on 1/9/18, when she visited the resident in the facility. Interview with the Administrator and the DON on 1/24/18 at at 12:11 PM in the conference room, confirmed they were aware of the 1/11/18 incident with Resident #1, and staff re-education had been provided.",2020-09-01
1208,CHURCH HILL CARE & REHAB CTR,445237,701 WEST MAIN BLVD,CHURCH HILL,TN,37642,2018-04-18,689,D,1,1,JPQC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation and interview, the facility failed to provide safe transfers resulting in bruising for 1 dependent resident (#32) of 4 residents dependent for transfers reviewed, of 21 residents reviewed. The findings included: Medical record review revealed Resident #32 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Continued review revealed Resident #32 was non-ambulatory, required extensive assistance of 2 for transfers and assistance of 1 for wheelchair locomotion. Medical record review of the resident's Care Plan, revised on 2/16/18, revealed interventions for ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) Limited Mobility included, .requires assist of 2 using gait belt with weight bearing as tolerated right lower extremity for transfers. Medical record review of a Care Plan Review, dated 2/26/18 revealed, Skin Issue on 2/26/18 at 00:41 (12:41 AM): Noted a yellowing bruise to left posterior axilla long and thin. Resident could not say what happened. Root Cause: Wound Care Nurse relates area appears to come from transfer under arm with two assist .continue to monitor . Intervention: Proper transfer technique review with therapy and caregivers . Observation of Resident #32, on 4/16/18 at 10:20 AM, in her room, revealed her sitting in a wheel chair, completely dressed, watching TV. Interview with the Director of Nurses (DON) on 4/16/18 at 10:25 AM, in the resident's room, revealed the DON referred to the sign posted at the bedside for 2 to transfer with a gait belt, weight bearing as tolerated to the right lower extremity. Interview with the DON on 4/17/18 at 9:30 AM, in the conference room, revealed the bruise to the left posterior axilla had resolved, .was already yellowing at the edges when found .we determined it was caused by improper use of the gait belt .an inservice by therapy was done for Certified Nurse Aides (CNA's) Continued interview confirmed proper use of a gait belt is included in CNA training for certification and the CNA staff failed to apply the gait belt correctly prior to transfers of Resident #32. Interview with the resident's daughter on 4/17/18 at 10:15 AM, in the resident's room, revealed the bruise to the axilla area identified on 2/26/18 was under the left arm and extended to the back. Interview with the Wound Care Nurse on 4/18/18 at 9:00 AM, in A hall revealed the bruise of the left posterior axilla was in the shape of the gait belt .long and thin .like the edge of the gait belt could have caused . Interview with the DON and Wound Care Nurse on 4/18/18 at 9:03 AM, in the DON's office, revealed Resident #32's gait belt had been improperly applied resulting in the long left posterior axilla bruise. The Wound Care Nurse indicated, with her hands, the belt had been placed incorrectly directly under the arms of the resident.",2020-09-01
1211,CHURCH HILL CARE & REHAB CTR,445237,701 WEST MAIN BLVD,CHURCH HILL,TN,37642,2018-04-18,807,D,1,1,JPQC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation and interview, the facility failed to provide water or fluids at the bedside for 2 residents (#32 and #66) of 21 residents reviewed. The findings included: Medical record review revealed Resident #32 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Continued review revealed Resident #32 was non-ambulatory, required extensive assistance of 2 for transfers and assistance of 1 for wheelchair locomotion. Observation and interview with Resident #32, on 4/16/18 at 10:20 AM, in her room, revealed her sitting in a wheel chair with the overbed table placed in front of her and the call light clipped to the wheelchair. Continued observation revealed the resident did not have any water or fluids within reach. Interview during the observation, revealed the resident readily interacted, speech was moderately impaired, responses to questions did not make sense, and she had difficulty using her call light. Observation and interview with the Director of Nurses (DON) on 4/16/18 at 10:25 AM, in the resident's room, when the DON answered the call light, confirmed the resident did not have water or fluids available. Interview with the resident's daughter on 4/17/18 at 10:15 AM, in the resident's room, revealed an unsolicited comment, .I have come into visit (Resident #32) plenty of times and found she didn't have water to drink . Further interview revealed the daughter had share this concern with the facility each time she found her mother without water available, .nothing has changed .still have found her without water at times . Medical record review revealed Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MDS, dated [DATE], revealed Resident #66's short and long term memory severely impaired and a BIMS unable to be completed. Continued review revealed the resident used a wheelchair for locomotion. Observation of the resident on 4/16/18 at 10:55 AM, in her room, revealed the resident seated in a wheelchair with her overbed table within reach. Observation revealed there wasn't any water pitcher, water, or fluids at the resident's bedside. Interview with Certified Nurse Aide (CNA) #3 on 4/16/18 at 10:57 AM, in Resident #66's room, confirmed the resident did not have any water, water pitcher, or fluids at the bedside.",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
849,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2018-11-29,690,D,1,0,E9TM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview revealed the facility failed to have a [DIAGNOSES REDACTED].#24) of 6 with Foley catheters. The findings include: Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Medical record review of the physician orders [REDACTED].Foley-insert for diuresis . Observation on 11/21/18 and 11/26/18 Resident #24 had a Foley Catheter in place. Interview Resident #24 on 11/21/18 at 3:01 PM in her room revealed she had requested for a Foley Catheter. Interview with Nurse Practitioner (NP) on 11/21/18 at 1:24 PM in the conference room revealed Resident #24 never had urine retention, and could void. Further interview confirmed it was for her comfort that is the reason for the catheter. She does not have it for [MEDICAL CONDITION] nor does she need it. It was never intended for long term use, only for a short amount of time.",2020-09-01
680,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-07-30,686,D,1,0,MKNB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview the facility failed to follow physician orders [REDACTED].#2 and #3) sampled residents reviewed with pressure ulcers. The findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Clean sacral wound c (with) NS (normal saline). Pat dry. Apply Santyl oint. (ointment) to slough. Apply collagen & (and) calcium alginate to wound bed. Cover c protective dressing. (symbol for change) QD (everyday) & PRN (as needed) Observations in Resident #2's room on 7/30/19 at 11:22 AM, revealed Treatment Nurse #1 did not apply the Collagen dressing to the wound bed during wound care. Interview with Treatment Nurse #1 on 7/30/19 at 4:40 PM, at the First Floor Nursing desk, the Treatment Nurse #1 was asked were the physician orders [REDACTED]. Treatment Nurse #1 stated, .I didn't put the Collagen, I forgot . Medical record review revealed Resident #3 was admitted to facility 3/20/19 with [DIAGNOSES REDACTED]. The physicians's order dated 7/13/19 documented, .Cleanse area to sacrum, R (right) hip c NS, pat dry, apply santyl + (and) cover drsg (dressing) (symbol for change) QD + PRN . Observations in Resident #3's room on 7/30/19 at 1:36 PM, revealed Treatment Nurse #2 applied Santyl ointment to a Calcium Alginate dressing and applied to the wound bed, and then applied the a cover dressing during wound care. Interview with Director of Nursing (DON) on 7/30/19 at 4:15 PM, at the First Floor Nursing desk, the DON was shown the physician order [REDACTED].#2 have applied Calcium Alginate to this wound. The DON stated, No .",2020-09-01
4851,SIGNATURE HEALTHCARE OF MONTEAGLE REHAB & WELLNESS,445393,26 SECOND STREET,MONTEAGLE,TN,37356,2016-07-20,241,D,1,0,5MLN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview the facility failed to maintain the dignity and respect of 3 (Resident #2, #4, and #5) residents of 13 residents observed during dining. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident had short and long term memory loss, was rarely or never understood, sometimes understood others and was severely cognitively impaired. He required extensive assistance of 1 person for eating. Observation on 7/18/16 in the East Dining Room from 1:20 PM until 2:00 PM revealed CNA #1 was asked if Resident #2 was present in the dining room. The CNA pointed to the resident sitting next to her and stated, He's right here, he's a feeder. Continued observation revealed Resident #2 was alert and seated in a wheelchair at a table with 2 other residents. One resident had a partially eaten meal tray in front of him, the CNA was assisting the other resident with feeding, and Resident #2 had not eaten or been served a meal tray. Further observation revealed Resident #2 was observed watching CNA #1 feed the other resident, and grabbed at the resident's dining tray a few times. Resident #2 was served and assisted with his meal at 1:45 PM by CNA #1. Interview with CNA #2 at the entry door of the East Dining Room at 2:00 PM confirmed the dining cart was delivered to the East Dining Room between 12:30 PM and 1:00 PM. Continued interview confirmed the 2 CNA's assisted 8 of the 11 residents with feeding during dining. Continued interview with CNA #2 revealed the CNA stated, it takes a while to feed them all. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed she required limited assistance for eating. Observation on 7/18/16 in the East Dining Room from 1:20 PM until 2:00 PM revealed Resident #4 seated at a table with 2 other residents eating her mid day meal. The resident had food crumbs from her shoulders to her lap and on her face. CNA #1 was at an adjacent table in view of the resident. The resident was talking to staff and other residents. The resident finished her meal and stated she was leaving. Resident #4 was observed self propelling in her wheelchair out of the dining room into the hallway with food debris covering the front of her shirt and lap. Interview with the Director of Nursing (DON) on 7/18/16 at 3:00 PM in the Conference Room confirmed referring to Resident #2 as a feeder did not promote dignity or respect for the resident. Continued interview confirmed the dignity of Resident #2 was not maintained during dining while seated at a table watching other residents assisted with eating when he had not been served or assisted with eating at the same time. Further interview with the DON confirmed Resident #4 had food crumbs on her face and clothes after eating her mid day meal, and stated, I know she did, because I saw her and went and changed her myself. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was severely cognitively impaired and required extensive assistance of 1 person for eating. Observation on 7/19/16 in the East Dining Room at 12:30 PM revealed 13 residents were seated at tables waiting for the meals to be served. CNA #1 was seated at a table with 2 residents assisting them both with feeding. Licensed Practical Nurse (LPN) #1 entered the dining room and CNA #1 pointed to Resident #5 and stated, (resident's name) is a feeder. LPN #1 nodded and proceeded to assist the resident with feeding. Observation on 7/19/16 in the Main Dining Room at 12:55 PM revealed Resident #4 had completed all of her meal and was seated in her wheelchair at the table with food crumbs present from her shoulders to her lap. An Occupational Therapist (OT) was seated across the table from her. Continued observation at 1:10 PM in the East Hall revealed Resident #4 was self propelling in her wheelchair still covered in food debris. CNA #3 exited a door out into the hallway, looked at Resident #4 and continued walking down the hall without assisting the resident. Interview with the OT at 1:44 PM in the Conference Room confirmed she had observed Resident #4 eating during the mid day meal. Continued interview confirmed the resident had food debris from her shoulders to her lap and she did not assist her with cleaning up prior to leaving the dining room. Interview with LPN #1 on 7/19/16 at 1:55 PM in the East Hall confirmed CNA #1 referred to Resident #5 as a feeder and stated, I hear that all the time, but we shouldn't be calling them that. She did say that to me though. Interview with the DON on 7/19/16 at 2:00 PM in the Conference Room confirmed Resident #4 should have been cleaned up prior to leaving the dining room. Continued interview confirmed CNA #1 had been inserviced on 7/18/16 regarding calling residents feeders. The DON confirmed the facility failed to provide dignity and respect to Resident's #2, #4 and #5 during dining.",2019-07-01
5032,THE MEADOWS,445496,8044 COLEY DAVIS ROAD,NASHVILLE,TN,37221,2016-06-30,278,D,1,0,19ML11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview the facility failed to provide 1 (Resident #1) resident of 3 residents reviewed an accurate admission assessment. The findings included: Medical record review revealed Resident #1 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 moderately cognitively intact, did not receive a scheduled pain medication regimen, was on a physician prescribed weight loss regimen, received a therapeutic diet, and weighed 101 pounds. Medical record review of physician's orders [REDACTED]. Continued review revealed an order for [REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Continued review revealed the resident had received the [MEDICATION NAME] 5% Patch daily from 6/11/16 per physician's orders [REDACTED].>Observation of Resident #1 on 6/28/16 at 12:00 PM in the resident's room revealed the resident was provided, and eating a regular diet for the mid day meal. Medical record review of Dietary Notes dated 6/13/16 revealed Resident #1 weighed 107# (pounds) upon admission to the facility on [DATE]. Continued review revealed .she receives a Regular diet .and UWR (usual weight requirement) is 110-115# .She is 100% of IWR (ideal weight requirement) of 94-116 . Interview with Licensed Practical Nurse (LPN) #1 on 6/29/16 at 11:05 AM in the Conference Room confirmed she was the MDS nurse. Continued interview with the LPN confirmed Resident #1 was on a scheduled pain medication regimen during the look back period of 6/10/16-6/17/16, and the LPN had coded the MDS incorrectly. Continued interview confirmed the resident had a weight loss of 5% since admission, was not on a physician prescribed weight loss regimen, and did not receive a therapeutic diet. The LPN confirmed the facility failed to provide Resident #1 with an accurate Admission Assessment that reflected the resident's current status.",2019-06-01
4099,ELK RIVER HEALTH & REHABILITATION OF FAYETTEVILLE,445320,4081 THORNTON TAYLOR PARKWAY,FAYETTEVILLE,TN,37334,2016-12-07,241,D,1,0,Z5BS11,"**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 that promoted and enhanced the dignity for 1 (Resident # 4) resident of 4 residents reviewed. The findings included: Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Continued review of a 14 day Minimum (MDS) data set [DATE] revealed the resident was severely cognitively impaired, required extensive assistance of 2 people for bed mobility, transfers, hygiene and toileting, was unsteady on her feet, and only able to stabilize herself with assistance from staff, and was occasionally incontinent of bowel and bladder. Observation of Resident #4 on 12/7/16 in room [ROOM NUMBER] A at 8:45 AM revealed the resident was alert, laying on her back on a mattress on the floor in a hospital gown. Her hair was disheveled, and she had a bruise to her left eyelid. A fall mat was on each side of the mattress. The mat on the left side of the resident was torn in 3 places with dark brown saturated debris visible. A small pink plastic water pitcher and a small clear plastic cup was at the head of the bed to the right of the resident. A straight back chair and an over bed table were in the far corner of the room as well as a small table with a small TV on it. The call light was to the left of the resident on the floor. The resident attempted to get up off the mattress and she was not wearing any briefs and there was no pad underneath her on the mattress. Continued observation revealed there were no personal items, pictures on the walls, or decor of any kind in the room. Resident #2 was asked if she was still having diarrhea and she stated, Yes. When questioned about the bruise to her eye, she stated, I don't know. Interview with Licensed Practical Nurse (LPN) #2 on 12/7/16 at 9:00 AM in the Memory Lane Nurse Station revealed the bruise was found yesterday and was under investigation. Continued interview with the LPN revealed the resident could not walk on her own, but would scoot or crawl, but that's about it. Interview with the Director of Nursing (DON) on 12/7/16 at 10:40 AM in the resident's room confirmed the resident had no personal items, pictures or decor in her room and confirmed the dirty torn fall mat. When asked why the resident had nothing of interest to focus on in her room, the DON stated, We didn't anticipate her being on isolation this long. The DON confirmed staff had to stand over the resident when entering the room for all care, the resident was unable to move from the mattress on the floor without assistance, and crawled in the room. The DON confirmed the facility failed to provide an environment that enhanced the resident's respect and dignity.",2019-11-01
1533,GREEN HILLS CENTER FOR REHABILITATION AND HEALING,445267,3939 HILLSBORO CIRCLE,NASHVILLE,TN,37215,2017-10-31,278,D,1,0,EO0911,"**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 oxygen for 1 resident (#3) of 28 residents in the sample; failed to identify a previous fall for 1 resident (#28) of 7 residents reviewed. The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] and discharged 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 did not receive Oxygen while in the facility. Medical record review of a Physicians Order dated 8/15/17 revealed, .(Oxygen by nasal cannula at) 2 (liters per minute) continuous for (Shortness Of Breath) every shift . Medical record review of a 9/2017 Medication Administration Record [REDACTED]. Interview with MDS Coordinator #2 on 10/30/17 at 3:30 PM in the conference room confirmed the facility failed to accurately assess Resident #3's use of Oxygen on the 9/26/17 quarterly assessment. Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a History and Physical of dated 9/13/17 revealed .She apparently fell the other weekend .she has had ongoing pain and discomfort in her left knee .with new onset .and significant swelling . Medical record review of the admission MDS dated [DATE] revealed the resident had not fallen in the last six months. Interview with MDS Coordinator #2 on 10/30/17 at 3:30 PM in the conference room confirmed the admission MDS failed to identify a previous fall prior to admission and the facility failed to provide an accurate MDS for Resident #28 on admission.",2020-09-01
4810,CONCORDIA TRANSITIONAL CARE AND REHAB-MARYVILLE,445245,1012 JAMESTOWN WAY,MARYVILLE,TN,37803,2016-07-05,309,D,1,0,COP211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to address the needs of 1 resident (#11) of 3 residents reviewed for application of splints or hand rolls and heel protectors as ordered by the physician. The findings included: Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Order Summary Report dated 5/30/16 revealed .Apply heel protectors to be worn at all times . with an order date of 11/25/14. Further review revealed .Right hand splint to be applied 6 hours per day as patient tolerates. Hand roll to right hand when splint not in use, as patient allows. Hand roll to left hand daily as resident allows. (MONTH) be removed for hygiene and bathing . with an order date of 11/21/15. Review of a Physician's Progress note dated 6/1/16 revealed Resident #11 had bilateral contracted wrists and elbows with the legs and hips also contracted. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #11 did not code on the Brief Interview for Mental Status (BIMS) and was severely cognitively impaired. Further review revealed the resident was totally dependent on staff for transfer, dressing, eating, and hygiene/bathing. Observation on 7/3/16 at 10:40 AM, with Licensed Practical Nurse (LPN) #3 present, in the resident's room revealed Resident #11 did not have splints or hand rolls on the right or left hand. Further observation revealed the resident did not have heel protectors on as ordered by the Physician. Medical record review of the Medication Administration Record [REDACTED]#11. Interview with LPN #3 on 7/3/16 at 10:45 AM, at the South Nursing Station confirmed the splints or the hand rolls were not present on the resident's right or left hand. Further interview with LPN #3 confirmed the facility had an order for [REDACTED].#3 confirmed the facility had no documentation of the resident's refusal to have splints/hand rolls placed as ordered.",2019-07-01
3289,"THE WATERS OF SMYRNA, LLC",445502,202 ENON SPRINGS ROAD EAST,SMYRNA,TN,37167,2019-06-03,656,D,1,0,5UPJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to develop and revise the Comprehensive Care Plan to reflect the family's use of a syringe to administer liquids to the resident for 1 (Resident #1) of 3 residents reviewed. The findings included: Medical record review revealed Resident #1 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 #1 scored 0 on the Brief Interview for Mental Status (BIMS) indicating she was severely cognitively impaired. Continued review of the MDS revealed Resident #1 required extensive assistance of 2 people with transfers and toileting; extensive assistance of 1 person with dressing, eating, and grooming; was dependent on 2 people for bathing; and was always incontinent of bowel and bladder. Medical record review of an Interdisciplinary Resident Screen completed by Speech Therapy (SLP) dated 5/13/19 revealed .SLP asked to see pt (patient) due to reports of syringe feeding. SLP educated care giver on dangers of aspiration increased with use of syringe feeding. Pt able to take food from spoon/liquids with spoon . Medical record review of a Nurse Practitioner's (NP) note dated 5/16/19 revealed .Resident seen due to worsening cough/congestion x 3 days. Cough is wet but non-productive. She has some crackles on the lower lobes and lung sounds are generally diminished, Nurse reports family has been force feeding resident with syringes increasing risk of aspiration. Family has been discouraged from forced feeding but still engages in practice. Will obtain CXR (chest x-ray) today to check for pneumonia due to worsening cough . The NP also included a [DIAGNOSES REDACTED]. Medical record review of a report of a chest x-ray dated 5/16/19 revealed .Left base minimal infiltrate . Medical record review of the Comprehensive Care Plan dated 4/10/19 revealed no mention of the family using syringes to administer fluids to the resident. There was no documentation of the Speech Therapist, Nurse Practitioner, and Administrator educating the family on not using syringes since that would increase the risk of aspiration. There was no documentation for the staff to observe the family when in the resident's room to determine if they were still using syringes. Observation of Resident #1 on 6/3/19 at 12:10 PM in her room revealed the resident sitting upright in the bed and the sitter was preparing food brought in by the daughter. The sitter placed the food on a spoon and the resident ate the food. She did not refuse the food because it was mashed potatoes, mashed beans, and squash which the resident liked. Then the sitter filled a 10 ml syringe with tea; placed it in the left corner of the resident's mouth; and slowly pushed the fluid into the resident's mouth. Interview with the complainant on 6/3/19 at 12:00 PM revealed I will use whatever means I need to get nourishment into my Momma - she won't dehydrate on me. Momma will eat food we bring in such as cabbage, squash, b eans, dressing with gravy, and mashed potatoes. Anything is better than that pureed stuff they serve here; it tastes like something from the barn. That's my Momma - I'm not going to strangle her. We took her teeth out so we could make a pocket in her mouth to put the fluids in then they would trickle down her throat . Interview with the Director of Nursing (DON) on 5/21/19 at 2:30 PM in the conference room revealed the resident was not eating or drinking at that time. She clamped her mouth shut so she can't even get medications most of the time. The family forces her to eat and drink, even to the point of using a syringe to force fluids into the resident. The NP explained to the family force feeding was not permitted as it was against resident rights plus it greatly increased the likelihood of aspiration. Interview with the Director of Nursing (DON) on 6/3/19 at 11:30 AM in the conference room revealed the daughter of Resident #1 obtained the syringes from (named pharmacy). The family had been educated on not force feeding the resident. The daughter was willing to sign a waiver to use any means necessary to get fluids into the resident. The DON stated the family may still be using a syringe to feed the resident but was not sure. In summary, Resident #1 had a [DIAGNOSES REDACTED]. She would clamp her jaws together so no one could get anything into her mouth. The family began using syringes to force feed fluids to the resident. The family was educated by numerous people on not using the syringes but continued to do so. The facility failed to develop a care plan documenting these issues and alerting staff to needed observations in the resident's room.",2020-09-01
672,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-03-10,677,E,1,0,TO3W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to ensure Activities for Daily Living (ADL) assistance related to incontinence care was provided for 2 of 6 (Resident #4 and #11) sampled residents reviewed of the 12 residents included in the sample. The findings include: 1. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date of 12/12/18 revealed Resident #4 scored 14 on the Brief Interview of Mental Status (BIMS) which indicated the resident was cognitively capable for decision making. Section G of the MDS documented the resident was dependent for hygiene/bathing, dressing, and eating. Review of the Comprehensive Care Plan documented, .The resident has an ADL self-care performance deficit r/t (related to) Disease Process (Stiff ma[DIAGNOSES REDACTED]) .PERSONAL HYGIENE/ORAL CARE: The resident is totally dependent on staff for personal hygiene .TOILET USE: The resident is totally dependent on staff for toilet use .The resident has potential for impairment to skin integrity r/t immobility, and disease process .Keep skin clean and dry . Observations on 2/27/19 at 1:40 PM in Resident #4's room revealed the resident wearing a urine soaked incontinence brief. There was a foul urine odor in the room. Interview with Resident #4 on 2/27/19 at 12:50 PM in her room, the resident stated, Nobody has been in here .I have not been changed since 5 AM .fed me breakfast and that's all . Interview with Licensed Practical Nurse (LPN) #1 on 2/27/19 at 3:47 PM at the 200 Hall nurses' Station, the LPN was asked who was responsible for providing care for Resident #4 from 7:00 AM until 3:00 PM. LPN #1 stated, I can't say that anyone did. 2. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an assessment reference date of 1/30/19 revealed Resident #11 scored 12 on the Brief Interview of Mental Status (BIMS) which indicated the resident was cognitively capable for decision making. Section G of the MDS documented the resident required extensive assistance for hygiene/bathing and dressing. Review of the Comprehensive Care Plan documented, .The resident has an ADL self-care performance deficit r/t Disease Process .TOILET USE: The resident is totally dependent on staff for toilet use .The resident has potential for impairment to skin integrity r/t impaired mobility and incontinence .Keep skin clean and dry .The resident has bowel and bladder incontinence .Clean peri-area with each incontinence episode . Interview with Resident #11's wife on 3/10/19 at 1:32 PM in the 100 Hall chart room, the wife stated, .I have to change him because I can't find an aide to do it. They work with only 2 or 3 aides on this hall. They don't have enough help to take care of these people. I've had to call my son to come in and help me change my husband .He has not been checked or changed since he got up for breakfast. He is wet now . Resident #11 confirmed he was wet with urine and needed incontinence care. The facility failed to provide ADL care related to incontinence care.",2020-09-01
3181,"COLLIERVILLE NURSING AND REHABILITATION, LLC",445495,490 WEST POPLAR AVENUE,COLLIERVILLE,TN,38017,2018-03-21,693,D,1,1,RZTK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to ensure a continuous tube feeding was administered and failed to ensure a tube feeding was paused when the head of bed was lowered below 30 degrees during wound care for 2 of 7 (Residents #81 and 88) sampled residents reviewed for tube feedings. The findings included: 1. Medical record review revealed Resident #81 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #81 had no cognitive impairment and had a tube feeding. The physician's orders [REDACTED].Tube Feeding Continuous .at 45 cc (cubic centimeters)/hr (hour) x (times) 22 hrs. (hours) . Observations in Resident #81's room on 2/27/18 at 11:42 AM, revealed Resident #81 sitting in a geriatric chair, the tube feeding pump was turned off. Interview with Licensed Practical Nurse (LPN) #2 on 2/27/18 at 11:45 AM, in Resident #81's room, she was asked should the tube feeding be on. LPN #2 stated, .I am going to turn it back on now. 2. Medical record review revealed Resident #88 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] revealed Resident #88 had severely impaired cognitive skills for daily decision making and had a tube feeding. The physician's orders [REDACTED].Tube Feeding Continuous .at 60 cc/hr x 22 hrs . Observations in Resident #88's room on 2/27/18 at 10:45 AM, revealed a sign on the wall that documented, HOB (Head Of Bed) - PLEASE KEEP THE HOB ELEVATED 30 - 40 DEGREES . Resident #88 was lying in a bariatric bed with the head of bed elevated approximately 20 degrees. The tube feeding was running via a feeding pump. Interview with Licensed Practical Nurse (LPN) #2 on 2/27/18 at 10:49 AM, in Resident #88's room, she was asked should this tube feeding be on. LPN #2 stated, Yes. LPN #2 then raised the hob up and stopped the tube feeding for wound care.",2020-09-01
5496,CHURCH HILL CARE & REHAB CTR,445237,701 WEST MAIN BLVD,CHURCH HILL,TN,37642,2016-02-03,246,D,1,0,IWKE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to ensure a portable Oxygen (O2) tank was available for 1 resident (#3) of 14 residents reviewed. The findings included: Medical record review revealed Resident #3 was readmitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 13/15 on the Brief Interview for Mental Status (BIMS) with no impairment of cognitive skills; had no behaviors; required only supervision with locomotion on and off the unit; used a wheelchair for mobility; received antianxiety medications 7 days in the prior 7 days; and received O2 therapy. Medical record review of the physician's orders [REDACTED].O2 every shift related to [MEDICAL CONDITION] .2 lpm (liters per minute) via NC (nasal cannula) to keep sats (measure of how much O2 the blood is carrying) > (greater than) 90% (percent) . Medical record review of a nurse's note dated 1/10/16 at 9:47 AM revealed was sitting at the nurses' station for C/D wing and yelling and cursing because a portable O2 tank was not available for use by the resident. Continued review revealed portable tanks had been filling all night long. Continued review revealed the nurse informed the resident, he would be provided a portable tank as soon as one was available. Medical record review of a nurse's note by Registered Nurse (RN) #3/Supervisor dated 1/10/16 at 10:15 AM revealed the resident was at the C/D wing nurses' station, yelling loudly and cursing that he wanted an O2 tank (portable). Continued review revealed, .Instructed resident that 2 stations were available to fill all facility portable O2 tanks and that they were currently filling tanks .Tanks checked and the light on one tank noted to light up full as this nurse was checking them. Resident was provided with O2 tank for wheelchair . Observation and Interview with RN #4/Unit Manager on 1/11/16 at 12:20 PM, at the C/D nurses' station confirmed the facility had 2 fill stations for portable O2 tanks which were located on the C/D unit. Continued interview revealed tanks were filled on night shift because the tanks were in use on day shift. Observation of the fill stations with RN #4 revealed 2 portable tanks were being filled. Continued interview revealed the facility housed 3 different sizes of portable tanks and confirmed the larger tanks used by Resident #3 required 6-8 hours for filling. Observation and interview with the resident and a family member on 1/11/16 at 12:35 PM, in the resident's room revealed the resident sitting in the wheelchair connected to a portable O2 tank at 2.0 lpm. Interview with the resident and the family member revealed the facility had only 2 stations to fill machines, and 6-8 hours were required to fill the large portable tanks which were used by the resident. Interview confirmed the resident .had to stay in the room before and eat breakfast because a (portable) tank was not available. Interview with RN #3/Supervisor on 1/13/16 at 3:20 PM, in the Staff Development office revealed, over the weekend, night shift had filled some portable tanks, but those tanks were already in use by other residents on Sunday (1/10/16). Continued interview confirmed Resident #3 was upset on 1/10/16 because no portable tanks were filled and available for his use until 10:15 AM. Continue interview confirmed the resident .just wanted to get out and about the facility . Interview with the Activity Assistant on 1/14/16 at 9:50 AM, in the Staff Development office confirmed the resident was pretty independent .likes movies and popcorn in the big dining room .likes watching TV .does Bingo .men's club . Continued interview confirmed, if the resident was feeling well, he was out strolling around, talking to staff and other residents . Continued interview confirmed his activity would be limited without a portable O2 tank.",2019-02-01
3961,MCNAIRY COUNTY HEALTH CARE CENTER,445452,835 EAST POPLAR AVENUE,SELMER,TN,38375,2017-01-12,323,D,1,0,XE2W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to ensure interventions were implemented to prevent falls for 2 of 5 (Residents #6 and 7) sampled residents. The findings included: 1. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Peripheral Vascular Disease, Abdominal Aortic Aneurysm, Hypertension, Anxiety, [DIAGNOSES REDACTED], Diabetes, Benign Prostatic Hyperplasia, Dysphagia, Insomnia, Nicotine Dependence, Depression, Constipation, Generalized Muscle Weakness, and Pyloric Stenosis. The admission Minimum (MDS) data set [DATE] documented a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment, wandering behaviors occurred daily, and Resident #6 required extensive staff assistance for activities of daily living. The care plan dated 10/21/16 documented, .At Risk For Falls R/T (related to) weakness11/28/16 fall w/o (without) injury .Interventions .Footware (footwear) will fit properly and have non-skid soles .non skid socks placed on resident . Observations in Resident #6's room on 1/12/17 at 8:25 AM and 11:30 AM, revealed Resident #6 in his bed wearing smooth socks without non-skid soles. Observations in Resident #6's room on 1/12/17 at 9:45 AM, revealed Resident #6 ambulating in his room wearing smooth socks without non-skid soles. Interview with the Director of Nursing (DON) on 1/12/17 at 11:30 AM, in Resident #6's room, the DON was asked whether Resident #6 should be wearing non-skid socks. The DON stated, .Yes. 2. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum (MDS) data set [DATE] documented severe cognitive impairment per staff assessment, required extensive staff assistance with activities of daily living, and had 1 fall without injury since admission. The care plan dated 9/19/16 documented, .At Risk For Falls R/T unsteady gait/weakness/confusion/vertigo/impaired vision9/22/16 Fall w/out (without) injury-slid out of w/c (wheelchair)10/30/16 Leaned forward-fell out of w/c . Observations in the hall outside the weight room on 12/19/16 at 8:20 AM, revealed Certified Nursing Assistant (CNA) #1 and CNA #2 transferred Resident #7 from a shower chair to a rock-and-go wheelchair without locking the wheels on the receiving rock-and-go wheelchair. Interview with the Assistant Director of Nursing (ADON) on 12/19/16 at 4:45 PM, in the ADON's office, the ADON was asked what she expected staff to do when transferring residents to wheelchairs. The ADON stated, .should have locked the wheels .",2020-01-01
5495,CHURCH HILL CARE & REHAB CTR,445237,701 WEST MAIN BLVD,CHURCH HILL,TN,37642,2016-02-03,164,D,1,0,IWKE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to ensure privacy was maintained during care for 1 resident (#12) of 14 residents reviewed. The findings included: Medical record review revealed Resident #12 was readmitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had short and long-term memory problems and moderately impaired decision-making skills; required extensive assistance with all activities of daily living; and was incontinent of bowel and bladder. Observation on 1/12/16 at 12:37 PM with Certified Nursing Assistants (CNA) #1 and #2 in the resident's room revealed the CNAs failed to close the privacy curtain prior to positioning the resident on the right side on the bed, removing the brief, and exposing the buttocks. Observation revealed the roommate's sitter was sitting at the foot of the roommate's bed in clear line of sight of Resident #12. Observation at 12:38 PM revealed the sitter walked by the foot of the resident's bed, looked at the resident, and observed the resident's exposed buttocks. Interview with CNA #2 on 1/12/16 at 1:15 PM, in the hallway outside the resident's room confirmed the privacy curtain was not placed around the resident's bed during care and the sitter was in clear line of sight of the resident's exposed buttocks.",2019-02-01
3270,"THE WATERS OF SMYRNA, LLC",445502,202 ENON SPRINGS ROAD EAST,SMYRNA,TN,37167,2018-01-16,557,E,1,0,POU411,"**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 treated in a dignified manner for timely meal service and feeding assistance for 4 residents (#17, #18, #20, #21) of 13 residents observed for dining. The findings included: Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #17 scored 3 on the Brief Interview for Mental Status (BIMS) indicating she was severely cognitively impaired. Continued review of the MDS revealed Resident #17 required extensive assistance of 1 person with eating. Observation of Resident #17 on 1/9/18 at 11:30 AM in the 300 hall dining room revealed lunch trays were delivered at 11:30 AM. Continued observation revealed 2 other residents were assisted with eating then at 12:07 PM the Certified Nurse Aide (CNA) #7 assisted a male resident with his lunch. Further observation revealed at 12:19 PM CNA #7 asked Resident #17 what her name was then asked another staff member who the resident was before retrieving the lunch tray. Continued observation revealed at 12:22 PM Resident #17 was assisted with her lunch. Further observation revealed the food was not reheated before CNA #7 assisted the resident with eating. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 30 day MDS dated [DATE] revealed Resident #18 scored 3 on the BIMS indicating she was severely cognitively impaired. Continued review of the MDS revealed Resident #18 required extensive assistance of 1 person with eating. Observation of Resident #18 on 1/9/18 at 11:30 AM in the 300 hall dining room revealed lunch trays were delivered at 11:30 AM. Continued observation revealed 2 other residents were assisted with eating then at 12:07 PM CNA #7 assisted a male resident with his lunch. Further observation revealed at 12:19 PM CNA #7 asked Resident #18 what her name was then asked another staff member who the resident was before retrieving the lunch tray. Continued observation revealed at 12:22 PM Resident #18 was assisted with her lunch. Further observation revealed CNA #7 assisted both Resident #17 and Resident #18 with eating at the same time. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Dysphagia, and Retinal Detachment. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #21 scored 0 on the BIMS indicating she was severely cognitively impaired. Continued review of the MDS revealed Resident #21 required extensive assistance of 1 person for eating. Observation of the 300 hall dining room on 1/10/18 at 11:30 AM revealed lunch trays had just been delivered. Continued observation revealed 7 residents in the dining room and 5 of those residents were being assisted with eating by CNAs. Further observation revealed Resident #21 was reclined in a geri-chair at the table where another resident was being assisted with eating. Continued observation revealed CNA #2 obtained the lunch tray for Resident #21 at 11:55 AM and began to assist her with eating. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Entry MDS dated [DATE] revealed Resident #20 scored 3 on the BIMS indicating she was severely impaired cognitively. Continued review of the MDS revealed Resident #20 required extensive assistance of 1 person for eating. Observation of the 300 hall dining room on 1/10/18 at 11:30 AM revealed lunch trays were delivered. Continued observation revealed 7 residents in the dining room and 5 of those residents were being assisted with eating by CNAs. Further observation revealed Resident #20 was reclined in a geri-chair seated at a table by herself. Continued observation revealed CNA #2 obtained the lunch tray for Resident #20 at 12:05 PM and began assisting her with eating. Interview with Licensed Practical Nurse #3 on 1/10/18 at 1:00 PM on the 300 hall, confirmed it was an affront to resident dignity for residents to wait for their meal and sit at a table where other residents were being assisted with eating.",2020-09-01
1675,RAINBOW REHAB AND HEALTHCARE,445283,8119 MEMPHIS ARLINGTON ROAD,BARTLETT,TN,38133,2017-09-12,309,D,1,0,JM4F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to follow physician orders [REDACTED].#10) of 10 sampled residents. The findings included: Medical record review revealed Resident #10 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of a physician order, dated 7/29/17 documented, .Cleanse right lower leg with wound cleanser, pat dry, apply Silver alginate and cover with Dry dressing (every other day and as needed) - every 48 hours for wound . Review of a Wound Note dated 9/8/17 as a late entry for 9/5/17 documented, .location of wound: right shin. Type of wound: diabetic/ischemic .Wound measurements in centimeters: length: 2.0 width: 3.5 depth: 0.1 . Drainage: moderate serosanguinous. Odor: none. Wound base: granulation. Tunneling (if applicable): none. Peri-wound: [MEDICAL CONDITION] .Progress: no changes noted to the surface area at this time. Wound bed is stable with 100% pink granulation tissue noted. 2+ (plus) [MEDICAL CONDITION] noted to both lower extremities. Will continue to treat area with silver alginate (every other day) . The care plan dated 7/29/17 documented, .The resident has potential/actual impairment to skin integrity (related to) - diabetic ulcer-right chin (shin) .Provide all skin treatment as indicated . Review of the (MONTH) (YEAR) Treatment Administration Record (TAR) documented the treatment was scheduled for 8/8/17, 8/10/17, 8/12/17, and 8/20/17; however, there was no documentation to indicate it was done on those days. Review of the (MONTH) (YEAR) Treatment Administration Record (TAR) documented the treatment was not performed on 9/1/17, 9/5/17, 9/7/17, and 9/11/17. The treatment was scheduled for 9/3/17 and 9/9/17 as well; however, there was no documentation to indicate it was done on those days. Observations in Resident #10's room on 9/11/17 at 9:57 AM revealed Resident #10 seated on her bed in her room with her legs uncovered. There was a bandage on her right shin above the ankle. The bandage was dated 9/7/17. There were large yellow stains on the bandage and on the sock on her right foot. The resident stated she had a sore on her leg. Interview with the Treatment Nurse on 9/12/17 at 3:05 PM, the Treatment Nurse stated most of the missed treatments were during the weekend and during the week she was off on vacation. The treatment nurse stated Resident #10 does not refuse dressing changes, and she was unaware of a reason the above treatments were missed. On 9/12/17 at 3:10 PM, the Unit Manager (UM) stated the treatment nurses should have completed the wound treatments every other day as ordered, or should document on the TAR a reason for not doing the treatment.",2020-09-01
1283,LIFE CARE CENTER OF CLEVELAND,445244,3530 KEITH ST NW,CLEVELAND,TN,37311,2018-10-24,658,D,1,1,X6ME11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to follow physician's orders for 1 resident (#159) of 45 sampled residents. The findings include: Resident #159 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Resident #159's care plan, initiated 6/14/18 revealed, .Resident has [DIAGNOSES REDACTED]. Continued review revealed, .Approaches .Meds .as ordered by MD (medical doctor) . Medical record review of Physician's Orders for (MONTH) (YEAR) revealed, . [MEDICATION NAME] (anti-convulsant) 300 mg (milligrams) capsule PO (by mouth) daily . at 8:00 AM. Medical record review of a nurse Progress Note dated 8/27/18 revealed, .late entry for 8/23/18. At approximately 1:30 PM, resident turned on call light requesting pain medication for left hip. This nurse was getting ready to sign out pain medication [MEDICATION NAME] (narcotic pain medication) .this nurse mistakenly signed out [MEDICATION NAME] instead of [MEDICATION NAME] . Interview with Licensed Practical Nurse (LPN) #1 on 10/23/18, at 3:25 PM, at the nurses' station, confirmed the LPN had mistakenly gave an additional dose of the medication [MEDICATION NAME]. Interview with the Director of Nursing (DON) on 10/24/18, at 8:35 AM, in the DON's office, confirmed LPN #1 had not followed the physician's order for medication administration and confirmed Resident #159 had received an additional dose of [MEDICATION NAME].",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
5366,SUMMIT VIEW OF ROCKY TOP,445259,204 INDUSTRIAL PARK RD,ROCKY TOP,TN,37769,2016-03-22,282,D,1,0,5X0U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to implement the care plan to turn and reposition every two hours and keep the skin clean and dry for 1 resident (#1) who was at risk for the development of Pressure Ulcers of 28 residents reviewed. The findings included: Resident #1 was admitted to the facility from another nursing home on 7/9/15 with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 7/15 on the Brief Interview for Mental Status (BIMS) with moderately impaired decision-making skills, had disorganized thinking and delusions; required extensive assistance of 2 people with bed mobility, hygiene and bathing; and was always incontinent of bowel and bladder. Medical record review of the Braden Scale for Predicting Pressure Sore Risk dated 7/16/15, 10/16/15 and 1/16/16, revealed the resident was at high risk for the development of Pressure Ulcers. Medical record review of the Wound Care Center's orders dated 1/25/16 revealed, Turn q (every) 2 hours .Avoid position directing pressure to wound site . Medical record review of a nurse's note dated 2/23/16 revealed, .Turned every 2 hours . Review of the Wound Report dated 3/4/16 revealed the resident had a Stage 4 Pressure Ulcer to the coccyx which measured 4.0 cm (centimeters) X (by) 3.5 cm X 0.5 cm. Continued review revealed interventions included, Turn Q 1 hr (hour). Medical record review of the current comprehensive care plan revealed the resident had .open areas on coccyx and right scapula and right heel . Continued review revealed, .Turn and reposition with devices every 2 hours on air mattress .Keep clean and dry . Continued review revealed the resident was at risk for impaired skin integrity related to urinary and bowel incontinence and revealed, Check resident at intervals to ensure episodes of incontinence are addressed promptly . Observation and interview with Certified Nursing Assistant (CNA) #1 and #2 on 3/7/16 at 1:45 AM (night shift), in the resident's room revealed the resident was lying on the bed on her back. Observation revealed the CNAs positioned the resident on the right side. Observation revealed a gauze dressing on the sacrum. Interview with CNA #1 and #2 in the resident's room at the time of the observation confirmed the resident had a Pressure Ulcer on the sacrum and the resident required repositioning every two hours. Observation revealed the CNAs positioned the resident on the back and removed the brief. Observation revealed the resident had been incontinent of urine with a strong ammonia odor. Observation with the CNAs revealed the skin on the back and buttocks was intact except for the Pressure Ulcer on the sacrum. Continued interview with the CNAs confirmed the resident was in need of incontinence care and that incontinence care or repositioning off the back had not been provided for the resident since the evening shift (2:00 PM-10:00 PM) went off duty at 10:00 PM (3 hours, forty-five minutes).",2019-03-01
5614,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2016-01-05,252,D,1,0,8BJL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to maintain a clean, comfortable, and homelike environment, for 1 Resident (#1) of 12 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 7 Day Minimum Data Set ((MDS) dated [DATE] revealed the resident with a Brief Interview of Mental Status Score of 13/15 (cognitively intact). Observation and interview with Resident #1 on Thursday 12/3/15 at 4:15 PM, in the resident's room revealed the resident was alert and oriented in all spheres. The resident reported the facility consistently failed to clean the room thoroughly and pointed to the bottom of the privacy curtain between her bed and the adjacent bed and stated .just look at that, see what I mean, this place is a damned dump . Observation of the bottom of the privacy curtain on the side opposite the resident's bed revealed a prominent fecal smear across the bottom of the privacy curtain approximately the length of a ball point pen and roughly 2 inches wide. A faint odor of feces was detectable in the room. Continued observation of Resident #1's room on Monday 12/7/15 at 2:45 PM revealed the resident was out of the facility at a Physician appointment. Observation of the privacy curtain revealed its state was unchanged from the previous observation and the now dried fecal material remained on the curtain in the exact location noted on 12/3/15. Interview with the Housekeeping Service District Manager in the presence of the Administrator on 12/7/15 at 2:48 PM, in the resident's room confirmed the privacy curtain was soiled with fecal material and was to have been deep cleaned and replaced at least monthly routinely and daily by the housekeeping staff during routine activities and if necessary, replaced when heavily soiled. When informed I had observed the privacy curtain in the same soiled condition with the same fecal smear in the same location on the curtain 4 days prior, the District Manager offered no further comments and confirmed the facility had failed to maintain a clean, comfortable, and home like environment for Resident #1.",2019-01-01
4463,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2016-09-06,514,D,1,0,T33N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to maintain accurate and complete medical records for 3 Residents (#2, 4, and 8) of 9 records reviewed. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #2's Brief Interview for Mental Status (BIMS) scored14/15, which revealed the resident was cognitively intact. Observation on 8/22/16 at 9:05 AM and 12:28 PM, and on 8/23/16 at 8:18 AM revealed Resident #2 was wearing clean clothing, no personal odors were noted, was ambulatory, and was feeding herself her meal at bedside. Interview with Resident #2 on 8/22/16 at 12:28 PM in the Resident's room when asked if the facility offered the resident showers or baths stated .Yes . Medical record review revealed no documentation of showers/baths provided to Resident #2. Interview with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #2, on 8/23/16 beginning at 4:18 PM, in the Business Office Manager (BOM) office confirmed the facility failed to maintain documentation of showers provided, therefore the medical record was not complete. Medical record review revealed Resident #4 was admitted on [DATE] and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed no signed Physician order [REDACTED]. Interview with LPN #3 on 8/24/16 at 9:30 AM, in the BOM office confirmed the signed Physician order [REDACTED]. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident left the facility Against Medical Advice (AMA) on 8/18/16. Medical record review revealed no documentation of the Activities of Daily Living (ADL), no documentation of the number of bowel movements, no documentation of the food and fluid intake, no documentation of shower/bath provided from admission on 8/5/16 through 8/18/16. Interview with the DON on 8/25/16 at 8:10 AM, in the BOM office confirmed the facility failed to have a complete and accurate medical record. Medical record review of the 8/11/16 Physician Telephone Orders revealed .1.) .(various types of blood tests) .2.) Fingerstick BS (Blood Sugar) BID (2 times daily) . Medical record review of the 8/2016 Medication Administration Record [REDACTED]. Interview with the DON on 8/25/16 at 8:10 AM, in the BOM office confirmed the facility failed to have the results of the ordered blood tests in the medical record therefore the medical record was not complete.",2019-09-01
3042,CORNERSTONE VILLAGE,445483,2012 SHERWOOD DRIVE,JOHNSON CITY,TN,37601,2017-05-17,514,D,1,1,LW9W11,"**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 medical record for 2 residents (#64 and #133) of 46 residents sampled. The findings included: Medical record review revealed Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) quarterly review dated 3/25/17 revealed Resident #64 had a Brief Interview for Mental Status (BIMS) of 13, indicating the resident was independent with daily decision making, and required extensive assist of one person for personal hygiene. Medical record review of Resident #64's Daily Charting (electronic Certified Nursing Aide documentation) dated 4/1/17 - 5/9/17 revealed 20 blank sections in the PERSONAL HYGIENE Oral Care under the Signature & Date/Notes columns, indicating the care was not documented as performed by staff. Interview with the Director of Nursing (DON) on 5/11/17 at 7:25 AM, in the conference room, confirmed documentation in the Certified Nurse Aide (CNA) Daily Charting oral care was not completed on 20 occasions from 4/1/17 - 5/9/17. Medical record review revealed Resident #133 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Review of the Showers Form and Activities of Daily Living (ADL) Sheets revealed the resident received a shower on 1/25/17, 1/31/17, 2/3/17, 2/6/17, 2/8/17, 2/22/17, 2/25/17, 3/6/17, 3/10/17, and 3/13/17. Interview with the DON on 5/11/17 at 7:30 AM, in the conference room, confirmed there was no documentation the resident received a bath between 1/25/17 - 1/31/17, 2/8/17 - 2/22/17, and 2/25/17 - 3/6/17.",2020-09-01
3768,CHURCH HILL CARE & REHAB CTR,445237,701 WEST MAIN BLVD,CHURCH HILL,TN,37642,2017-02-07,312,D,1,0,3T3911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to maintain proper body positioning during a meal for one resident (Resident #6), of 5 residents sampled for nutritional status, of 9 residents reviewed. The findings included: Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #6 required maximum assistance of two persons for bed mobility and transfers and required set up assistance of one person for eating. Observation of Resident #6 on 2/2/17 from 12:45 PM to 12:53 PM, from the hallway outside the resident's room, during the lunch time meal, revealed the resident seated on the edge of the bed, with the bed side table pulled parallel to the edge of the bed. Continued observation revealed the resident's meal tray was set up on the bedside table and the food was partially consumed. Continued observation revealed the resident was lying across the bed in a nearly supine position, with the back of her head braced against the base of the far upper side rail near the edge of the mattress, as her legs hung over the near side of the bed swinging freely above the floor. Continued observation revealed the resident was feeding herself a dinner roll with her fingers, while lying nearly supine across the bed, and the resident was unable to right herself independently to rise to a seated position, or to reach the remainder of the food or the utensils on her dinner tray. Further observation revealed a confidential informant, who was present in the room during the observations, reported the resident had been eating as observed for the prior 20 minutes. Interview with the Assistant Director of Nursing (ADON) on 2/2/17 at 12:56 PM, in the conference room, confirmed the facility failed to provide necessary assistance and supervision to maintain proper body positioning during the meal for Resident #6.",2020-02-01
1206,CHURCH HILL CARE & REHAB CTR,445237,701 WEST MAIN BLVD,CHURCH HILL,TN,37642,2018-04-18,580,D,1,1,JPQC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to notify the resident's family when a bruise was identified for 1 resident (#32) of 21 residents reviewed. The findings included: Medical record review revealed Resident #32, was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Significant Change Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Review of a Care Plan Review, dated 2/26/18, revealed a long thin bruise was identified to the left posterior axilla. Medical record review revealed no documentation of the family being notified when the bruise to the left posterior axilla was identified on 2/26/18. Interview with the resident's daughter on 4/17/18 at 10:15 AM, in the resident's room, revealed the bruise to the axilla area was under the left arm and extended to the back. Continued interview revealed the family wasn't notified when the bruise was identified on 2/26/18. Interview with the Director of Nursing (DON) on 4/18/18 at 1:50 PM, in the conference room, confirmed Resident #32's family was not notified by the facility of the large left posterior axilla bruise when it was identified on 2/26/18.",2020-09-01
661,"AGAPE NURSING AND REHABILIATION CENTER, LLC",445162,505 N ROAN STREET,JOHNSON CITY,TN,37604,2018-03-14,725,E,1,0,2X2811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to provide adequate nursing staff to meet the needs of 2 residents ( #5, #13) of 6 residents ( #1, 3, 5, 9, 12, and 13) sampled for quality of care and residents who attended the resident council meetings. The findings included: Medical record review of Resident #13 revealed she had [DIAGNOSES REDACTED]. Review of the admission nursing assessment, dated 3/3/18 revealed she did not show signs of cognitive loss or communication limitations; she required assistance with all her activities of daily living (ADLs). Her plan of care with an effective date of 3/5/18 stated she had an ADL self-care problem because she required assistance with ADLs. Observation on 3/13/18 at 5:45 AM revealed the facility had a census of 76 residents, and there were a total of two certified nurse aides, (CNA) #1 and CNA #2, and two licensed practical nurses, (LPN) #1 and LPN #6 in the facility. On 3/13/18 at 6:10 AM CNA #2 was interviewed in the hallway. She stated they were supposed to have three CNAs working; however, one called in and that left just her and another CNA to care for 76 residents. She stated the LPNs helped when they could; however, they were still unable to meet the needs of the residents timely when they only had two aides working. CNA #2 was asked if any of the residents experienced falls or were not able to make it to the bathroom on time due to not having the third CNA to help. CNA #2 stated Resident #13 was not assisted to the bathroom timely and had a bowel movement in her incontinence brief when she normally made it to the bathroom and voided on the toilet. Interview with Resident #13 in her room on 3/13/18 at 8:15 AM, revealed she had been in the facility for a little over a week, and she felt she could, get better care at home. She stated when she put her call light on it, takes forever to get help. She stated she put her call light on last night because she needed to have a bowel movement (BM) and waited 10 minutes in her bed and when no one came and she could not hold it any longer she got up by herself with her walker to go to the bathroom. She stated her doctor told her not to get up without help because of her blood pressure, but she had no choice. She stated, just as she stood up she had an accident and got (BM) on the floor and in her brief. She stated once she got into the bathroom, she put the call light on because she had BM up her back and she needed help to get cleaned up. She stated she had to wait 20 more minutes while sitting on the toilet in the bathroom before staff arrived. The resident stated she found it frustrating to have to wait. Medical record review of Resident #5's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed he had a Brief Interview for Mental Status score of 14/15 (indicating he was cognitively intact). Continued review revealed Resident #5 required extensive assistance of 2 staff for bed mobility and transfers. Interview with Resident on 3/12/18 at 3:44 PM, in his room, revealed the facility needed more staff on the third shift. He stated, It just seems like there were no staff in the building on night shift. When asked if his call light was answered timely, he stated it took a while for it to get answered, but did not state how long. Review of the Resident Council Meeting Minutes for (MONTH) (YEAR) through (MONTH) (YEAR) revealed residents voiced concerns every month related to the facility not having adequate staff to meet their needs and/or not having care needs met timely. Cross reference F565. Interviews were conducted on 3/14/18 at 9:48 AM with the Director of Nursing (DON) and the Administrator in the activity room. The DON stated the goal was to have 3 to 4 CNAs and 2 nurses on the 11:00 PM to 7:00 AM shift. She stated a CNA called in prior to the beginning of the 3/12/18, 11:00 PM to 7:00 AM shift and she attempted to get a replacement without any luck. She stated the 11:00 PM to 7:00 AM staff called her at home after the shift started and informed her that the CNA had not come to work. Continued interview confirmed she informed them of the call off and again attempted to call in a replacement without any success. The Administrator was informed of what Resident #13 had stated about taking 30 minutes to get her light answered, and CNA #2 confirmed the resident had bowel incontinence because she (CNA #2) was unable to answer her call light in a timely manner, the Administrator stated if the resident stated it took 30 minutes then it took 30 minutes. The Administrator stated, Then we can do better. She stated they experienced high turnover and were having a hard time recruiting staff, despite advertising on the radio and on social media sources. She stated they also had a difficult time getting employees to fill in for staff who called off, despite offering pay incentives to work overtime and pick up additional shifts.",2020-09-01
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
5831,CUMBERLAND VILLAGE GENESIS HEALTHCARE,445276,136 DAVIS LANE,LAFOLLETTE,TN,37766,2015-11-17,315,D,1,0,6YVL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility failed to provide for a Urologist consult in a timely manner for 1 resident (#1) with recurring Urinary Tract Infections [MEDICAL CONDITION] of 11 residents reviewed. The finding included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Nurse's Notes, laboratory reports and physician's orders [REDACTED]. Medical record review and review of hospital records dated 4/3/15 and 6/4/15, revealed the resident was hospitalized with acute mental status alteration secondary to urinary tract infection. Medical record review of a computerized physician's orders [REDACTED]. Medical record review of a Nurse's Note dated 9/7/15 through 10/8/15, and review of the facility's transport log for (MONTH) (YEAR) revealed no evidence the physician's orders [REDACTED]. Medical record review of a physician's orders [REDACTED].(urology) ordered 9/6/15 for recurrent UTI. Observation on 10/27/15 at 3:50 PM revealed the resident sitting in a wheelchair at the nurses' station. Speech somewhat garbled. Observation revealed the resident was drinking fluids from a small, clear plastic cup. Interview with Certified Nursing Assistant (CNA) #3/Transporter and review of the (MONTH) (YEAR) transport calendar on 11/2/15, at 10:05 AM in the conference room confirmed the resident did not leave the facility during (MONTH) (YEAR) for a consult with a Urologist. Continued interview revealed the Transporter received a Transportation and Appointment Request Form from the nursing staff when a resident required scheduling of a Physician's appointment. Continued interview revealed the Transporter contacted the Physician's office to schedule appointments and log the appointments on the calendar. Continued interview confirmed the Transporter did not receive a referral in (MONTH) (YEAR) and did not receive a referral to schedule the Urologist's appointment until 10/8/15. The Transporter provided a copy of the request form dated 10/8/15, for Resident #1 to see a Urologist (one month after the initial order). The visit was scheduled for 10/29/15. Interview with the Assistant Director of Nursing (ADON) on 11/2/15 at 11:00 AM, in the conference room confirmed the ADON could find no evidence a Transportation and Appointment Request Form was completed for the order dated 9/6/15, for the Urologist's appointment.",2018-11-01
2172,STANDING STONE CARE AND REHAB,445363,410 W CRAWFORD AVENUE,MONTEREY,TN,38574,2017-10-04,312,D,1,1,S1XU11,"**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 and toileting assistance for 1 resident (#4) of 35 residents reviewed. The findings included: Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum (MDS) data set [DATE], revealed the resident required assistance of 1 person to transfer from the bed and 1 person to assist with toileting. Observation of Resident #4, at breakfast on 10/2/17, revealed she was eating, seated in a chair at her bedside. Observation at 6:50 AM on 10/3/17, revealed Resident #4 was being assisted to the bathroom and her bed was dry. Interview with the Assistant Director of Nursing (ADON) on 10/3/17 at 8:00 AM, confirmed the facility had received complaints related to delays in having call lights answered and care rendered in a timely manner over the past few months. Interview confirmed the facility had investigated a complaint from the daughter of Resident #4, who stated her mother had not been toileted or provided incontinence care through the evening and night of 9/10/17. Interview continued and the ADON volunteered an improvement plan was in place to address concerns and revealed it included a requirement for the Charge Nurses of each unit to check all residents after the 2 hour rounds to ensure residents had their care needs met. Interview with the Director of Nursing on 10/4/17 at 3:25 PM, confirmed the facility's investigation of Resident #4's family complaint substantiated the resident did not receive assistance to toilet or have incontinence care provided on the evening and night of 9/9/17 through 9/10/17.",2020-09-01
1027,HUNTINGDON HEALTH & REHABILITATION CENTER,445210,635 HIGH STREET,HUNTINGDON,TN,38344,2017-05-04,280,D,1,0,3EWH11,"**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 enteral feedings, pressure ulcers, and interventions to protect from further injury for 3 of 19 (Resident #93,116 and 121) sampled residents reviewed of the 33 residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #116 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Evaluation Data Sheet dated 3/10/17 documented Resident #116 was admitted with a Right (R) abdominal surgical incision, a Left (L) abdominal puncture wound, 3 retention sutures to the middle abdomen, stage 3 pressure area to her coccyx and a stage 1 abraded area around the coccyx wound. The (MONTH) and (MONTH) (YEAR) physician's orders [REDACTED]. The (MONTH) (YEAR) Medication Administration Record (MAR) documented Resident #116 received [MEDICATION NAME] 1.5 (a tube feeding) as ordered every night, except on 3/13/17 and 3/21/17 when it was documented as refused. The (MONTH) (YEAR) Treatment Administration Record (TAR) documented Resident #116 received wound care to the coccyx and abdominal wounds beginning 3/17/17. The admission care plan 3/10/17 documented, . resident has a PEG (Percutaneous Endoscopic Gastrostomy) tube that is used only for medications .Risk for alteration in skin integrity R/T (related to) mobility status . The surgical wound to the abdomen and the pressure areas to coccyx were not addressed on the care plan. Interview with MDS Coordinator #2 on 5/3/2017 at 2:39 PM, in the conference room, MDS Coordinator #2 was shown a copy of the (MONTH) (YEAR) MAR and asked if the care plan that documented, .PEG .used only for medications . was correct. MDS Coordinator #2 stated, No it is not. MDS Coordinator #2 was shown the wound documentation from (MONTH) (YEAR) and asked if she could find wounds on the care plan. MDS Coordinator #2 stated No, its not on there . 2. Medical record review revealed Resident #121 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility investigation report dated 3/25/17 documented, .Resident was sitting (at) table lying on table noted to have bruised area to forehead on (right) side .will offer pillow when leaning on table to decrease pressure to forehead . Review of the care plan dated 2/28/17 revealed the care plan was not revised to include the intervention to offer a pillow when Resident #121 leans on the table to decrease pressure to forehead. Interview with the Director of Nursing (DON) on 5/3/17 11:35 AM, in the conference room, the DON was asked if the care plan was revised to reflect the intervention to offer a pillow to the resident when she has her head on the table. The DON reviewed Resident #121's care plan and stated, No, it's not.",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
686,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2017-11-15,520,G,1,0,JVWH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, and interview, the facility's Quality Assessment and Assurance Committee (QAA) failed to have an effective ongoing quality program that identified, developed, implemented, and monitored appropriate plans of action to correct issues. The failure to ensure staff provided appropriate care and services for the Percutaneous Endoscopic Gastrostomy (PEG) Tube resulted in actual harm to Resident #1 when staff failed to ensure that PEG tube feedings were appropriately administered through the PEG tube to Resident #1 who had Nepro Carb Steady (carbohydrate nutritional product for residents with kidney disease) administered through his peritoneal [MEDICAL TREATMENT] catheter. The findings included: 1. The QAA Committee failed to ensure that care and services were provided appropriately to a resident with a PEG tube. The failure to provide appropriate care and services of a PEG tube feeding to a resident resulted in actual harm when Resident #1 received a feeding of Nepro Carb Steady through his peritoneal [MEDICAL TREATMENT] catheter for 9 hours. Resident #1 was sent to the hospital and had emergent surgery. Refer to F322. The deficient practice of F322 is a repeat deficient practice for failure to provide appropriate care and services to a resident with a PEG tube feeding. The facility was cited F322 on the recertification survey on 12/4/16. Interview with the Director of Nursing (DON) on 11/12/17 at 6:50 PM, in the conference room, the DON stated, Registered Nurse #1 was not aware he had 2 tubes .she checked placement .checked residual .tubing had a flap on it, said she (RN#1) wondered why they did that .took the flap off and put an adapter on it .",2020-09-01
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
4809,RAINTREE MANOR,445216,415 PACE STREET,MC MINNVILLE,TN,37110,2016-07-15,323,D,1,0,HCFE11,"**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 provide care in accordance with the care plan to prevent a fall for one (#1) resident of 3 residents reviewed for falls. The findings included: Medical record review revealed resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE],revealed the resident scored 15 (maximum score) on the Brief Interview for Mental Status indicating no cognitive impairment; required extensive assistance for transfers, walking, dressing, toilet use and personal hygiene. Continued review of the MDS revealed the resident's balance was unsteady and was only able to stabilize with the assistance of staff for the activities of walking, turning around while walking, moving on and off toilet, and surface to surface transfer. Review of the care plan dated 5/24/2016 revealed the resident required assistance with ADLs (Activities of daily living) related to weakness. Continued review of the care plan revealed the staff were to provide extensive assistance with transfers, dressing, personal hygiene, bathing, ambulation, and the resident required supervision for eating. Further review revealed the resident was at risk for falls and staff were to give the resident verbal reminders not to ambulate or transfer without assistance. Review of the facility investigation dated 6/12/16 revealed the resident's call light was turned on at 6:20 PM and when answered the resident requestd to go to the bathroom and then to bed. Continued review revealed the CNA assisted the resident to the bathroom with the rolling walker (RW) and stand by assist of one and the resident was wearing non-skid shoes. Review revealed was toileted and ambulated from the bathroom to the side of the bed; the resident's gown was changed gown while standing, and the resident's sweater jacket was removed and placed in the closet. Continued review revealed the resident was turning using R.W. to get in position such as turning and backing up to side of bed .as (the resident) turned and I was right at the foot of the bed she somehow lost balance and fell back/side to bed rail and then towards wall and down to floor . Review of the Fall Scene Investigation Report dated 6/12/16 revealed the root cause of the fall was determined to be the resident lost balance, and Educated staff on providing more assistance when assisting resident to bed. Medical record review revealed the resident was not sent to the hospital and had no residual bruising or injury as a result of the fall. The fall was witnessed and the resident did not hit her head during the fall. Interview by telephone with CNA #1 on 7/13/16 at 8:35 PM revealed the CNA did recall the incident regarding Resident #1. Continued interview revealed the CNA clarified the resident did remove the sweater jacket and asked the CNA to put it in the closet. Continued interview revealed the CNA turned away and walked to the closet to put the sweater in the closet, and stated .the resident was in the process of turning around to back up to the bed as I turned to go the closet and fell away from me toward the wall .I was at the foot of the bed . I could not reach . Review of the personnel file of CNA #1 revealed a Consultation form dated 6/13/16 regarding the fall on 6/12/16 for Resident #1. Review of the report revealed a verbal consultation was performed related to left pt (patient) unattended while assisting pt to bed causing pt to fall. Observation and interview with the resident on 7/13/16 at 2:00 PM revealed the resident recalled the fall last month recounting, I just got dizzy and lost my balance .am much better and stronger .will be going home soon . The resident described the fall to include she fell toward the bed and to the wall and slowly fell to the floor while the CNA was putting a sweater jacket in the closet. Interview with the Director of Nursing in the conference room on 7/13/16 at 1:50 PM revealed the resident had been progressing well in therapy at the time of the fall. Continued interview confirmd the care plan approach in place at the time of the fall was for the resident not to ambulate or transfer alone; and interview confirmed the facility failed to provide care according to the care plan when the CNA turned away from the resident prior to completing the transfer to the bed.",2019-07-01
954,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,279,D,1,0,SMVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observation, review of facility policy,and interview, the facility failed to revise the care plan to reflect the resident's current status for 2 residents (#4, #7) of 11 residents reviewed. The facility failed to update care plans for 2 residents (#4, #7) when previous approaches were no longer appropriate and/or new interventions were needed to prevent accidents. The findings included: Review of the facility's undated policy, Care Plans Comprehensive, revealed: The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of Care Plans: When there has been a significant change in the resident's condition .At least quarterly. Observation on 9/18/17 at 11:40 AM revealed Resident #4 was sitting in a wheelchair. The resident was observed to have an amputation of the left leg below the knee and was using a stabilizer to hold the stump of her leg in place. Review of Resident #4's clinical record revealed the resident was readmitted to the facility on [DATE], after a [MEDICAL CONDITION] (BKA) of the left leg due to a gangrenous toe. Review of a comprehensive assessment, dated 7/10/17, was completed based on the changes in the resident's condition due to the amputation. Review of her Comprehensive Care Plan revealed the last care conference was held on 7/19/17 and the Care Plan showed a goal date of 10/17/17. Review of Resident #4's Care Plan revealed approaches were not revised to reflect the resident's current status. For example, the Care Plan noted the resident was at risk for infection r/t Left BK[NAME] Approaches to meet the goal of remaining free of infection revealed the resident was to have Shoes on only during therapy r/t L (left) heel blister. The Care Plan also noted the resident is a fall risk r/t S/P (Status/Post) BK[NAME] Approaches to meet the goal of no avoidable falls included Therapy states that she is able to ambulate herself to and from the bathroom. Observation on 9/18/17 at 8:35 AM revealed Resident #4 was asleep in bed with 4 side rails raised. The bed was not in a low position. No fall mats were in use on either side of the bed. Additional observation on 9/18/17 at 1:49 PM. revealed the resident was asleep in bed. Although the bed was now in a low position, no fall mats were in use and all 4 side rails were raised. Review of Resident #4's Physician order [REDACTED]. Further review of Resident #4's Comprehensive Care Plan revealed, although the Care Plan identified the resident was at risk for falls, neither of these Physician ordered interventions had been added to the Care Plan. Interview on 9/19/17 at 9:12 AM with Minimum Data Set (MDS) Coordinator #1, in the first floor administrative wing, revealed the facility currently had a Care Plan Nurse. He stated, although the facility's system was changing in (MONTH) (YEAR), the Care Plan Nurse was currently responsible for developing Care Plans from required assessments, as well as making any needed revisions, including new approaches identified during falls meeting. Interview on 9/19/17 at 9:30 AM with the Care Plan Nurse, in his office revealed it depended on the type of Care Plan revision as to who was responsible for updating the Care Plan. He stated if the resident had a fall, the floor nurse should update both the comprehensive Care Plan and the summarized Care Plan used by direct staff with new interventions to prevent further accidents. The Care Plan Nurse stated he then completed the Care Plan reviews that were required after each quarterly or comprehensive MDS. He stated, When I review, I try to make sure what's in Matrix (the facility's electronic health system used for comprehensive care plans) jibes with what's in the closet (where the summary care plans used by direct care staff are stored.) The Care Plan Nurse confirmed the resident's Care Plan should have been updated, saying, The obvious answer is yes. He stated the approaches of shoes and walking to the bathroom were no longer appropriate for Resident #4, and the Care Plan should have been revised, as the resident had completely different needs after the amputation of her leg. Further interview with the Care Plan Nurse revealed he did not know the reason for the delay in revising the Care Plan with new interventions. He stated he was not alerted when every new order was received, and the nurse on the unit who was aware of the order should have revised the Care Plan if needed. Medical record review of Resident #7's revealed [DIAGNOSES REDACTED]. Medical record review of Resident #7's Comprehensive Care Plan with a review date of 9/7/17, revealed the resident was an elopement risk r/t (related to) dementia. Review of the approaches for this problem revealed they included, Apply wander alert safety bracelet to resident, if ambulatory, and w/c (wheelchair) if chair bound. Observation on 9/18/17 at 5:06 PM revealed the resident was seated in a wheelchair in her room. Additional observations on 9/19/17 at 8:10 AM and 3:15 PM, revealed the resident was seated in her wheelchair in the third floor dining/day room. No wander alert bracelet was applied to the wheelchair and none was visible on the resident during any of these observations. Interview on 9/19/17 at 8:10 AM with Certified Nursing Assistant (CNA) #1, in the third floor dining/day room, confirmed the resident did not have a wander alert bracelet on either her body or her wheelchair. Interview on 9/19/17 at 3:15 PM with Licensed Practical Nurse (LPN) #1, in the third floor dining/day room, confirmed the resident did not currently use a wander alert bracelet. Interview on 9/19/17 at 3:22 PM with Unit Manager (UM) #1, in his office, revealed Resident #7 doesn't need or use a wander alert bracelet anymore. He stated the facility had used one when the resident was ambulatory, but it was no longer needed because she was no longer at risk for elopement and used a wheelchair for locomotion. Interview with UM #2, who was also present during the interview on 9/19/17 at 3:22 PM, confirmed Resident #7 had not used a wander alert bracelet since at least (YEAR). Interview with UM #1 revealed the care plan should have been revised when the wander alert bracelet was discontinued. He stated any nurse in the building could update Care Plans, and the need for revision could have also been identified when required quarterly care plan reviews were completed.",2020-09-01
1499,LAUGHLIN HEALTH CARE CENTER,445264,801 E MCKEE ST,GREENEVILLE,TN,37743,2018-10-29,725,D,1,0,DT0611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observations, and interviews, the facility failed to provide sufficient nursing staff to meet the toileting needs for 1 resident (#1) of 3 residents reviewed. The findings included: Medical record review revealed Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Significant Change in Status Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Continued review revealed the resident required extensive to limited assistance for transfers and toileting with 2 person assist. Further review revealed the resident was frequently incontinent of bowel. Medical record review of the Care Plan, revised date 7/12/18, revealed the facility had identified Resident #1 had an increased need for assistance with toileting. Interview with Certified Nurse Assistant (CNA) #3 on 10/29/18 at 1:15 PM, in the conference room, revealed .Someone is supposed to be in each dining room (3) during meals so that leaves no one on the floor, except one nurse for each wing . Interview with CNA #5 on 10/29/18 at 1:40 PM, in the conference room, revealed .staffing is horrible right now .have worked with 1 CNA for each wing .just can't get to everyone . Interview with CNA #9 on 10/29/18 at 2:00 PM, in the conference room, revealed .residents have to wait for care .how long .just depends . Interview with Resident # 1 on 10/29/18 at 2:15 PM, in his room, revealed he had to wait a long time for assistance to the bathroom and had episodes of bowel incontinence a few times. Continued interview revealed .they just don't have enough help . Observation on 10/29/18 at 2:25 PM, in Resident #1's room, revealed the resident turned on his call light and requested assistance to the bathroom. Further observation revealed the unit secretary responded through the call light speaker system and stated she would let a CNA know. Continued observation revealed no staff member entered the room until 3:00 PM (43 minutes later). Interview with the Director of Nursing on 10/29/18 at 3:15 PM, in the conference room, confirmed there was a delay in staff response to the resident's request for assistance with toileting.",2020-09-01
1498,LAUGHLIN HEALTH CARE CENTER,445264,801 E MCKEE ST,GREENEVILLE,TN,37743,2018-10-29,550,D,1,0,DT0611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, observations, and interviews, the facility failed to respond to a request for assistance timely for 1 resident (#1) of 3 residents reviewed. The findings included: Medical record review revealed Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Significant Change in Status Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Continued review revealed the resident required extensive to limited assistance for transfers and toileting with 2 person assist. Further review revealed the resident was frequently incontinent of bowel. Medical record review of the Care Plan, revised date 7/12/18, revealed the facility had identified Resident #1 had an increased need for assistance with toileting. Interview with Certified Nursing Assistant (CNA) #5 on 10/29/18 at 1:40 PM, in the conference room, revealed .have worked with one CNA for each wing .just can't get to everyone . Interview with CNA #9 on 10/29/18 at 2:00 PM, in the conference room, revealed .residents have to wait for care .how long .just depends . Interview with Resident # 1 on 10/29/18 at 2:15 PM, in his room, revealed he had to wait a long time for assistance to the bathroom and had episodes of bowel incontinence a few times. Continued interview revealed .they just don't have enough help . Observation on 10/29/18 at 2:25 PM, in Resident #1's room, revealed the resident turned on his call light and requested assistance to the bathroom. Further observation revealed the unit secretary responded through the call light speaker system and stated she would let a CNA know the resident needed assistance with toileting. Continued observation revealed no staff member entered the room until 3:00 PM (43 minutes later). Interview with the Unit Secretary on 10/29/18 at 3:05 PM, at the West Wing Nurses' Station, revealed the Unit Secretary reported Resident #1's request for assistance to a CN[NAME] Continued interview revealed the CNA stated she would respond to Resident #1's need for toileting when the CNA working the next shift arrived to assist. Interview with CNA # 10 on 10/29/18 at 3:08 PM, on the West Wing hallway, confirmed he was not notified of Resident #1's request for assist with toileting. Interview with the Director of Nursing on 10/29/18 at 3:15 PM, in the conference room, confirmed the resident was not assisted with toileting in a timely manner. In summary, Resident #1's request for assistance with toileting was not met for 43 minutes after the request was made.",2020-09-01
1674,GRACE HEALTHCARE OF WHITES CREEK,445281,3425 KNIGHT DRIVE,WHITES CREEK,TN,37189,2019-12-18,687,D,1,0,668P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, podiatry record review and interview, the facility failed to provide podiatry care for 1 (#1) resident of 5 residents reviewed. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the residents scheduled of podiatry care in 2019 revealed Resident #1 was scheduled on 10/8/19 only. Review of the podiatry progress note dated 10/8/19 revealed Resident #1 was a new patient seen. Further review revealed .painful, thick toenails on both feet .nails are long, severely thick, painful, discolored with subungual (under the toenail) debris . Further review revealed 9 nails were debrided using sharp nail clippers. Interview with the nursing consultant on 12/17/19 at 11:30 AM in the Administrator's office, confirmed Resident #1 had not been scheduled to see the podiatrist until 10/8/19. Further interview revealed Registered Nurses were expected to cut the nails of diabetic residents and the diabetic residents were to see a podiatrist as needed for their toenails.",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
956,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,282,G,1,0,SMVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of Event Report, interview, and observation, the facility failed to ensure Care Plans were followed for 5 residents (#2, #6, #7, #8, #9) of 11 residents reviewed. Resident #2 sustained HARM (laceration to head which required stitches) during a fall when staff failed to follow his Care Plan for using 2 staff to provide care. In addition, the facility failed to follow other Care Plan interventions designed to prevent accidents, such as low bed, fall mats, and call light in reach for Resident #8; failed to provide respiratory care for Resident #6 and #9; and failed to use geri-sleeves to prevent skin tears for Resident #7. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE]. The resident had a [MEDICAL CONDITION] and was dependent on supplemental oxygen. The resident's [DIAGNOSES REDACTED]. Review of an Event Report dated 1/1/16 revealed the resident was lowered to floor. Review of the investigation notes revealed, while she was giving him a bed bath, resident coughed violently multiple times that had him leaning off bed. For safety, resident was lowered to floor to keep from falling off bed .Care Plan to reflect x2 (2 staff) assist for all care. Continued review revealed the staff were educated to use x2 assist for Activities of Daily Living (ADLs) and turning. Review of the 11/16/16 Minimum Data Set (MDS) revealed Resident #2 continued to require total assistance of 2 staff for ADLs, as noted on his Care Plan, which indicated the resident was at risk for falls r/t (related to) impaired mobility, need for 2 staff members with ADL assistance. Review of an Event Report dated 12/4/16 revealed at 6:00 AM, Resident #2 sustained a fall when staff failed to follow the Care Plan and provided only 1 staff during ADL care. Per the resident, the 1 Certified Nurse Aide (CNA) had resident turned twards (towards) herself as she was providing incontinent (incontinence) care. Resident began to forcefully cough multiple times. Resident's body came off the bed and (staff) was unable to stop him from falling due to weight. The Event Report noted the resident had a 2-inch gash above the right eye. The resident was transferred to the hospital, where stitches were applied to the laceration above the resident's eye. In addition, review of the hospital report revealed a computerized tomography (CT) scan of the resident's head was conducted and found a small amount of new intraventricular hemorrhage within the atria of both lateral ventricles, greatest on the left. Interview with the Quality Assurance (QA) Nurse on 9/19/17 at 11:04 AM on the first floor administration wing revealed she had been responsible for the investigation of the incident. She stated the fall with injury occurred when the resident's Care Plan was not followed. The QA Nurse confirmed the Care Plan called for 2 staff to be present whenever ADL care was given; however, only one staff was present to give care when the fall occurred. The QA Nurse stated the CNA, who no longer worked at the facility, was aware of the resident's Care Plan, stating the CNA knew that there were supposed to be 2 people in the room, but she was in a hurry. She made a big mistake resulting in a fall from the bed requiring stitches to a laceration on the forehead (Harm). Medical record review revealed Resident #6 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 30 day MDS dated [DATE] revealed the resident was cognitively intact with modified independence, and altered level of consciousness that fluctuated; was bed bound and was dependent with assistance of 1 person for bed mobility, dressing, eating, hygiene, bathing and toileting. Continued review revealed the resident had bilateral upper extremity impairments and received services from Respiratory Therapy for oxygen, suctioning, [MEDICAL CONDITION] care and ventilator care. Review of a facility investigation dated 7/26/17 revealed Resident #6 pushed his call light between 8:00 AM and 8:30 AM and told CNA #5 he needed respiratory therapy. The CNA told Respiratory Therapist (RT) #1 the resident requested him and he said OK. The RT was caring for another resident at that time. The resident pushed his call light a 2nd time and CNA #8 answered the call light and was told he needed respiratory because he couldn't breathe. The CNA informed RT #1 who was caring for another resident, stated OK, thanks. Approximately 5 minutes later the call light went off a 3rd time and CNA #8 answered it and the resident again stated he needed respiratory and he couldn't breathe. The CNA asked if RT #1 had made it in yet and the resident said No. The CNA said she would let him know again and found RT #1 sitting at a table in the hallway charting. CNA #8 told him Resident #6 still needed him because he said he couldn't breathe, and the RT smiled and said OK, thanks. The resident pushed his call light a 4th time and CNA #5 and Licensed Practical Nurse (LPN #7) entered the resident's room and he asked to be transferred out of the facility because he didn't feel safe. Medical record review of the Comprehensive Care Plan dated 6/2/17 revealed a problem of Impaired Gas Exchange-Ventilation with approaches to Perform Ventilator Checks every 4 hours and as needed.; a problem of Impaired Gas Exchange-Oxygenation with an approach to initiate SP02 (peripheral capillary oxygen saturation - an amount of oxygen in the blood) monitoring; a problem of Airway Patency and [MEDICAL CONDITION] Hygiene with approaches to Administer [MEDICATION NAME][MEDICATION NAME] via Nebulizer per orders, Tracheal Suctioning as needed. Review of a Tek-Care Report dated 7/31/17 revealed the ventilator alarm for Resident #6 went off on 7/26/17 at 8:49:42 AM and alarmed for 5 minutes, 18 seconds. Continued review revealed the oxygen saturation alarm went off on 7/26/17 at 8:49:53 AM and alarmed for 3 minutes, 44 seconds. Medical record review of the Respiratory Treatment Flo Administration History dated 7/1/17-7/31/17 revealed End Tidal Capnography every 4 hours (checks carbon [MEDICATION NAME] level) was scheduled to be checked at 8:00 AM on 7/26/17. RT #1 documented it was checked at 9:50 AM. Continued review revealed Resident #6 received his breathing treatment scheduled at 8:00 AM and 9:50 AM by RT #1. Continued review revealed Resident #6 was suctioned by RT #1 at 9:50 AM on 7/26/17 and received a moderate amount of thick pale yellow secretions. Interview with the Director of Nursing (DON) on 9/20/17 at 3:36 PM in the conference room confirmed the facility failed to respond to ventilator and oxygen saturation alarms timely, failed to provide care and assistance to Resident #6 timely, and failed to follow the Comprehensive Care Plan. Medical record review revealed Resident #7 was admitted with [DIAGNOSES REDACTED]. Review of a quarterly MDS dated [DATE], revealed the resident was moderately cognitively impaired, totally dependent on staff for transfer, and required extensive assistance with bed mobility. The resident did not walk and required either supervision or limited assistance from staff with locomotion in her wheelchair. Review of Resident #7's Progress Notes revealed the resident had a history of [REDACTED]. Review of Resident #7's Comprehensive Care Plan, dated 9/7/17, revealed the resident has impaired/potential for impaired skin integrity r/t impaired mobility, incontinence of bowel and bladder, age related skin changes, ASA (aspirin) in use. [MEDICAL CONDITION], chronic [MEDICAL CONDITION]. Approaches to help the resident meet the goal of avoidable skin breakdown included 8/21/16 - Geri-sleeves to be in place. Review of the Safety Care Plan used by direct care staff and posted in the resident's closet also revealed the instructions: Geri-sleeves to be in place at all times d/t (due to) frequent STs (skin tears) - 8/21/16. Observation of Resident #7 on 9/18/17 at 8:48 AM, 3:00 PM., 5:06 PM., and on 9/19/17 at 8:10 AM., 8:26 AM, and 3:15 PM, revealed the resident was not wearing geri-sleeves. Bruising was noted on the resident's right hand, which extended from the index finger to the thumb, across the back of the hand. Interview on 9/19/17 at 8:26 AM with CNA #1 in the third floor dining/dayroom confirmed the resident was not wearing geri-sleeves at that time, and her arms were bare from below her elbow. CNA #1 stated, No, she doesn't use them. Interview with CNA #1 revealed she used the Care Plans posted in each resident's closet to know what care needed to be provided. After a review of the Care Plan posted in Resident #7's closet, CNA #1 confirmed it called for the use of geri-sleeves at all times, and she stated she had not known this intervention was listed on the Care Plan. Interview on 9/19/17 at 3:15 PM with LPN #1 in the third floor dining/dayroom, confirmed Resident #7 was not wearing geri sleeves. She stated the facility had geri-sleeves available, and they should be in place if the Care Plan called for their use. Interview on 9/19/17 at 3:22 PM with Unit Manager (UM) #1 in his office also confirmed the facility had geri-sleeves available for the resident's use and stated, If it's on the Care Plan, they should have been used. Review of Resident #8's Comprehensive Care Plan, initiated 11/10/16, was reviewed on 9/18/17. The Care Plan indicated the resident is at risk for falls r/t dependent on staff for ADLs, limited mobility, antihypertensive and [MEDICAL CONDITION] medications in use. To meet the goal of no avoidable falls, interventions since 12/20/16 included Floor mats at bedside. Interview on 9/18/17 at 1:52 PM with CNA #3 on the third floor hallway revealed the facility posted Care Plans in each resident's closet so direct care staff knew what care the resident needed. She stated the Care Plans included the amount of ADL assistance the resident needed, as well as any special devices or equipment that were to be used. Observation on 9/18/17 at 5:34 PM revealed Resident #8 was in his bed, which was in a high position. A fall mat was observed on the left side of the bed. However, no fall mat was present on the right side of the bed. Observation in Resident #8's closet revealed there was no Care Plan posted to provide information on the resident-specific approaches to be implemented. Review of Resident #9's Admission MDS, dated [DATE], revealed the resident was moderately cognitively impaired, was bedfast, had a [MEDICAL CONDITION], and was totally dependent on staff for all care, including transfers and bed mobility. Review of an Event Report revealed, on 9/17/17 at 2:20 AM, the resident had a fall from the bed and was found on the floor between the two beds in the room. The Event Report noted injuries from the fall, as the resident was decannulated ([MEDICAL CONDITION] came out), complained of pain after the fall, and had to have a [MEDICAL CONDITION]. In response to this fall, Resident #9's Care Plan for fall risk, initiated 8/23/17, was revised on 9/17/17 to include a Low bed when unattended. Observation on 9/18/17 at 5:24 PM, revealed the resident was asleep in bed, with his [MEDICAL CONDITION] in place, and nutrition infusing via gastrostomy tube. No staff were present in the room. The resident's bed was not in a low position and was higher than that of his roommate in the next bed. Interview on 9/19/17 at 3:22 PM with UM #1 in his office revealed if an intervention was listed on the Care Plan, it should have been used.",2020-09-01
1853,SIGNATURE HEALTH OF PORTLAND REHAB & WELLNESS CENT,445306,215 HIGHLAND CIRCLE DRIVE,PORTLAND,TN,37148,2017-09-21,309,D,1,0,DUCD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of Weekly Skin forms, and interview, the facility failed to complete skin assessments for 1 resident (#3) of 24 residents reviewed. The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident expired on [DATE]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 required extensive 1 person assistance with hygiene, was total dependence with 1 person assistance for bathing, and had no pressure ulcers or any other type wound or skin problems. Review of the Quarterly MDS dated [DATE] revealed Resident #3 was total dependence with 1 person assistance for hygiene and bathing, and had no pressure ulcers or any other type wound or skin problems. Review of the Weekly Skin form dated [DATE] written by Licensed Practical Nurse (LPN) #9 revealed .Wound Location: Right Popliteal (hollow back of knee) .Wound Type: Skin Tear .Status: Resolved; Left Popliteal .Bruise .Resolved; Left Popliteal .Abrasion .Still Present; Right Popliteal .Blisters .Still Present; Left Heel . Abrasion .Change Condition . Medical record review of the Progress Notes Report dated [DATE] written by LPN #9 revealed .(Resident) also has some purplish discolored bruising noted around left great toe and 2nd toe on left foot . Review of the Weekly Skin forms revealed no forms were completed after [DATE] until [DATE], which was written by LPN #9. Interview with LPN #9 on [DATE] at 9:25 AM in her office confirmed the LPN had been the Wound Nurse during ,[DATE] to ,[DATE] and had written the [DATE] Progress Note. Further interview confirmed the Weekly Skin forms were not completed after [DATE] until [DATE] due to the LPN working on the unit. Interview with the Director of Nursing (DON) on [DATE] at 2:35 PM in the conference room revealed the DON expected nursing to complete the Weekly Skin forms. Further interview confirmed the facility failed to complete the Weekly Skin forms after [DATE] until [DATE].",2020-09-01
1852,SIGNATURE HEALTH OF PORTLAND REHAB & WELLNESS CENT,445306,215 HIGHLAND CIRCLE DRIVE,PORTLAND,TN,37148,2017-09-21,282,D,1,0,DUCD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of Weekly Skin forms, interview, and observation, the facility failed to follow the care plan for 2 residents (#3, #9) of 24 resident care plans reviewed. The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident expired on [DATE]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 required extensive 1 person assistance with hygiene, was total dependence with 1 person assistance for bathing, and had no pressure ulcers or any other type wound or skin problems. Review of the Quarterly MDS dated [DATE] revealed Resident #3 was total dependence with 1 person assistance for hygiene and bathing, and had no pressure ulcers or any other type wound or skin problems. Medical record review of the Care Plan dated [DATE], updated to the present, revealed Resident #3 had potential for impaired skin integrity with .Approaches Complete Weekly Skin Check .Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration note during bathing or daily care . Review of the Weekly Skin form dated [DATE] written by Licensed Practical Nurse (LPN) #9 revealed .Wound Location: Right Popliteal (hollow back of knee) .Wound Type: Skin Tear .Status: Resolved; Left Popliteal .Bruise .Resolved; Left Popliteal .Abrasion .Still Present; Right Popliteal .Blisters .Still Present; Left Heel . Abrasion .Change Condition . Medical record review of the Progress Notes Report dated [DATE] written by LPN #9 revealed .(Resident) also has some purplish discolored bruising noted around left great toe and 2nd toe on left foot . Review of the Weekly Skin forms revealed no forms were completed after [DATE] until [DATE], written by LPN #9. Interview with LPN #9 on [DATE] at 9:25 AM in her office confirmed the LPN had been the wound nurse during ,[DATE] to ,[DATE] and had written the [DATE] Progress Note. Further interview confirmed the Weekly Skin forms were not completed after [DATE] until [DATE] due to the LPN working on the unit. Interview with the Director of Nursing (DON) on [DATE] at 2:35 PM in the conference room confirmed the facility failed to complete the Weekly Skin forms and therefore failed to follow the Care Plan. Medical record review of Resident #9's Admission Record Face Sheet revealed facility admission on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14-day MDS dated [DATE], revealed Resident #9's cognitive skills for daily decision making were severely impaired; and she required supervision (oversight, encouragement, or cueing) when walking in her room, walking in the corridor, and for locomotion in the unit. Medical record review of Resident #9's Fall Risk Evaluation dated [DATE] revealed she was at risk for falls. Review of the facility's Event Reports revealed Resident #9 had fallen on [DATE], [DATE], and [DATE]. Medical record review of Care Plan dated [DATE] revealed Resident #9 was at risk for fall related injury. The Care Plan revealed a hand written undated addition .Intervention .Observe while ambulating in hallway-no clutter . Interview with Licensed Practical Nurse (LPN) #4 on [DATE] at 10:55 AM in secure unit hallway revealed Resident #9 paced continuously and described Resident #9 as independently on-the-go during the day. LPN #4 stated she was not sure what fall precautions might be in place for Resident #9. Observation on the secure unit on [DATE] at 4:45 PM, revealed Resident #9 seated in the recliner in the small living room. Two staff were in the adjoining dining room. Resident #9 got up and walked into the dining at 4:50 PM. The 2 staff exited the dining room. Resident #9 paced between the dining room and the living room unobserved by staff until 5:00 PM when Certified Nurse Aide (CNA) #3 entered the living room. Observation on the secure unit on [DATE] at 5:33 PM revealed CNA #9 and CNA #3 delivering dinner trays to resident rooms. Resident #9 walked out of room [ROOM NUMBER] (which was not her room) pulling an empty wheelchair behind her. No staff were present in the hallway to see what room Resident #9 had exited. CNA #9 entered the hall, asked Resident #9 if she wanted to eat, and pushed the wheelchair down the hall trying to find to whom the wheelchair belonged. Resident #9 walked into the living room and dining room area unobserved by staff. Interview with CNA #1 on [DATE] at 8:45 AM in the facility conference room, revealed Resident #9 paced and was at risk for falls. When asked what special precautions for falls the resident required CNA #1 stated they should make sure Resident #9 does not get out of the unit. Interview with LPN #2 on [DATE] at 10:32 AM in the conference room revealed Resident #9 was a fall risk, and they must watch her (keep her in line of sight), but she walks all the time. LPN #2 said with one nurse and two aides in the secure unit they could not keep Resident #9 in line of sight all the time, but they try to. Interview with the DON on [DATE] at 3:15 PM in the conference room revealed the expectation was staff would watch Resident #9 when she was out in the hallway because of her fall risk. When asked if two aides were enough in the secure unit to do that, the DON responded there was usually a nurse present too.",2020-09-01
2174,STANDING STONE CARE AND REHAB,445363,410 W CRAWFORD AVENUE,MONTEREY,TN,38574,2018-10-17,677,D,1,0,OCRB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of a facility document, observation, and interviews, the facility failed to provide incontinence care in a timely manner, for 3 residents (#1, #4, #5) of 8 residents reviewed for incontinence. The findings included: Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a staff assessment was completed for cognitive status indicating the resident had short and long term memory problems. Further review revealed the resident was dependent for toileting, required extensive assistance with personal hygiene, and was always incontinent of both bowel and bladder. Medical record review revealed Resident #1 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly MDS dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. Further review revealed the resident required extensive assistance with toileting, personal hygiene, and was always incontinent of both bowel and bladder. Medical record review revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly MDS dated [DATE], revealed a staff assessment was completed for cognitive status indicating the resident had short and long term memory problems. Continued review revealed the resident was dependent for toileting, personal hygiene, and was frequently incontinent of both bowel and bladder. Review of the facility's investigation dated 8/10/18, revealed .It has been reported that expectations of care may not have occurred for Resident .(#4) on the night shift .Resident .(#4) was found wet in the morning of 8/10 (18) and a family member has alleged neglect. Our investigation cannot substantiate neglect but did discover the need for a systems correction to ensure that CNA resident care assignments are clear and that the charge nurse follow-up is completed .if for whatever reason mid-shift staffing assignments change, a new assignment sheet is to be implemented to prevent confusion and assure coverage . Observation of Resident #1 on 10/15/18 at 7:40 AM, in her room, revealed the resident lying in bed, awake and alert, the resident did not appear to be in any distress. Continued observation revealed no odor, or visual signs of incontinence. Observation of Resident #5 on 10/15/18 at 7:50 AM, in her room, revealed the resident lying in bed, the resident was awake. Further observation revealed no odor, or visual signs of incontinence. Observation of Resident #4 on 10/15/18 at 8:00 AM, in the common area near the front lobby, revealed the resident seated in a rock and go chair, the resident was covered with a blanket, however no odor was observed, and the resident was in no apparent distress. Observation of Resident #4 on 10/16/18 at 8:55 AM, on the 300 hall, revealed the resident seated in a Rock and go chair, the resident was clean and well groomed. Further observation revealed no odor or visual signs of incontinence. Observation of Resident #1 on 10/16/18 at 9:05 AM, in her room, revealed the resident lying in bed. The resident appeared to be asleep, and did not respond to verbal stimuli. Continued observation revealed no odor, and no visual signs of incontinence. Observation of Resident #5 on 10/16/18 at 9:15 AM, in her room, revealed the resident lying in bed with her eyes closed, no apparent distress was identified. Further observation revealed no odor, and no visual signs of incontinence. Interview with Resident #4's daughter on 10/15/18 at 9:00 AM, in the conference room, revealed I came in to see her, like I do every day before I start working. When I went in she had slid down in the bed, I put her pillow under her head, and I smelled a strong odor. I started to adjust her blanket there was a brown urine ring on the sheet, from her knees to her waist. I called for the nurse on the floor and she said it looks like she hasn't been changed. I was told it was possible her room was overlooked with the new room assignment. Interview with Licensed Practical Nurse (LPN) #1 on 10/15/18 at 10:20 AM, via telephone, revealed she (Resident #4's daughter) reported the incident to me. I went to the resident's room, and the CNA (Certified Nursing Assistant) and I cleaned the resident and checked on her roommate who was continent. The resident and her bed were soaked, and it appeared she had not received incontinence care during rounds. We checked all the residents in the section in question. We identified one additional room with two incontinent residents, both were also saturated and had an odor. It appeared they had not received incontinence care during rounds. What happed was a CNA left early and the rooms were to be divided. One CNA thought that the other CNA had the rooms and vice versa. Interview with the Administrator on 10/5/18 at 11:50 AM, in the conference room, confirmed she was not the Administrator at the time of this allegation, but based on the facility's investigation it appeared Resident #1, #4, and resident #5 had not received incontinence care as expected on the evening shift for 8/9/18 from 7:00 PM through 8/10/18 at 7:00 AM. Interview with CNA #1, on 10/15/18 at 2:15 PM, via telephone, revealed I was on station 3, the other CNA was moved at midnight, I wasn't given report, but I did know I had the extra people. Sometimes a dry round is a continuous round, I know I went into the rooms but I don't know what time. I included the additional residents on my 2:00 AM, and 4:00 AM rounds. To the best of my memory I did go in check and change the additional residents I had including .(Resident #1, #4 and #5). It is possible I missed those residents on my last round. Continued interview confirmed If a resident was totally saturated, and dark urine rings were on the sheets it would indicate the residents had not been changed timely. Interview with CNA #3 on 10/15/18 at 3:40 PM, revealed on the shift in question I did my regular rounds at 6:00 PM, but at 10:00 I still wasn't through with my first round, things were just crazy that night. I had to move to station 2 at about 10:00 PM. I know I changed her (Resident #4) on my first round. Normally I am done by 8:30 PM, but that night it was almost 10:00 PM. Interview with LPN #3 on 10/15/18 at 5:35 PM, via telephone, revealed I took over that section between 11:00 PM and midnight, I informed the two CNA's of the hall assignment change, and told them what rooms they were responsible for. I didn't observe them doing their rounds, but I had no reason to believe they weren't. Interview with CNA #4 on 10/15/18 at 7:00 PM, via telephone, revealed she was the CNA on the 300 hall on the day shift for 8/10/18. The nurse asked me to help her change .(Resident #4). Her daughter had come in and found her soaked. When we went in the room and she was soaked from top to bottom, and it smelled like it had been there for a few hours. The bottom sheet had dried dark circle spots. We checked the rest of the residents in that section, and also found .(Resident #1 and #5) soaking wet. It looked like they hadn't been changed during the last round at least. Interview with the previous Administrator on 10/16/18 at 10:33 AM, via telephone, revealed during our investigation we identified a need for a system correction to ensure that CNA resident care assignments were clear. The correction included a directive that if for whatever reason mid-shift staffing assignments change, a new assignment sheet is completed to prevent confusion and assure coverage. Continued interview confirmed It was obvious incontinence care was not provided timely for .(Resident #1, #4, and #5) but we were unable to confirm a length of time. Interview with the Diretor of Nurses (DON) on 10/16/18 at 4:20 PM, in the conference room, confirmed our expectation is rounds will be done every 2 to 3 hours by CNAs based on patient needs. Incontinence care is expected to be provided as needed.",2020-09-01
1811,WYNDRIDGE HEALTH AND REHAB CTR,445304,456 WAYNE AVENUE,CROSSVILLE,TN,38555,2018-06-04,584,D,1,0,TNDX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of a facility documents, and interviews the facility failed to provide a clean and homelike environment free from odors for 1 resident (#2) of 3 residents reviewed for homelike environment. The findings included: Medical record revealed Resident #2 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. Observation of Resident #2 on 6/1/18 at 2:10 PM, on the 300 hall revealed a slight, foul odor. Continued observation at this time revealed the surveyor was unable to ascertain if the odor was from the resident or his rock and go chair. Observation on 6/1/18 at 2:15 PM, on the 300 hall, of Resident #2's rock and go chair without the resident seataed in the chair, revealed the chair had a strong, foul odor. Observation/interview with Licensed Practical Nurse (LPN) #3 on 6/1/18 at 2:15 PM, on the 300 hall, confirmed a strong foul odor was present on Resident #2's rock and go chair. Continued interview with LPN #3, confirmed the resident's chair had a strong, foul, urine smell, and the facility had failed to clean and remove the odor, providing the resident with a clean chair. Review of a facility document Daily Cleaning Schedule for 4/18 through 5/18, revealed no documentation Resident #2's rock and go chair had been cleaned. Review of a facility document Routine Cleaning Schedule for 4/18 through 5/18, revealed no documentation Resident #2's rock and go chair had been cleaned. Interview with the Director of Nurses on 6/4/18 at 4:05 PM, in the conference room, confirmed the facility failed to remove a foul odor from Resident #2's rock and go chair, and failed to provide a clean, homelike environment.",2020-09-01
2528,ETOWAH HEALTH CARE CENTER,445422,"409 GRADY ROAD, PO BOX 957",ETOWAH,TN,37331,2017-10-24,225,D,1,0,UNTC11,"**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 all allegations of abuse, neglect, exploitation, or mistreatment were reported timely to the state agency for 4 residents (#7, #8, #3, and #9) of 9 residents revealed for abuse. The finding revealed: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Significant Change Minimum Data Set ((MDS) dated [DATE] revealed Resident #7 scored 03/15 (severely cognitive impaired) on the Brief Interview for Mental Status (BIMS). Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed resident #8 scored 03/15 (severely cognitive impaired) on the BIMS. Review of a facility investigation dated 10/15/17 revealed Resident #8 had her head down on the dining room table when Resident #7 rolled up to the side of Resident #8 and hit Resident #8 on the chest. Further review revealed the facility did not report the incident to the state agency until 10/18/17 (3 days later). Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] revealed Resident #3 scored 03/15 (severely cognitive impaired) on the BIMS. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #9 scored 03/15 (severely cognitive impaired) on the BIMS. Review of a facility investigation dated 10/15/17 revealed around 12:55 PM the Director of Nursing (DON) saw Resident #3 and Resident #9 walking together outside in the facility yard. Continued review revealed the staff responded to the door alarm and the residents were directed back into the facility. Further review revealed the incident was not reported to the state agency until 10/17/17 (2 days later). Interview with the Administrator on 10/24/17 at 2:00 PM, in the conference room, confirmed the incidents were not reported to the state agency timely.",2020-09-01
1005,SPRING CITY CARE AND REHABILITATION CENTER,445209,331 HINCH STREET,SPRING CITY,TN,37381,2018-02-26,842,D,1,0,ZK7Y11,"**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 maintain accurate medical records for 1 resident (#1) of 3 residents reviewed. The findings included: Medical record review revealed Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 5 Day Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview Mental Status score of 14 (cognitively intact). Continued review revealed the resident required extensive assist with transfers and personal hygiene with 2 person assist. Further review revealed the resident was always incontinent of bowel and bladder. Interview with Licensed Practical Nurse #3 on 2/23/28 at 5:30 PM, at the nurses station revealed .I was told in report by (named Registered Nurse) her (Resident #1's) admission was done .gave her what (medications) were in the computer .it made medication errors . Interview with Registered Nurse #4 on 2/26/18 at 10:15 AM, in the conference room, revealed .I enter the admission orders [REDACTED].if not the nurse on the floor enters them . Interview with the Director of Nursing on 2/26/18 at 10:30 AM, in the conference room, confirmed the facility failed to reconcile the medications for Resident #1. Further interview confirmed the facility failed to ensure the medical record for Resident #1 was accurate.",2020-09-01
1034,MOUNTAIN CITY CARE & REHABILITATION CENTER,445214,919 MEDICAL PARK DRIVE,MOUNTAIN CITY,TN,37683,2019-09-18,600,D,1,0,661Y11,"**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 prevent abuse for 1 resident (#1) of 5 residents reviewed for abuse. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored a 3 (severe cognitive impairment) on the Brief Interview for Mental Status. Continued review revealed the resident had no physical behaviors towards others and verbal behaviors of 1 to 3 times during the assessment period. Review of a facility investigation dated 5/29/19 at 8:22 PM revealed Licensed Practical Nurse (LPN) #1 and LPN #2 witnessed a visitor to the facility holding Resident #1's cane perpendicular across Resident #1's chest and pushing Resident #1 across the hall. Continued review revealed the visitor was escorted to the front office by the Social Worker (SW) and the police were called. Further review revealed the visitor was charged with simple assault. Continued review revealed the resident had no injuries. Telephone interview with LPN #1 on 9/17/19 at 12:00 PM revealed she witnessed the visitor holding Resident #1's cane perpendicular across Resident #1's chest and pushing him across the hall. Continued interview revealed the visitor had not been allowed back into the facility. Telephone interview with LPN #2 on 9/17/19 at 12:05 PM revealed she saw the visitor holding Resident #1's cane perpendicular across Resident #1's chest and pushing him across the hall. Interview with the SW on 9/17/19 at 12:10 PM revealed .I saw the visitor with the resident (Resident #1) at the wall .saw the visitor had his (Resident #1's) cane across his (Resident #1's) body holding him against the wall .took the visitor up front .police showed up .the visitor is not allowed back in the building . Interview with the Director of Nursing (DON) on 9/18/19 at 9:00 AM, in the conference room, revealed .I heard a loud noise .went out into the hall and when I looked down the hall the visitor had (Resident #1) up against the wall with his (Resident #1's) cane held to him (Resident #1) at chest level .I called the police .the visitor has not been allowed in the building .",2020-09-01
5425,ETOWAH HEALTH CARE CENTER,445422,"409 GRADY ROAD, PO BOX 957",ETOWAH,TN,37331,2016-03-22,333,D,1,0,MXJV11,"**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 prevent significant medication errors for 2 residents (#8, #11) of 6 residents reviewed for medication administration. The findings included: Medical record review revealed Resident #8 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 the resident scored 15/15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Medical record review revealed Resident #11 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 #11 was not scored (severely cognitive impaired) on the BIMS. Review of the facility's investigation revealed on 2/11/16 it was reported Resident #8 and #11 did not receive all of their evening shift medications on 2/10/16 as evidenced by the medications in question were still contained in their roll packs and were still on the medication cart. Continued review revealed the medications in question for Resident #8 included [MEDICATION NAME] 25 mg (milligrams) for [MEDICAL CONDITION] Fibrillation, Montelukast Sodium 10 mg for allergies [REDACTED]. Continued review revealed Resident #11 had missed 1 dose of [MEDICATION NAME] (mood stabilizer) 250 mg. Continued review of the facility investigation revealed the medications had been signed by the nurse as administered on 2/10/16. Interview with Registered Nurse (RN) #1 on 3/3/16 at 12:40 PM, in the Conference Room revealed the RN was on duty the morning of 2/11/16 and witnessed with the day shift nurse the medications found in the medication cart with the date of 2/10/16 and the time 8:00 PM to 10:00 PM to be given printed on the packaging of the medications. Continued interview with RN #1 confirmed the medication packaging was labeled with the name of the resident, name of the medication, and date and time, to be given confirming the medication found on the cart dated 2/10/16 for 8:00 PM and 10:00 PM, had not been given to Resident #8 and #11 as ordered by the Physician resulting in significant medication errors.",2019-03-01
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
1199,CHURCH HILL CARE & REHAB CTR,445237,701 WEST MAIN BLVD,CHURCH HILL,TN,37642,2019-02-04,609,D,1,0,3I6611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of a facility investigation, and interviews, the facility failed to report an allegation of abuse timely for 1 resident (#1) of 3 residents reviewed for abuse. The findings included: Medical record review revealed Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive impairment). Continued review revealed the resident required extensive assistance for transfers and toileting with 2 person assist and extensive assist for personal hygiene with 1 person assist. Medical record review of a nurse's progress note dated 1/22/19 at 7:42 PM revealed .Resident stated that the person that raped her was here .on call supervisor notified . Review of a facility investigation dated 1/25/19 revealed Resident #1 reported the incident to Licensed Practical Nurse (LPN) #1 on 1/22/19. Interview with LPN #1 on 2/4/19 at 6:15 PM, in the treatment nurse's office, revealed on 1/22/19 Resident #1 alleged a Certified Nurse Assistant (CNA) sexually assaulted her. Further interview revealed LPN #1 immediately removed the CNA from resident care and notified the supervisor. Interview with Registered Nurse #2 on 2/4/19 at 6:30 PM, in the treatment nurse's office, revealed she was notified of Resident #1's allegation and contacted the Administrator. Interview with the Administrator on 2/4/19 at 7:30 PM, in her office, confirmed the facility reported the incident to the state agency on 1/25/19 (3 days after the alleged incident). In summary, the facility failed to report an allegation of abuse to the state survey agency within 2 hours after the allegation was made.",2020-09-01
3575,SERENE MANOR MEDICAL CTR.,4.4e+252,970 WRAY ST,KNOXVILLE,TN,37917,2020-01-08,609,D,1,0,245H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of a facility investigation, and interviews, the facility failed to report an allegation of sexual abuse timely for 2 residents (#1 and #2) of 8 residents reviewed for abuse. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's Admission MDS dated [DATE] revealed a Brief Interview Mental Status score of 14 (cognitively intact). The resident required supervision for bed mobility, transfers, and ambulation. Medical record review of Resident #1's care plan dated 10/28/2019 revealed the resident had demonstrated previous inappropriate sexual behaviors on 10/27/2019 and 11/1/2019 and the resident was placed on observations every 15 minutes after each incident. The resident also had a medication change. The resident's care plan was updated on 11/30/2019 for inappropriate sexual behaviors involving Resident #2. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed had both short and long term memory problems and was moderately impaired for daily decision making skills. Medical record review of Resident #2's care plan dated 3/13/2019 revealed the resident had demonstrated previous inappropriate sexual behaviors on 2/18/2019 and 3/30/2019 and was placed on observations every 15 minutes after each incident. The resident's care plan was updated on 11/30/2019 for inappropriate sexual behaviors involving Resident #1. Review of a facility investigation dated 11/30/2019 revealed an incident of sexual abuse occurred between Resident #1 and Resident #2 on 11/30/2019. The facility failed to report the incident to the state survey agency until 12/1/2019 at 12:00 PM (24 hours after the incident). Interview with the Administrator on 1/8/2020 confirmed the facility failed to report an incident of abuse within 2 hours to the state survey agency. Refer to F-600.",2020-09-01
3576,SERENE MANOR MEDICAL CTR.,4.4e+252,970 WRAY ST,KNOXVILLE,TN,37917,2020-01-08,610,D,1,0,245H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of a facility investigation, and interviews, the facility failed to report the results of an investigation involving sexual abuse to the state survey agency within 5 days for 2 residents (#1 and #2) of 8 residents reviewed for abuse. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's Admission MDS dated [DATE] revealed a Brief Interview Mental Status score of 14 (cognitively intact). The resident required supervision for bed mobility, transfers, and ambulation. Medical record review of Resident #1's care plan dated 10/28/2019 revealed the resident had demonstrated previous inappropriate sexual behaviors on 10/27/2019 and 11/1/2019 and the resident was placed on observations every 15 minutes after each incident. The resident also had a medication change. The resident's care plan was updated on 11/30/2019 for inappropriate sexual behaviors involving Resident #2. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed had both short and long term memory problems and was moderately impaired for daily decision making skills. Medical record review of Resident #2's care plan dated 3/13/2019 revealed the resident had demonstrated previous inappropriate sexual behaviors on 2/18/2019 and 3/30/2019 and was placed on observations every 15 minutes after each incident. The resident's care plan was updated on 11/30/2019 for inappropriate sexual behaviors involving Resident #1. Review of a facility investigation dated 11/30/2019 revealed an incident of sexual abuse occurred between Resident #1 and Resident #2 on 11/30/2019. Review of the facility investigation on 1/8/2020 revealed the facility had not reported the investigation findings to the state survey agency (40 days later). Refer to F-600.",2020-09-01
5422,ETOWAH HEALTH CARE CENTER,445422,"409 GRADY ROAD, PO BOX 957",ETOWAH,TN,37331,2016-03-22,314,D,1,0,MXJV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of a facility investigation, review of sixty minute checks, and interview the facility failed to remove a bedpan timely resulting in a Stage 1 pressure ulcer for one Resident (#6) of 3 residents reviewed for Activities of daily living. The fidnings included: Medical record review revealed Resident #6 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 #6 scored 14/15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required total assistance for transfer and dressing with extensive assistance for hygiene/bathing. Review of a facility Resident Abuse Investigation Report Form revealed on 1/7/16 at 6:30 PM, the resident's daughter came to the nurse's station and reported her mother felt something hard under her and when she looked a bedpan was found underneath the resident placed by the day shift staff before leaving for the day. Review of the facility documentation revealed the resident was on every 60 minute checks and on 1/7/16 it was documented at 3:00 PM, 4:00 PM, 5:00 PM, and 6:00 PM, Resident #6 was C/D (clean and dry) and initialed by Certified Nursing Assistant (CNA) #9. Interview with CNA #8 on 3/2/16 at 11:10 AM, in the Conference Room revealed CNA #8 and #11 worked 6:30 AM to 3:00 PM on 1/7/16 and assisted Resident #6 with a bed bath between 2:30 PM-2:50 PM. Continued interview revealed Resident #6 asked for the bedpan after the bed bath and the day shift CNAs placed the resident on the bedpan, reported to the CNAs on the evening shift the resident was still on the bedpan, and left the facility at 3:00 PM. Interview with CNA #9 on 3/2/16 at 2:40 PM, in the Conference Room revealed CNA #9 and CNA #10 worked the 2:30 PM to 11:00 PM shift on 1/7/16. Continued interview revealed the day shift CNAs gave the evening shift CNAs a report but never reported the resident was on the bedpan. Further interview with CNA #9 revealed when the CNA had initialed the every 60 minute checks sheet for 1/7/16 indicating Resident #6 was clean and dry at 3:00 PM, 4:00 PM, 5:00 PM, and 6:00 PM, the CNA had never checked underneath the resident but had asked the resident if she needed changing or turned. Interview with Registered Nurse (RN) #3 on 3/2/16 at 3:30 PM, in the Conference Room confirmed when the CNAs sign their initials on the hourly check sheet it meant they had checked the resident to see if she was clean and dry, that you actually did it. Interview with the DON on 3/7/16 at 2:00 PM, in the Conference Room confirmed the day shift had placed the resident on the bedpan on 1/7/16 between 2:30 PM - 2:50 PM, and was not discovered until 6:30 PM by the resident's daughter. Further interview revealed the evening shift CNA had documented on the every 60 minute checks at 3:00 PM, 4:00 PM, 5:00 PM, and 6:00 PM the resident was clean and dry without actually turning or checking the resident but just asking the resident if she needed anything. Continued interview confirmed the every 60 minute checks meant the resident was to be turned and checked to determine if the resident was clean and dry and the facility failed to do the checks leaving the resident on the bedpan for an extended length of time resulitng in a Stage 1 presssure ulcer to the right buttock.",2019-03-01
1214,CHURCH HILL CARE & REHAB CTR,445237,701 WEST MAIN BLVD,CHURCH HILL,TN,37642,2019-08-14,600,D,1,0,M6UV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of a facility investigation, review of witness statements, and interviews, the facility failed to ensure 1 resident (#1) was free from abuse of 3 residents reviewed for abuse. The 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 (MDS) data set [DATE] revealed a Brief Interview Mental Status score of 3 (severe cognitive impairment). Continued review revealed the resident required extensive assist for bed mobility and transfers with 1-2 person assist. Further review revealed the resident required extensive assist for dressing, eating, and personal hygiene with 1 person assist. Review of a facility investigation dated 7/7/19, untimed, revealed Certified Nurse Assistant (CNA) #4 witnessed Licensed Practical Nurse (LPN) #2 hold Resident #1's nose in an attempt to get Resident #1 to swallow her medications. Further review revealed LPN #2 was terminated for abuse. Review of a witness statement by CNA #4 dated 7/7/19, untimed, revealed .I was in the (Resident #1's) room when the nurse (LPN #2) .grab (grabbed) a resident (Resident #1) by the nose so that she had to swallow her pills .she (LPN #2) said she let it go cause she (Resident #1) was turning purple and said '[***] you gotta breathe' .I went and told (LPN #1) . Review of a witness statement by Licensed Practical Nurse (LPN) #1 dated 7/7/19, untimed, revealed .(CNA #4) told her .LPN #2) had pinched (Resident #1's) nose to get her to swallow medications .told the resident '[***] you gotta breathe sometime' . Review of a witness statement by CNA #2 dated 7/7/19, untimed, revealed .(LPN #2) came into (Resident #1's room) to get her (Resident #1) to swallow meds (medications) .I heard (LPN #2) say 'why were you being so difficult .you're being such a [***] ' . Review of a witness statement by CNA #1 dated 7/7/19, untimed, revealed .heard (LPN #2) say she held (Resident #1's) nose until she turned purple . Interview with CNA #4 on 8/14/19 at 1:00 PM, in the treatment nurse's office, confirmed she witnessed LPN #2 hold Resident #1's nose and tell Resident #1 .she would have to breathe [***] . because the resident was refusing to swallow her medications. In summary, the Resident #1 refused to swallow the medications that were being administered by LPN #2. LPN #2 held Resident #1's nose in an attempt to force the resident to swallow the medications. LPN #2 cursed the resident and called the resident a derogatory term. The facility failed to protect Resident #1 from abuse.",2020-09-01
1405,SUMMIT VIEW OF ROCKY TOP,445259,204 INDUSTRIAL PARK RD,ROCKY TOP,TN,37769,2020-01-17,658,G,1,0,XWNL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of a facility's fall investigation, review of emergency services transport report, review of a hospital record, and interview, the facility failed to ensure nursing staff provided immediate and appropriate medical assessment and treatment after a fall for 1 resident (Resident #2) of 4 residents reviewed for accidents. The facility's failure to ensure emergency medical transport was called for transport of a resident after a fall resulted in Resident #2 lying on the floor in pain for 2 hours and 15 minutes after a fall (Harm). The findings include: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE], showed Resident #2 was moderately cognitively impaired, inattentive, required limited assistance of 1 staff member for activities of daily living (ADLs); except toileting, which required extensive assistance of 1 staff member and eating which required supervision and set up. The resident's gait was unsteady, but the resident was able to stabilize without staff assistance during transitions and walking. The resident did not use mobility devices, had a urinary catheter, was frequently incontinent of bowels, and had a previous fall with minor injury. Review of the facility's fall investigation dated 1/2/2020 at 9:30 PM showed .Fall.fell into floor next to bed.bruising to R (right) leg and extreme pain.resident lying in floor on R side next to bed. Review of a Nurse's Progress Note dated 1/2/2020 at 9:30 PM showed .CNA (Certified Nurse Assistant) informed this nurse that (Resident #2) was in the floor at this time. This nurse observed resident lying in floor on right side next to bed. Head to toe assessment done at this time. Noted bruise to right hip and resident had right leg drawed (drawn) up. Resident moaning and groaning in pain at this time. Called NP (Nurse Practitioner) and orders for stat (immediate) x-ray to right hip and pelvis. Order for [MEDICATION NAME] (pain medication) 5/325 mg (milligrams) po (by mouth) x (times) 1 dose only for pain now. Neuro check done at this time and WNL (within normal limits). Awaiting mobile images at this time. Review of a Physician's Telephone Order (TO) dated 1/2/2020 showed .Stat x-ray to R hip + (and) R pelvis.[MEDICATION NAME] 5/325 mg x 1 dose now for pain.TO per (named NP). Review of a Nurse's Progress Note dated 1/2/2020 at 10:20 PM showed .received report from second shift (nurse) that patient (Resident #2) fell at 9:40 PM and mobile x-ray was in room. (2nd shift) Nurse reported that (named NP) ordered stat x-ray and not to move patient due to possible fracture of lower limb. Patient in floor with blanket and pillow no pain this time resting. 15 minute vital checks completed. Review of a Mobile Image Patient Report dated 1/2/2020 showed .Arrived 1000 (10:00) PM IN 10:07 PM OUT 10:17 PM.Acute right femoral neck fracture ([MEDICAL CONDITION]). Review of a Nurse's Progress Note dated 1/2/2020 at 11:30 PM showed .Received report from mobile x-ray of fracture to right head of femur. Report given to (named NP) new orders to send to ER (emergency room ). E[CONDITION] (emergency medical service) called and on there (their) way patient resting with eyes open no distress noted covered by blanket and head on pillow 15min (minute) vital sign checks continue. Review of a Nurse's Progress Note dated 1/2/2020 at 11:45 PM showed .E[CONDITION] arrived at facility patient covered with blanket and head on pillow transferred patient to stretcher pain noted on transfer to stretcher. Patient transferred to ER via ems. Review of a Nurse's Progress Note dated 1/2/2020 at 11:54 PM showed .patient sent to ER via ems at 11:45 PM as ordered by (named NP) on fall that happened on second shift. X-ray results confirms right head of femur fracture. V/S (vital signs) 108/[AGE] bp (blood pressure) [AGE].2 temp (temperature) 98 pulse 24 resp (respirations) 95 o2 (oxygen saturation) facial grimacing noted. Review of an E[CONDITION] Prehospital Care report dated 1/2/2020 showed .Nursing advised that the ptn (patient) had fallen at approximately 2130 (9:30 PM).The nurse that was on duty gave the ptn pain meds and contacted the nurse practitioner to get further instructions. He advised that the NP told nursing not to move the ptn until mobile imaging returned with the x-rays. Ptn was lying on the floor of his room with his right knee drawn into his body at approximately 90 degrees angle with his left leg straight. As E[CONDITION] entered the room, the ptn rolled onto his left side. E[CONDITION] got a draw sheet, rolled him onto his back onto the draw sheet, and two men lifted him onto the stretcher while supporting his right knee in a position of comfort. Ptn secured.At this point, E[CONDITION].asked nursing why they waited so long to call 911, and (nurse) advised that he wanted to call sooner, but that the NP told him to wait until the x-rays came back.Ptn made groaning noises when he was lifted, but was mostly unresponsive besides that.16 respirations per minute, BP 112/[AGE], heart rate 110, o2 saturation was 78% (normal range 92% - 100%) on room air. E[CONDITION] initiated o2 at 3L (liters) via nasal cannula and his saturation slowly climbed to [AGE]%. Review of an Acute Care Hospital Emergency Department Physician's report dated [DATE] at 6:55 AM showed .Chief Complaint.patient had witnessed fall.was in the floor for about 2 hours before E[CONDITION] was notified. Pt has right hip fx. (fracture) Patients RA (room air) sat (saturation) was 78%.found on floor.He apparently was left on the floor for 2 hr (hours) until portable x-ray was obtained. During interview on 1/14/2020 at 2:51 PM, Licensed Practical Nurse (LPN) #2 stated .I arrived on shift.at 9:50 pm.got report from the other nurse (LPN #1) on second shift.the resident had fallen about 10 mins (minutes) before I came on shift.(LPN #1) told me the doctor ordered a stat x-ray and not to move (Resident #2) because of a suspected hip break.I asked the nurse at this point.why not just send (the resident) to ER.she said the doctor wanted an x-ray first before he (Resident #2) was to be sent out.no pain at that point.he was laying on the ground.pillows.vital signs were normal.no rotations (of the resident's leg).no bruising at this time.looked at his hip and did not see bruising at the time.bruising came up about 30 minutes after that.(Resident #2 was in severe pain) because he couldn't move. When asked why the LPN did not call 911, LPN #2 stated .I didn't want to over-ride my doctor.did not question her (NP) order.was not aware I could.I did not get the order.I waited until x-ray came back.he wasn't able to move his broken leg.they (mobile x-ray) called me at 11:20 (PM).confirmed fracture.I immediately called (named NP) and (named NP) confirmed to send to ER.I reported to the NP.he was laying in the floor with a blanket on.comfortable.did VS (vital signs) every 15 minutes.he (Resident #2) did not report pain.(on the floor) for about 2 hours.she (LPN #1) told me that the patient was ambulating to the bathroom and slipped and fell and he was on the floor and not to move him from doctor's orders for a suspected hip break and.to wait until mobile x-ray result. During interview with the NP on 1/14/2020 at 4:52 PM, the NP stated .a fall with pain I will typically order an x-ray and if there is a fracture I will send them out.if there is a fall there may just be soft tissue injury.jarred from a fall but not a fracture.unnecessary transfer if no need.expected time frame is a couple of hours.I was told by the nurse.he was found in the floor.had pain in his leg.they said they don't know if there was an injury.they didn't give me a pain scale.didn't say how much leg pain.they were concerned enough they wanted an x-ray.there was a possible injury.they just said he was in pain.they said it appeared he was in pain.they didn't say severe.So I gave an order for [REDACTED]. NP stated .we do morning meeting.there wasn't any talk about him lying in the floor in severe pain.there was no talk about the [MEDICATION NAME] being ineffective.I wouldn't think there was a reason to not move resident unless suspected cervical injury.just his leg.I don't think it was necessary for him to lay on the floor. there was no report of bruising.rotation.open skin.they just said pain.there wasn't severe pain or notification of medication not being effective either. During interview with the Director of Nursing (DON) on 1/15/2020 at 9:52 AM, the DON said she was unaware the resident was lying on the floor for 2 hours until 1/14/2020. The DON stated LPN #1 called the NP and the NP gave an order for [REDACTED].(LPN #1) stayed with the resident.he (Resident #2) was in extreme amount of pain.I am just guessing that is why he was left there for that long.I would have called 911 and sent him (Resident #2) out right away. During telephone interview on 1/17/2020 at 8:25 PM, the Medical Director confirmed she was aware of Resident #2's fall on 1/2/2020, but she was not aware the resident was on the floor for 2 hours. The Medical Director stated .that is absolutely not acceptable.nurses should not allow that to happen.E[CONDITION] should have been called. During telephone interview on 1/21/2020 at 3:10 PM, Certified Nursing Assistant (CNA) #2 stated .we were told to leave him (Resident #2) on the floor by our nurse (LPN #1).because he had fallen.she asked me and the other CNA to not move him.if it (hip) was broke would've hurt him more.we helped mobile x-ray do the x-ray on the ground.we put a pillow.put blankets.I was under the impression if we moved him we'd hurt him worse. During telephone interview with LPN #1 on 1/21/2020 at 4:05 PM, LPN #1 confirmed she took care of the resident on 1/2/2020 .(Resident #2) was in the floor next to his bed on his right side.no floor mats.when I was doing head to toe.he was favoring that right side.excruciating pain.his leg was drawed (drawn) up.moaning, groaning, wincing.he was tense.could definitely tell he was in a lot of pain.I knew something was fractured I just didn't know how bad.I left him with an aide (CNA) to call the NP to let her know.told her he fell .and I wanted to send him to the ER.she told me no.she wanted a stat x-ray.told her I was very sure it was broken.she said we needed an x-ray.we need to verify that first.so I did what I was ordered to do.got an order for [REDACTED].(named NP) mentioned to just do an x-ray before we go any further.so I just took that as don't move him until the x-ray comes in.no order (was given to not move the resident). Refer to F-689",2020-09-01
5303,MAGNOLIA CREEK NURSING AND REHABILITATION,445461,1992 HWY 51 S,COVINGTON,TN,38019,2016-04-13,278,D,1,0,53WE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of an incident investigation and interview, the facility failed to accurately assess a resident for falls for 1 of 7 (Resident #6) sampled residents. The findings included: Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility incident investigation dated 3/17/16 revealed the resident was found by staff sitting on the floor in the resident's restroom. Review of the comprehensive admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had not had a fall since admission to the facility. Interview with Licensed Practical Nurse (LPN) #1 on 4/13/16 at 3:55 PM, in the MDS office, LPN #1 was asked if the MDS was correct for falls. LPN #1 confirmed Resident #6 had fallen on 3/17/16 and the MDS was inaccurate.",2019-04-01
1539,GREEN HILLS CENTER FOR REHABILITATION AND HEALING,445267,3939 HILLSBORO CIRCLE,NASHVILLE,TN,37215,2017-10-31,353,K,1,0,EO0911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of daily assignment sheets, time punches, agency nurse time sheets, the nursing home licensure checklist, observation and interview, the facility failed to provide sufficient nurse staffing for supervision and care in the prevention of falls to 5 residents (#1, #16, #17, #19, #28) of 7 residents reviewed; failed to provide showers and personal hygiene for 2 residents (#6, #7) of 11 residents reviewed; and failed to monitor behaviors for 2 residents (#20, #22) of 4 residents reviewed. The resulting failure constituted an 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 failure to provide sufficient nurse staffing for resident care. The District Director of Operations was notified of the Immediate Jeopardy on 10/30/17 at 3:00 PM in the Administrator's Office. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located on the 3rd floor secure unit. Medical record review revealed the resident had a fall on 6/20/17 which resulted in a left [MEDICAL CONDITION] and was hospitalized ; a fall on 8/2/17 which resulted in a right [MEDICAL CONDITION] and was hospitalized . Medical record review revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] and 8/1/17 with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located on the 3rd floor secure unit. Medical record review revealed the resident had a fall on 7/31/17 and sustained a [MEDICAL CONDITION] and right [MEDICAL CONDITION] resulting in hospitalization ; a fall on 8/24/17 resulted in a skin tear to the right eyebrow; a fall on 9/6/17 resulted in bleeding from the forehead; and a fall on 9/27/17 resulted in no injury. Medical record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located on the 3rd floor secure unit. Medical record review revealed the resident had a fall on 9/7/17 and experienced a decreased loss of consciousness, was unresponsive, had head trauma and was hospitalized . Medical record review revealed Resident #19 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED].#2, History of Falling, Head Injury, Weakness, Hypertension, Anorexia, Lack of Coordination, and Difficulty Walking. Medical record review revealed the resident had a fall on 10/18/17 with unknown injury due to lack of documentation; another fall on 10/15/17 resulting in a bumped back and hit to the head; and a fall on 10/16/17 resulting in a left [MEDICAL CONDITION] and hospitalization . Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed the resident had a fall on 10/5/17, was taken to the emergency room and returned to the facility with a [DIAGNOSES REDACTED]. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed the resident received only 1 documented shower on the dates of 9/27/17 through10/23/17 and no further documentation pertaining to showers was provided. Observation of Resident #6 on 10/23/17 at 9:40 AM on the 3rd floor secure unit, revealed the resident presented with strong body odor and was unshaven. Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Observation of Resident #7 on 10/23/17 at 9:40 AM on the 3rd floor secure unit, revealed the resident had dirty nails, clothes, and dried debris on her clothing. Observation of Resident #7 on 10/25/17 at 11:40 AM in the 3rd floor dining room revealed the resident was wearing the same clothing as observed on 10/23/17. Observation of Resident #7 on 10/26/17 at 11:15 AM in the 3rd floor dining room revealed the resident had dried debris on the right side of her mouth and was wearing a soiled top with debris and staining down the front. Interview with Certified Nurse Aide (CNA) #9 on 10/25/17 at 12:05 PM in the 3rd floor revealed the resident had been in the same clothes since 10/23/17. Continued interview confirmed the resident had been wiped off but had not received a shower for several days due to not having enough staff scheduled. Continued interview confirmed the facility failed to carry out and maintain grooming, bathing and personal hygiene for Resident #7. Interview with Resident #23 on 10/24/17 at 10:45 AM in the resident's room revealed the resident wasawake, alert, and oriented, watching television. She stated she frequently had to wait for help and usually had already wet or soiled herself before the Certified Nurse Aides (CNAs) can get around to performing every 2 hour rounds for turning and drying/cleaning her. Continued interview revealed it embarrassed her to wet or soil herself. Further interview revealed she had waited for longer amounts of time in the evenings, nights, and on the weekends, waiting for up to 40 minutes before being helped on most evenings, nights, and weekends. Interviews with Residents #24, #25, and #26 on 10/24/17 at 10:55 AM in the 2nd floor south hall revealed they have had to wait for help, after pushing their call lights especially on the weekend nights. Futher interview confirmed they stated the wait time was 20 to 30 minutes. Interview with Resident #27 on 10/24/17 at 11:10 AM in her room revealed many times the CNAs did not turn her every 2 hours, it would be longer than every 2 hours. Continued interview revealed many times she had wet or messed herself which made her feel bad. Further interview revealed she had to ask for water to fill her water pitcher when the previous shift forgot to fill the pitcher. Medical record review revealed Resident #20 was admitted to the facility on [DATE], readmitted on [DATE] and 9/14/17 and was discharged to a psychiatric facility on 10/9/17 with [DIAGNOSES REDACTED]. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's behaviors in the SBAR Summaries, Progress Notes, Nurses Notes dated 9/25/17 to 10/26/17 revealed agitation, removal of several window blinds from the windows and carried the blinds down the hall, throwing an empty bucket, yelling, and grabbing at the nursing staff hard enough to leave bruising. Medical record review of the Psychiatric Diagnostic Evaluations performed by the Psychiatric Nurse Practitioner dated from 9/11/17 to 10/24/17 revealed behaviors of impulsive, anxious, confused, wandering, trying to shoot others playfully with a plastic plant water bottle, verbal and physical aggression against other residents and staff members and threatening toward staff especially when they try to redirect. Interview with the Staffing Coordinator on 10/24/17 at 8:50 AM in the conference room revealed CNA #6 (agency staff) was listed on the daily schedule; however, was not in the facility for direct resident care from 9:30 AM to 3:30 PM on Monday, Wednesday, and Friday when he accompanied and remained with a resident on the 3rd floor to his [MEDICAL TREATMENT] appointment. Continued interview confirmed there was no CNA to fill-in for CNA #6 while he was not on the floor. Telephone interview with Registered Nurse (RN) #3 on 10/24/17 at 3:50 PM revealed a lot of resident falls occur on all shifts and stated the facility is short-staffed; not having enough CNAs and the facility was staffed mostly with agency staff and they seldom arrived on time. Continued interview revealed she had worked with only 3 CNAs on day shift when 4 to 5 CNAs were needed. Interview with RN #1 (agency nurse) on 10/24/17 at 4:40 PM at the 2nd floor medication cart revealed she is scheduled for shifts on the 2nd and 3rd floors of the facility and stated it was mostly staffed by agency nurses and CNAs. Continued interview revealed the schedule is short on CNAs a lot and she had worked with 3 CNAs on the day shift when 4 or 5 more staff is needed. Further interview revealed more staff is needed on the 3rd floor secure unit because most of the residents walk all the time and stated, .It's poorly staffed . Interview with Licensed Practical Nurse (LPN) #1 on 10/24/17 at 5:40 PM on the 3rd floor secure unit revealed an additional CNA would help to observe dementia residents on the 3rd floor, especially the secure unit side. Continued interview revealed he stated, .the residents wander about and another CNA would really help in redirection of the more impaired and dependent residents . Interview with CNA #4 on 10/24/17 at 6:38 PM on the 3rd floor secure unit revealed only 3 CNAs are usually scheduled for the entire 3rd floor and 3 CNAs are not enough for secure unit residents with Sundow[DIAGNOSES REDACTED], Dementia, Confusion, and Wandering. Continued interview revealed the south hall of the 3rd floor had 7 residents totally bedridden, needed assistance with meals and had to wait for assistance with meals. Interview with the Director of Nursing (DON) on 10/24/17 at 6:50 PM in the conference room revealed when asked what the facility could have done to prevent the falls on the 3rd floor, the lack of showers and personal hygiene, the lack of adequate hydration, and the behavior monitoring she stated, .If we had our own staff it would have been easier for consistency and to notice any subtle changes . Interview with CNA #2 on 10/25/17 at 9:25 AM on the 3rd floor, south hall revealed the residents received more attention from the CNAs when 4 to 5 were scheduled on days and evenings. Continued interview revealed at least 3 CNAs scheduled for the secured unit helped to monitor residents that wander about, have confusion, and require redirection. Further interview revealed the CNA agreed with statements made by Resident #23 and Resident #27 about getting help from CNAs on time and stated the 2 residents are credible. Continued interview confirmed when 3 to 4 CNAs are scheduled she is unable to make resident rounds, many times finding the bedbound residents with wet or soiled adult briefs and linens. Interview with CNA #1 on 10/25/17 at 9:30 AM on the 3rd floor, south hall revealed if 3 to 4 CNAs were scheduled for the entire 3rd floor, it was hard to make the every 2 hour checks on the residents. Interview with CNA #5 on 10/25/17 at 10:00 AM on the 2nd floor nurses station revealed working on the 3rd floor was difficult with just 3 CNAs. Continued interview revealed at least 2 CNAs were needed for the secure unit, leaving 1 CNA for the south hall. Further interview confirmed Resident #23 and Resident #27 were correct on their statements about getting help timely. Continued interview confirmed residents requiring 2 staff and every 2 hour turning were not getting turned and changed timely. Interview with the Administrator and the DON present on 10/25/17 at 6:50 PM, in the conference room confirmed the facility had problems with staffing and used 6 different agencies to staff the facility with nurses and CNAs. Continued interview revealed the Administrator stated when she began working at the facility in (MONTH) there were at least 20 agency staff working in the facility on a daily basis. Telephone interview with the Medical Director on 10/30/17 at 2:25 PM revealed the number of falls on the secured unit, .may be a little higher than most and maybe it does has to do with staffing. Review of the daily assignment sheets, time punches, agency nurse time sheets, and nursing home licensure checklist revealed the range of census for the 3rd floor (a long hall with a nurses station and dining room in the middle with a keypad used to enter the dining room) for the period of mid-September (YEAR) to (MONTH) (YEAR) was 45 to 47 residents with the secure unit (half of the long hall, also called north hall) ranging from 23 to 29 residents. Continued review of the daily assignment sheets, time punches, and agency nurse time sheets for dates coinciding with complaints and accidents dated 9/3/17, 9/20/17, 9/24/17, 9/27/17, 10/4/17, and 10/15/17 revealed the nursing schedule with the following data: 9/3/17: 45% agency nurses and 45% agency CNAs for the entire facility. 60% agency nurses and 45% agency CNAs for the 3rd floor. 2 nurses worked double shifts; 3 CNAs worked double shifts. 9/20/17: 0% agency nurses and 36% agency CNAs for the entire facility. 0% agency nurses and 9% CNAs for the 3rd floor. 2 nurses worked double shifts; 3 CNAs worked double shifts. 9/24/17: 36% agency nurses and 14% agency CNAs for the entire facility. 20% agency nurses and 9% agency CNAs for the 3rd floor. 2 nurses worked double shifts; 2 CNAs worked double shifts. 9/27/17: 36% agency nurses and 30% agency CNAs for the entire facility. 20% agency nurses and 36% agency CNAs for the 3rd floor. 1 nurse worked double shifts; 3 CNAs worked double shifts. 10/4/17: 27% agency nurses and 28% agency CNAs for the entire facility. 20% agency nurses and 8% agency CNAs for the 3rd floor. 2 nurses worked double shifts; 3 CNAs worked double shifts 10/15/17: 63% agency nurses and 92% agency CNAs for the entire facility. 40% agency nurses and 42% agency CNAs for the 3rd floor. 3 nurses worked double shifts; 6 CNAs worked double shifts Interview with the DON and the Director of Operations on 10/30/17 at 4:50 PM in the conference room confirmed the facility failed to provide sufficient nursing staff to provide quality of care, supervision and intervention to the residents. Refer F224 K Refer F309 K Refer F323 K",2020-09-01
4036,BROOKHAVEN MANOR,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2016-12-07,353,K,1,0,E8N511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of daily staffing assignments, review of staffing schedules, and interview, the facility failed to ensure adequate staffing to provide necessary personal care assistance and incontinence care in a timely manner for 11 residents (#106, #123, #75, #103, #65, #27, #68, #21, #45, #12, #145) of 43 residents reviewed. The facility's failure placed Residents #106, #123, #75, #103, #65, #27, #68, #21, #45, #12, #145 in Immediate Jeopardy (a situation which the provider's non compliance has caused, or is likely to cause, serious harm, injury, impairment of death). The Immediated Jeopardy was effective 2/6/16 and is ongoing. The findings included: Medical record review of the Treatment Administration Record (TAR) for Resident #54 dated 7/2016 revealed pressure ulcer treatment to the right buttocks was not completed on 9 out of 24 days. Review of the Daily Staffing Sheet revealed no treatment nurse scheduled for 7/9/16, 7/10/16, 7/16/16, 7/17/16, 7/22/16, 7/23/16, 7/24/16, 7/27/16, and 7/28/16. Medical record review of the TAR for Resident #54 dated 8/16 revealed pressure ulcer treatment to the right buttocks was not completed on 3 out of 19 days. Review of the Daily Staffing Sheet revealed no treatment nurse scheduled for 8/7/16, 8/13/16, and 8/14/16. Interview with the Director of Nursing (DON) on 12/6/16 at 8:34 AM, in the conference room, confirmed no pressure ulcer treatments to the right buttocks were documented on 9 occasions in (MONTH) (YEAR) and 3 occasions in (MONTH) (YEAR). Interview with the Treatment Nurse on 12/7/16 at 3:22 PM, in the conference room, confirmed .They pull me off the cart (treatment cart) somedays at 3PM (and assigned patient care) .I also work the cart (medication cart) if don't have a scheduled nurse working to cover shift . Continued interview confirmed the nurse failed to provide pressure ulcer treatment to Resident #54's pressure ulcers. Medical record review of the Interdisciplinary Progress Notes dated 12/12/15 for Resident #21 revealed .Resident is paraplegic and requires total care for ADL's (activities of daily living) .Incont (incontinent) of B&B (bowel and bladder) c (with) peri care q2 (every 2 hours) + (and) PRN (as needed) . Interview with Certified Nursing Assistant (CNA) #19 on 11/30/16 at 8:04 PM, in the 400 hall, revealed .I have done my first dry rounds (6:00PM rounds) .Starting 8's (8:00 PM rounds) now .Last rounds at 4 (4:00 PM) before I got here . Observation on 11/30/16 at 8:08 PM, on the 400 hall, revealed Resident #21 had a strong urine odor. Continued observation revealed a wet stain to the resident's pants from the groin, inner thigh, down to the knee. Interview with Resident #21 on 11/30/16 at 8:08 PM, on the 400 hall, confirmed .They haven't changed or clean me yet .not since last state person (state surveyor) was here . Interview with CNA #19 on 11/30/16 at 8:09 PM, on the 400 hall, confirmed .I haven't changed her (Resident #21) yet tonight . Observation and Interview with Licensed Practical Nurse(LPN) #13 on 11/30/16 at 8:12 PM, on the 400 hallway, revealed Resident #21 sitting in a wheelchair with wet saturation pants from the groin, to inner thigh, down to the knees. Interview with LPN #13 confirmed .She (Resident #21) is soiled .She is a lift transfer .I expect her to be changed every 2 hours . Medical record review of Resident #45's Care Plan dated 3/25/16 and updated 9/15/16 revealed .Self Care Deficit .Assist with ADL's as needed .Has incontinence bowel & bladder .Incontinence to be provided by staff as needed . Medical record review of Resident #45's Nursing Weekly Summary dated 11/19/16 revealed .ass (assist) x (times) 2 c ADL's + t/f's (transfers) .Incont of B+B (bowel and bladder) peri care PRN (as needed) + q2 (every 2 hours) .non amb (ambulatory) is in the bed most of the time . Interview with Resident #45 on 11/30/16 at 8:18 PM, in the resident's room, confirmed .I haven't been changed since before supper before 5 (PM) . Continued interview revealed the resident was aware she was soiled and needed to be changed. Interview with RN #2 on 11/30/16 at 8:25 PM, on the 300 hall, confirmed the CNAs were to check and change the residents every 2 hours. Continued interview confirmed the CNAs started their rounds at 6:00 PM. Further interview confirmed CNA's were not to change residents during meals times. Telephone interview with CNA #18 on 12/1/16 at 8:38 PM, confirmed she was assigned to Resident #45 on the night of 11/30/16. Continued interview confirmed she finished her first dry rounds after 10:00 PM. Further interview confirmed the CNA's were instructed in training not to change residents while passing trays or when trays are on the halls. Interview with the DON on 12/5/16 at 2:17 PM, in the conference room, confirmed she expected the residents to be checked and changed every 2 hours and as needed. Interview with Resident #45 on 12/7/16 at 9:39 AM, in the resident's room, confirmed .It is what it is. What can you do about it . Medical record review of a TAR for Resident #123 dated 10/2016 revealed .Twice Daily [MEDICATION NAME] dressing until seen by (Orthopedic Doctor) 11/3/16 . Further review revealed treatment was not documented as completed on 10/29/16. Continued medical record review of a TAR dated 11/2016 revealed a dressing order dated 10/21/16 .Clean Surgical Incision To RT (right) Knee with [MEDICATION NAME], Apply (named dressing) & (and) Wrap with (named gauze), Change BID (twice a day) . Continued review revealed treatments were not documented as completed on 11/8/16,11/11/16, 11/12/16 and 11/14/16. Review of the monthly staff schedules, revealed no treatment nurse on the schedule for 10/29/16, 11/8/16, 11/11/16,11/12/16, and 11/14/16. Interview with the Treatment Nurse on 11/29/16 at 2:37 PM, at the 100 nursing station, confirmed Resident #123 had a pressure area on the posterior right leg. Further interview confirmed the pressure ulcer was not measured on 11/28/16 because the Treatment Nurse was working on the medication cart. Interview with the Treatment Nurse on 12/5/16 at 9:15 AM, in the conference room, confirmed it was difficult to complete all wound treatments when she was pulled to the medication cart. Further interview confirmed wound treatments not completed by the treatment nurse are not always completed by the other nurses. Interview with Registerd Nurse (RN) #1 on 12/6/16 at 9:50 AM, in the 100 hall, confirmed there were times she was unable to complete treatments and dressing changes as ordered by the physician. Review of a facility investigation dated 2/7/16 revealed Resident #65 reported on 2/7/16 she told CNA #14 she was soaking wet and requested to be changed. CNA #14 told the resident he was 2 hours behind and he could not get to her and did not return. RN #2 reported the incident to the DON on 2/8/16. The DON interviewed Resident #65 and the resident repeated the same incident. Interview with Resident #65 on 11/9/16, in the resident's room, revealed .can't remember exactly what he said .didn't have time or something like that .it made me feel like I wasn't important . Medical record review of the Admission Resident Data Set for Resident #106 dated 7/25/16 revealed the resident had a sacral area circled on the body diagram with .shearing . written out beside of the area. There were no measurements or description of the wound and no treatment was initiated. Medical record review of the care plan dated 7/25/16 revealed .treatments as ordered .Measure wound at least weekly .Record . Medical record review of the Nursing Weekly Summary dated 7/29/16 revealed .open area in coccyx area. Bilateral buttocks reddened irritated, blood noted in brief from irritated areas on buttocks . Continued review revealed there were no measurements of the wound. Review of the Daily Staffing Sheets for 7/22-7/31/16 revealed there was no Treatment Nurse scheduled. Medical record review of the wound assessment report dated 8/12/16 revealed no measurements for the right buttock wound. Medical record review of the TAR dated 8/2016 revealed no treatment of [REDACTED]. Review of the Daily Staffing Sheets revealed there was no Treatment Nurse scheduled on 8/7/16, 8/13/16, and 8/14/16. Interview with the Treatment Nurse on 11/8/16 at 4:45PM, in the small conference room, confirmed there were no weekly wound assessments completed on 8/12/16 for the right buttock. Interview with the Treatment Nurse on 12/5/16 at 9:15 AM, in the conference room, confirmed it was difficult to complete all wound treatments when she was pulled to the medication cart. Further interview confirmed wound treatments not completed by the treatment nurse are not always completed by the other nurses. Interview with Registerd Nurse (RN) #1 on 12/6/16 at 9:50 AM, in the 100 hall, confirmed there were times she was unable to complete treatments and dressing changes as ordered by the physician. Medical record review revealed Resident #145 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the wound assessment reports for the R BKA and the L BKA revealed 15 out of 30 assessments for 8/25/16 through 12/1/16 were not completed. Review of the daily staffing revealed no Treatment Nurse was scheduled for 11 days out of 30 days. Medical record review of the TAR dated 11/2016 revealed the treatments to the left lower extremity stump and the right hip wound had not been initialed as complete for 5 out of 30 days (11/12/16, 11/13/16, 11/19/16, 11/26/16, and 11/27/16). Interview with the Treatment Nurse on 12/7/16 at 3:20 PM, in the conference room, confirmed she did not have any additional measurements for the wounds for Resident #145. Continued interview revealed .if I work a cart (medication cart) I do the treatments on that hall only .the other nurses are supposed to do their treatments . Interview with Resident #145 on 12/6/16, in the 200 hall way, revealed .yes, they change it pretty much every day especially if the treatment nurse is here, but if she's not it's usually every other day . Medical record review of Resident #145's (MONTH) (YEAR) TAR revealed no documentation the treatment had been completed on 9/29/16 and 9/30/16. Review of the Monthly Schedule, Daily Staffing Sheets, and Payroll Reports for (MONTH) (YEAR), revealed no Treatment Nurse was working at the facility on 9/29/16 and 9/30/16. Interview with the DON on 12/5/16 at 11:15 AM, in the conference room, revealed .knew there were holes in the MARS/TARS so we can't prove they were done . Interview with CNA #7 on 11/19/16 at 10:20 AM, on the 100 hallway, revealed . it's hard to cover both hallways with 2 people .can't hear alarms down the other hall especially if you are in a room or giving a shower . Interview with Resident #46 at 10:45 AM, in her room, revealed .we have not got enough help .just once in a while someone will come in here .takes a half a day or longer sometimes to answer call light . Interview with CNA #21 on 11/19/16 at 11:00 AM, on the 400 hallway, revealed .no I haven't gotten to everyone yet .no haven't told my nurse . Interview with CNA #20 on 11/19/16 at 11:20 AM, on the 300 hallway, revealed .still have 3 or 4 residents to get to .came in at 6:00 AM .typical day .it takes time .the nurses know . Interview with LPN #15 on 11/19/16 at 12:15 PM, in the 300-400 nurses station, revealed she was unaware the CNA's were behind on their rounds. Continued interview revealed .think staffing could be better .If we have call ins we really don't have a lot of prn help . Interview with LPN #1 on 11/19/16 at 12:35 PM, in the 300 hallway, revealed .not aware the CNA's were behind .just happens sometimes . Interview with Resident #93 on 11/30/16 at 10:07 AM, in the resident's room, revealed she requires a walker and assistance of staff to ambulate to the bathroom. Further interview confirmed she is incontinent at times because it takes up to 30 minutes for staff to come to her room. Interview with Resident #47 on 12/1/16 at 7:40 AM, in resident's room, revealed .we don't have enough help cause sometimes don't have enough people to get me up cause it takes 2 people . Telephone interview with LPN #10 on 12/3/16 at 2:05 PM revealed .I had someone fall .I can't get the treatments done .the DON is here and I ask for help and she told me not to get so worked up over this. I could do it and if I couldn't I just needed to write a statement and clock out and go home. I had to work over 21 1/2 hours last weekend because someone called in last Saturday and we have had another call in today .I can't do it again .It's not safe to work here. We can't get everything done .These people are not being taken care of like they should be. On 11/13 into 11/14/16 when I was working there were several dressings that had not been changed since 11/8/16. I called the DON and told her about it and she told me to just write a statement of who the residents were. So I did and (LPN #13) signed it too .everybody has been mad since then .(RN #1) told me I lied and I told her if they were done then why did the dressing say 11/8/16 .the Treatment Administration Records were not signed but they probably are now .if I don't get to them I don't initial that I did them. I'm sure sometimes others initial when they didn't change the dressing . Interview with the DON on 12/5/16 at 11:15 AM, in the conference room, revealed she was aware treatments were not being completed as ordered. Interview with the Medical Director on 12/5/16 at 1:55 PM, in his office, confirmed he was aware of the staffing issues at the facility. Continued interview revealed .I have been the Medical Director for [AGE] years and it's always been an issue here . Interview with the Treatment Nurse on 12/6/16 at 3:40 PM, on the 100 hall, confirmed sometimes she has come back to work after being off and discovered wound treatment had not been done while she was off. Telephone interview with LPN #13 on 12/6/15 at 4:30 PM revealed .we found multiple, multiple, multiple dressings that had been signed as done but the dressings were dated 11/8/16. I cannot remember everybody .(LPN #10) and I wrote a statement out of how many dressings were dated 11/8, 11/9, and 11/10 (2016) had been initialed as having been changed but were not .I have to stay over every day .I do my med pass and treatments and have to stay over to do documentation and charting .things like that .it's too much to get done in one shift . Interview with the Treatment Nurse on 12/7/16 at 3:20 PM, in the conference room, revealed .If I work a cart (medication cart) I work a cart and then do treatments on that hall. Sometimes I get to work on treatments 1/2 day .I'm not going to lie .it's been hell around .I actually do 3 peoples jobs. I am the treatment nurse, a cart nurse, and I do the scheduling too. If there is no one to schedule to work the shift I have to work the cart .we don't have any open positions right now . Refer to F-157 (J); F-223 (K); F-224 (J); F-225 (K); F-241 (J); F-280 (J); F-309 (J); F-312 (J); and F-314 (J).",2019-11-01
2187,HARRIMAN CARE & REHAB CENTER,445368,240 HANNAH ROAD,HARRIMAN,TN,37748,2020-01-15,622,D,1,0,JJIZ11,"**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 document in the medical record the specific needs the facility was unable to meet and the steps taken to meet the resident's needs for 1 of 5 (Resident #3) reviewed for transfer and discharge requirements. The findings include: Review of the medical record, showed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Progress Notes showed multiple entries which documented Resident #3's noncompliance with the use of [MEDICAL CONDITION] (Bilevel Positive Airway Pressure- device worn while sleeping to treat/prevent episodes of sleep apnea) while sleeping and the facility's education to the resident of importance of wearing. The review of the Progress Notes also showed multiple entries of Resident #3 yelling out from her room and not utilizing the call light to request staff assistance. Review of Physician order [REDACTED].[MEDICAL CONDITION] .Humidified .at Bedtime. Bleed in O2 (oxygen) @ (at) 8 liters per minute AS TOLERATED with NASAL MASK . Review of Resident #3's Quarterly Minimum Data Set ((MDS) dated [DATE], showed the resident had a Brief Interview of Mental Status Score (BIMS) of 15 indicating the resident was cognitively intact, exhibited verbal behaviors symtpoms directed towards others and rejection of care, was totally dependent on staff for all Activities of Daily Living (ADLs), and was on oxygen therapy. Review of a General order dated 11/24/2019, showed an order to transfer Resident #3 to the hospital for evaluation and treatment as indicted. Review of the Transfer Form dated 11/24/2019, showed the resident was transferred to a local hospital due to a change in mental status, difficulty waking, decreased blood pressure, and had an oxygen saturation level of 98%. Continued review showed the resident was transported by ambulance. Review of the facility form Referrals (electronic communication form between the facility and the hospital) showed 11/25/2019 'Yes (will accept patient back from the hospital). Review of the hospital History and Physical Reports dated 11/25/2019, showed Resident #3 was admitted to the hospital on [DATE]. Review showed Resident #3 presented to the emergency room with altered mental status and was found to have Influenza B and atelectasis (partial or complete collapse in lung) in the right lung base. Review of an email from the Respiratory Therapist (RT) to the Director of Nursing (DON) dated 12/2/2019, showed .Nursing reported to me (Resident #3) was not doing well. That her CO2 (carbon [MEDICATION NAME]) was high and she was having to use supplemental oxygen when not on the BI PAP .It was also reported that they had a full face mask on her .It is my opinion that we cannot meet her needs anymore, as a full code .She needs a facility that has external alarms for her BI PAP and 24 hour RT coverage .It is not safe for her to use a full face mask or chin strap here due to her inability to use her puff call light (type of call light utilized by a resident who is unable to use traditional call light- the puff call light works by the resident blowing into the device with the mouth) .Again these are my professional opinions . Review of the facility form Referral showed 12/2/2019 No (indicating the facility would not accept the resident back to the facility on ce discharged from the hospital) with unable to meet needs as the documented reason. Review of the Hospital Discharge Summary dated 12/23/2019, showed .Patient's long-term center (Name of Nursing Home) refused to take her back .So case management looking for a different facility .Discharge pending to accepting facility with a bed for long term care .Will also need BI PAP .Patient has been at her usual baseline for several days now and has no new issues or concerns .Stable treated for [REDACTED]. Review of facility Discharge Summary dated 1/14/2020 showed Resident #3 was discharged from the facility on 11/24/2109 .Admission Status .admitted to facility total care R/T (related to) DX (diagnosis) MS ([MEDICAL CONDITION]). Long term care resident. Up in power w/c (wheelchair) in which she maneuvered with head piece/chin piece .Significant changes in condition: slow overall decline in status throughout her stay at facility. Recent change in respiratory status requiring [MEDICAL CONDITION] in which she is noncompliant with use .Final diagnoses/Condition Upon Discharge .Progressive Disease .required total assist with all ADL care. Was able to mobilize power chair with chin device when assisted up to her chair. Hx (history) Non-compliant with [MEDICAL CONDITION] usage . During an interview on 1/15/2020 at 10:45 AM, the Social Service Director stated .During the hospitalization Resident #3 had a decline in her respiratory and clinical side .We were not able to keep the resident clinically safe . During an interview on 1/15/2020 at 11:27 AM, the Admissions Director confirmed she instructed the hospital Case Manager .unless the Resident's respiratory status changed the facility could not meet the resident's needs and she could not return to the facility after being discharged . During an interview on 1/15/2020 at 12:57 PM, the Medical Director (MD) stated he met with the Respiratory Therapist and the DON and discussed Resident #3 and it was determined the facility was not a good fit for the resident. The MD stated .We saw repeated back and forth aspiration issues and breathing issues. We are not set up to handle those kinds of things. Everything she did was orally. She couldn't lift a finger. Resident #3 used a breathing puffer call light and with the full face mask the resident could not use the call light for help . Interview confirmed the facility failed to document specifically the needs the facility was unable to meet for Resident #3 and failed to specifically document the attempts the facility made to meet the resident's needs in the medical record. During an interview on 1/15/2020 at 3:12 PM, the DON confirmed Resident #3 was non-compliant with BI PAP use and oxygen use at the facility. The resident used a breath activated call light at the facility to communicate the need for help. The resident was re-educated several times of the importance of wearing her BI PAP while asleep. The hospital diagnosed the resident with Flu B. The resident was placed on a full mask with a BI PAP machine while hospitalized . The DON stated The Respiratory Therapist, Medical Director, and I felt (Resident #3) needed a respiratory facility with a full time RT on staff. The RT here was shared by 3 facilities for full time hours . The DON confirmed the facility failed to document in the medical record what specific needs the facility was unable to meet and the steps taken by the facility to attempt to meet the resident's needs.",2020-09-01
483,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-09-13,692,D,1,0,9GQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of facility documentation, and interview, the facility failed to follow a recommendation from the Registered Dietitian for an oral Nutritional Supplement for weight loss for 1 resident (#1) of 3 residents reviewed for weight loss. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] and discharged on [DATE], with [DIAGNOSES REDACTED]. Review of an Admission Minimum (MDS) data set [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Review of a facility document, Weights, revealed Resident #1's weight on 7/23/18 was 220.4 pounds, and on 7/31/18 was 211.8 pounds, indicating a weight loss of 8.6 pounds or 3.9% in 8 days. Review of a Nutrition Note dated 8/1/18, revealed .Res (resident) obese/[MEDICAL CONDITION] and wt. (weight) Review of the Medication Administration Record [REDACTED] Review of Physician Telephone Orders dated 8/1/18 through 8/6/18, revealed no order for Med pass 90 ml TID. Interview with the Director of Nursing on 9/11/18 at 4:21 PM, in the conference room, confirmed Resident #1 did have weight loss during admission. Continued interview confirmed the Registered Dietitian's recommendation on 8/1/18 for Med Pass 90 ml 3 times daily was not followed and facility failed to provide the recommended oral supplement for weight loss.",2020-09-01
3589,SERENE MANOR MEDICAL CTR.,4.4e+252,970 WRAY ST,KNOXVILLE,TN,37917,2017-10-11,225,D,1,0,9S1Y11,"**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 report an allegation of abuse in a timely manner to the State Survey Agency (SA) for one resident (#3) of five residents reviewed for abuse. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Nurse Progress note dated 8/12/17 revealed Resident (Resident #1) was in dayroom attempting to take a sandwich from a female resident when another female resident (Resident #3) started to tell him not to .This resident then went over and slapped another female resident (Resident #3) on the L) (left) side of head and face . Review of facility documentation revealed the allegation of abused occurred on 8/11/17. Continued review revealed the incident was not reported to the SA until 8/15/17. Interview with the Director of Nursing on 10/11/17 at 12:20 PM, in the manager's office, confirmed the facility failed to report an allegation of abuse to the SA in a timely manner. Interview with the Administrator on 10/11/17 at 12:37 PM, in the manager's office confirmed the facility failed to report the allegation of abuse in a timely manner to the S[NAME]",2020-09-01
3783,TRI STATE HEALTH AND REHABILITATION CENTER,445263,600 SHAWANEE RD,HARROGATE,TN,37752,2017-02-15,225,D,1,0,9SLL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of facility documentation, interview, and observation, the facility failed to ensure 1 allegation of abuse was reported immediately to the administrator and state agency; thoroughly investigate, and failed to protect the resident from further abuse, for 1 resident (#142) of 5 residents reviewed for abuse, of 31 sampled residents. The findings included: Medical record review revealed Resident #142 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE], revealed the resident scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition, and was totally dependent on staff for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. Review of a facility concern and comment form, with a handwritten note dated 2/12/17, revealed a concern had been filed on behalf of Resident #142 and witnesses were Licensed Practical Nurse (LPN) #1, Certified Nurse Aide (CNA) #2, and CNA#3. The admission staff reported to the Assistant Director of Nursing (ADON), Resident #142's family member told the admissions staff, LPN #1 had told Resident #142 she was going to get her in a chair and take her to the nurse's station. Further review revealed the form was signed by the ADON, and the investigation report stated, I talked with (LPN #1) and (CNA #2) at separate times. They said the resident was restless all evening; that she had rang the call light several times, nothing they did would satisfy her, so NA's (Nurse Aides) asked nurse to come talk to her (Resident #142), to see if she (LPN#1) could help them. (LPN #1) told the resident she could call the doctor or send her to the emergency room or maybe she would like to sit up in a chair for a while to see if that would help her. They said resident said no. Further review revealed the back of the form was signed by the ADON and dated 2/12/17, but there was no date or time of the allegation on the form. Review of LPN #1's time card revealed the LPN worked the following days and hours: 2/6/17 at 5:59 PM to 2/7/17 at 6:23 AM 2/7/17 at 6:01 PM to 2/8/17 at 6:25 AM 2/8/17 at 5:50 PM to 2/9/17 at 6:15 AM 2/10/17 at 5:41 PM to 2/11/17 at 6:48 AM 2/11/17 at 5:51 PM to 2/12/17 at 6:36 AM 2/12/17 at 6:00 PM to 2/13/17 at 6:24 AM Medical record review of physician notes, daily skilled observation notes, nurses progress notes, social service progress notes, care plans, care plan meeting notes, and post-admission notes from 2/3/17 (admission) to 2/13/17 revealed there was no documentation regarding Resident #142's allegation. Interview with the Administrator on 2/15/17 around 8:25 AM, revealed he had not received any allegations of abuse or complaints related to Resident #142. Interview with the Director of Nursing (DON) on 2/15/17 around 8:45 AM, revealed she had not received any allegations of abuse or complaints involving Resident #142. Interview with the Director of Rehab on 2/15/17 around 11:30 AM, revealed she was with a physical therapist (PT) doing a rehab assessment on Resident #142, and Resident #142 reported LPN #1 told her to stay off the call light or she would be put in a chair at the nurse's station. LPN #1 told the resident this is not a hospital, this is a nursing home. The Director stated she reported the allegation to the DON, but could not recall the date of the allegation or the date she reported it to the DON. The Director stated she and the PT both worked on 2/9/17, and it could have been that day. Interview on 2/15/17 around 11:30 AM, with the PT who assessed the resident on 2/9/17 with the Rehab Director, revealed as soon as the Rehab Director heard Resident #142's allegation, she left the room to report it immediately to the SW. Interview with the Assistant Director of Nursing (ADON), with the DON present, on 2/15/17 around 11:45 AM, revealed she completed an investigation after admission staff told her of Resident #142's concern, reported by the family. She said LPN #1, CNA #2, and CNA#3 were working the night of the allegation, but did not provide the date and time of the allegation. Interview with the DON on 2/15/17 at 2:12 PM, revealed the DON did not receive a report of the allegation. She said she had been the DON for the past 6 weeks, and staff may have confused her with the ADON (who had been the previous DON). Observation of Resident #142 on 2/15/17 at 2:15 PM, revealed Resident #142 was working with therapy staff while sitting in a wheelchair in her room. She was following directions and was calm and smiling as she spoke with staff. Interview with the SW on 2/15/17 at 2:22 PM, revealed the SW had been informed of the allegation of abuse involving Resident #142 on 2/15/17. Interview with Resident #142 on 2/15/17 at 2:27 PM, in her room, revealed she was calm, smiling, and spoke in a matter of fact manner about the allegation. The resident stated she told PT staff about the allegation, but could not recall the date or time, and said it involved the evening nurse, LPN #1. She said LPN #1 told her we don't have time to fool with you, don't aggravate us or we will put you in a chair at the nursing station, and do not ring the call light one more time. Resident #142 said later that night she rang the call light for assistance to toilet and was assisted. She said LPN #1 had cared for her since that incident and LPN #1 had been different since she got talked to, more appropriate. Interview with the Administrator on 2/15/17 at 2:30 PM, revealed, I just found out about it (the allegation of abuse) a bit ago today. I have 5 days to turn it in, but I need to look at it and decide if it is an allegation or grievance. I'll look at it and decide if it is, I'm not saying it is or isn't, I need to look at it. Interview with the Administrator on 2/15/17 at 3:25 PM, confirmed the allegation met the definition of abuse according to the facility's policy. Interview with the ADON on 2/15/17 at 3:44 PM, revealed the ADON received the allegation from the admissions person, who reported something about a chair and a nurse, as reported by a family member. The ADON said she called LPN #1 and CNA #2 on 2/12/17 about the incident. The ADON confirmed she did not tell anyone else about the allegation and did not call the resident's family member (who had reported the allegation to the admissions person). The ADON said she did not call LPN #1 until Sunday, 2/12/17, since she did not see any danger to the resident. Interview with the Administrator on 2/15/17 at around 4:15 PM, confirmed the facility was out of compliance with reporting. Interview confirmed reporting to any of my staff is like reporting to me. Interview with resident #142's family member on 2/15/17 at 6:03 PM, revealed Resident #142 said a nurse on the evening shift said to her, if you ring that call light one more time, I will put you in a chair and leave you there. Do not pull that call light again. The family member did not provide the date or time of the incident or the nurse's name. The family member stated Resident #142 reported the incident to facility staff, but did not provide the names of staff the incident was reported to. In summary, the facility did not complete and document a thorough investigation to determine when the allegation occurred and the investigative findings and the conclusion of the investigation. A timely statement from involved staff and witnesses, including staff the allegation was reported to, was not obtained. No actions were taken for the accused perpetrator to protect other residents while an investigation was conducted. And, staff failed to ensure reporting of the allegation of abuse to Administration and the State Survey Agency was done immediately.",2020-02-01
1814,WYNDRIDGE HEALTH AND REHAB CTR,445304,456 WAYNE AVENUE,CROSSVILLE,TN,38555,2018-06-04,677,D,1,0,TNDX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of facility documents, and interviews, the facility failed to provide daily showers as requested by the family to 1 resident (#2) of 4 residents reviewed for Activities of Daily Living (ADL). The findings included: Medical record revealed Resident #2 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. Further review revealed the resident was dependent for personal hygiene. Review of a care plan dated 12/14/17 revealed .Self-Care Deficit .needs assistance with bed mobility, transfers, locomotion, eating, toileting, personal hygiene, bathing . Further review revealed no documentation Resident #2 was to receive daily showers. Review of facility documentation ADL worksheet for 1/18 through 5/18, revealed Resident #2, did not receive a shower on 1/1/18, 1/2/18, 1/5/18, 1/20/18, 3/1/18, 3/13/18, 3/20/18, 4/29/18, 5/5/18, 5/12/18, 5/24/18, 5/26/18, and on 5/29/18. Review of a facility document Certified Nurse Aide (CNA) Assignment Sheet for 5/18 revealed . showers daily on 7:00 AM-3:00 PM shift . Interview with family member of Resident #2 on 5/31/18 at 10:05 AM, revealed she had requested the resident receive a shower daily, and he had not. Continued interview revealed it was supposed to be on his care plan, and the facility wasn't following his care plan. Interview with Licensed Practical Nurse (LPN) #5/Unit Manager for Unit 3 and 4 on 6/4/18 at 11:50 PM, in the conference room confirmed she was aware Resident #2 was to receive a shower daily, and she had updated the CNA Assignment Sheet to reflect daily showers, but had not updated the comprehensive care plan. Further interview confirmed she was unable to provide documentation why the resident had not received showers on 16 of the 123 days. Interview with LPN #1 on 6/4/18 at 12:15 PM, at the 300 hall nurses station confirmed she was aware the resident was to have a shower daily. Continued interview revealed if a CNA was unable to provide the daily care the nurse was to be informed. Interview with the Director of Nurses on 6/4/18 at 4:05 PM, in the conference room confirmed Resident #2 was to receive a daily shower, and the facility failed to provide daily showers on 16 of 123 days. Further interview confirmed the facility failed to update Resident #2's comprehensive care plan to reflect daily showers.",2020-09-01
1813,WYNDRIDGE HEALTH AND REHAB CTR,445304,456 WAYNE AVENUE,CROSSVILLE,TN,38555,2018-06-04,657,D,1,0,TNDX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of facility documents, and interviews, the facility failed to revise a comprehensive care plan to reflect a resident was to receive daily showers, resulting in failure to provide daily showers for 1 resident (#2) of 3 residents reviewed for revision of comprehensive care plans. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. Further review revealed the resident was dependent for personal hygiene. Review of a care plan dated 12/14/17 revealed .Self-Care Deficit .needs assistance with bed mobility, transfers, locomotion, eating, toileting, personal hygiene, bathing . Further review revealed no revised documentation to reflect Resident #2 was to receive daily showers. Interview with family member of Resident #2, on 5/31/18 at 10:05 AM, revealed she had requested the resident receive a shower daily, and he had not. Continued interview revealed the request was supposed to be on his care plan, and the facility wasn't following his care plan. Interview with Licensed Practical Nurse #5/Unit Manager for Unit 3 and 4, on 6/4/18 at 11:50 PM, in the conference room revealed she was aware Resident #2 was to receive a shower daily, and she had updated the CNA Assignment Sheet to reflect daily showers, but had not updated the comprehensive care plan. Interview with the Director of Nurses on 6/4/18 at 4:05 PM, in the conference room confirmed Resident #2 was to receive a daily shower, and the facility failed to provide daily showers on 16 of 123 days. Further interview confirmed the facility failed to update Resident #2's comprehensive care plan to reflect daily showers.",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
5325,CREEKSIDE CENTER FOR REHABILITATION AND HEALING,445516,306 W DUE WEST AVENUE,MADISON,TN,37115,2016-04-01,272,G,1,0,2CEQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of facility incident reports, interview, and review of facility policy, the facility failed to assess the safe transfer needs for 1 resident (#210) and failed to complete a comprehensive assessment for the urinary continence status for 6 residents (#131, #67, #86, #281, #43, #7) of 41 residents reviewed. The facility's failure to assess the transfer needs for Resident #210 resulted in Harm to the resident. The findings included: Medical record review revealed Resident #210 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Risk assessment dated [DATE] revealed, under the section Transfer Needs Assessment, Registered Nurse (RN) #2 chose Dependent. Continued review revealed the Risk Assessment defined dependent as requires staff to lift more than 35 lbs. (pounds) of the resident's weight or resident is unpredictable in the amount of assistance needed. In this case assistive devices should be used. Further review revealed the next section required the Unit Coordinator to assess Weight-bearing capability - Full, Partial, or None. Review revealed the weight-bearing assessment was not done. Continued review revealed a section titled, Appropriate lift/transfer devices needed: (answer based on appropriate Transfer Need Algorithm (a guided decisionmaking tool)). Continued review revealed 10 options were available and RN #2 chose Stand and Pivot with gait belt (although the weight bearing ability of the resident had not been assessed). Medical record review of the Admission/Interim Care Plan revealed ADLS (activities of daily living), dated 7/7/15, and Potential for ADL Decline as evidenced by increased need for assistance .Complete .Lift Program Lift/Transfer Assessment Form and report findings to ADON (Assistant Director of Nurses) as per instructions of appropriate use - communicate findings to CNA (Certified Nurse Aide). Review revealed no documentation the Lift/Transfer Assessment was completed. Medical record review of the Occupational Therapy Screen dated 7/7/15 revealed, Pt (patient) is dependent for all functional ADL and does not present with recent change in functional status . Medical record review of the Physical Therapy Screen dated 7/8/15 revealed, Pt is dependent for all moving. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment; and required extensive assistance to total dependence for all ADLS, with extensive physical assistance of 1 person for bed mobility and transfer. Medical record review of the Care Area Assessment (CAA) Summary dated 7/12/15 revealed, .05. ADL Functional/Rehabilitation Potential was not triggered for a decision to care plan the CAA. Continued review revealed the CAA Worksheet for ADLS was not completed. Review revealed the CAA was not completed for the resident's most dependent ADL Self-Performance, Input from Resident or Family, Analysis of Findings, or Care Plan Considerations. Medical record review of the Physical Therapy Screen dated 10/29/15 revealed, Total assist bed mobility, 2 person transfer .No changes in functional status at this time .per nsg (nursing). Medical record review of the Occupational Therapy Screen dated 10/29/15 revealed, Total care. Medical record review of the Quarterly MDS dated [DATE] revealed the resident required extensive assistance to total dependence for ADLS, with extensive physical assistance of 2 persons for bed mobility and transfer, and had no impairment of the range of motion for upper and lower extremities. Review of the facility's Resident Incident Report for Resident #210, dated 1/15/16 revealed, .Incident Type: Other, Type of Injury: Fracture, Location: Resident's room, Associate Involved: (CNA #5), Incident Reported by: Certified Tech, Report Prepared by: (LPN #2) . Review of a written statement revealed it had been obtained from CNA #4, the CNA assigned to care for the resident on 1/14/16 on the evening shift, I had pt. (Resident #210) on 1/14/16 on the 3-11 shift pt. was put to bed by me and she was normal just the no, no, stop like she always does. Medical record review of the stat mobile xray report dated 1/15/16 at 5:01 AM, revealed, SIGNIFICANT FINDINGS .Acute spiral mildly displaced fractures of the distal diaphysis and metadiaphysical junctions of the tibia and fibula. Overlying soft tissue [MEDICAL CONDITION] and swelling .Impression: Acute mildly displaced fractures of the distal diaphysis and metadiaphyseal junctions of the tibia and fibula (fractures of the 2 bones in the lower leg) . Medical record review of the Physician's Telephone Orders dated 1/15/16 at 6:15 AM, revealed 1. Send to the ER (emergency room ) .for ortho (orthopedic) evaluation and treatment of [REDACTED]. Medical record review of the ER xrays, dated 1/15/16 at 8:41 AM, revealed, Impression 1. Comminuted spiral fracture distal tibia metadiaphysical. No significant angulation or displacement. 2. Spiral [MEDICAL CONDITION] diaphysis extending to the distal metaphysis. Medical record review of the ER Physician's History and Physical dated 1/15/16 revealed, History of Present Illness .severely demented .has contractures of her left knee and left hip .from nursing home with left tibia and fibula fracture. There is no real documentation when she suffered her fall. Per daughter she is non-ambulatory and in a wheelchair .Physical Examination .Noted contracture of her left lower extremity with flexion contracture of her knee of approximately 90 degrees and a flexion contracture of the left hip .Assessment and Plan .suffered an unfortunate event that was not witnessed, resulting in a left minimally displaced comminuted spiral pattern mid shaft tibia fracture, which extends intraarticularly with a posterior malleolus (ankle) fracture as well as minimally displaced comminuted fracture of her left distal fibular shaft . Interview with the Director of Nurses (DON) on 3/30/16 at 9:35 AM, in the conference room, confirmed the DON had not completed a root cause analysis to determine the cause of the incident that lead to the spiral [MEDICAL CONDITION] and fibula bones of the lower left leg. Interview with the DON on 3/30/16 at 3:35 PM, in the conference room, confirmed the staff nurse completing the Interim Care Plan included the approach/intervention Complete .Lift Program Lift/Transfer Assessment Form . Interview confirmed a mechanical lift was not assessed for use with the resident. Interview by telephone with the Medical Director (MD) on 3/31/16 at 11:45 AM, confirmed the spiral fractures (of the tibia and fibula) indicated the ankle was twisted. The MD stated the fractures could have occurred as the resident was transferred to bed and the pain didn't happen until the care during the night .if the fractures possibly displaced at that time. Interview with MDS Coordinator #1 on 4/1/16 at 9:00 AM, in the conference room, confirmed the Quarterly MDS completed 1/10/16 did not identify the contractures of Resident #210's left knee and hip as assessed by the emergency room Physician on 1/15/16. Interview with the Regional Nurse, with the Administrator present, on 4/1/16 at 10:30 AM, in the conference room, confirmed the resident's need for assistance for all activities of daily living, including transfer needs, was not addressed in the required Care Area Assessment. Interview with the DON on 4/1/16 at 3:35 PM, in the conference room, confirmed RN #2 did not assess Resident #210's weight-bearing status on the Nursing Risk Assessment prior to determining the resident's method of transfer was to Stand an pivot with gait belt. Review of the facility policy, Bladder and Bowel Assessment Policy, undated, revealed .1. Implement Bladder and Bowel (B&B) assessment on all Residents at the time of admission, quarterly, and when there is a change in cognition, physical ability or urinary tract or bowel function. 2. Record Resident bladder and bowel patterns for 72 hours using the Bladder and Bowel Record. 3. Following completion of the 72 hour Bladder and Bowel Record and the Bladder and Bowel Assessment which includes a targeted history, physical examination (if applicable), urinalysis and post void residual (if indicated) will be completed by qualified staff. Assessment will be forwarded to MDS (Minimum Data Set) Coordinator/Care Plan Coordinator . Medical record review revealed Resident #131 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Risk Assessments dated 11/3/15, 12/3/15, and 12/29/15, revealed multiple unanswered questions for the Incontinence Risk Assessment section. The assessments dated 11/3/15 and 12/29/15 did not indicate if the resident was continent or incontinent. The assessment dated [DATE] indicated the resident was incontinent of urine. Further review revealed a 72 hour Bladder and Bowel Record had not been completed. Medical record review of the Admission MDS dated [DATE], section H (Bowel and Bladder), revealed Resident #131 had not had a trial toileting program, was frequently incontinent of urine, occasionally incontinent of bowel, and was not currently on a toileting program. The resident's Brief Interview for Mental Status (BIMS) score was a 15 out of 15 (cognitively intact), and section G (Functional Status) revealed the resident required extensive assistance of 2 for transfers and extensive assistance of 1 assist for toileting. Medical record review of the Significant Change MDS completed on 1/4/16 revealed the resident was frequently incontinent of urine and always incontinent of bowel, had a BIMS score of 15, and required extensive assistance of 2 for transfers and extensive assistance of 1 for toileting. Interview with the Director of Nursing (DON) on 4/1/16 at 10:48 AM, in the conference room, confirmed the facility had failed to complete a Bladder and Bowel assessment and failed to complete a 72 Hour Bladder and Bowel Record for Resident #131. Medical record review revealed Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Risk Assessments dated 11/26/15, 3/9/16, and 3/14/16, revealed the Incontinence Risk Assessment sections had multiple unanswered questions. All three assessments indicated the resident was incontinent, but the assessments were incomplete for contributing factors and causes, and implementation to improve bladder function. Further review revealed the 72 hour Bladder and Bowel Record had not been completed. Medical record review of the Admission MDS dated [DATE], section H, revealed Resident #67 had not been placed on a trial toileting program, was frequently incontinent of urine and bowel, and had no current toileting program. The resident scored a 10 on the BIMS, indicating a moderate impairment. Continued review of section G, revealed the resident required extensive assistance of 1 for transfers and extensive assistance of 1 for toileting. Medical record review of the Bowel and Bladder Continence Roster for 3/24/16 through 3/31/16 revealed the resident was frequently incontinent of urine and continent of bowel. Interview with the DON on 4/1/16 at 10:48 AM, in the conference room, confirmed the facility had failed to complete the Bladder and Bowel assessment and failed to complete a 72 Hour Bladder and Bowel Record for Resident #67. Medical record review revealed Resident #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Risk Assessments dated 10/16/15 and 11/16/15 revealed the Incontinence Risk Assessment section contained multiple unanswered questions. The assessment dated [DATE] did not indicate if the resident was continent or incontinent and the assessment dated [DATE] indicated the resident was continent. Further review revealed the 72 hour Bladder and Bowel Record had not been completed. Medical record review of the Admission MDS dated [DATE], revealed the resident scored 10 on the BIMS, indicating moderately impaired cognition, had not had a trial toileting program, was occasionally incontinent of bladder, frequently incontinent of bowel, and currently not on a toileting program. Continued review revealed the resident required assistance of 1 for transfers and toileting. Medical record review of the Quarterly MDS dated [DATE] revealed the resident scored 11 on the BIMS, was always incontinent of urine and frequently incontinent of bowel, and required assistance of 1 for transfers and toileting. Medical recored review revealed there was not a Nursing Risk Assessment completed with the Quarterly MDS on 2/22/16. Interview with the Assistant Director of Nursing (ADON) on 3/31/16 at 8:30 AM, in the Director of Nursing office, confirmed Resident #86 did not have the Nursing Risk Assessment completed for the Quarterly MDS dated [DATE]. Interview with the DON on 4/1/16 at 10:48 AM, in the conference room, confirmed the facility had failed to complete the Bladder and Bowel assessment and failed to complete a 72 Hour Bladder and Bowel Record for Resident #86. Medical record review revealed Resident #281 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Nursing Risk Assessment Urinary Continence Status dated 3/18/16 revealed the assessment did not indicate whether the resident was continent or incontinent of urine. Continued review revealed the assessment was incomplete with multiple questions unanswered. Further review revealed a 72 hour Bladder and Bowel Record had not been completed for Resident #281. Medical record review of the Admission MDS dated [DATE] revealed Resident #281 had a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Continued review revealed the resident was frequently incontinent of urine. Interview with MDS Coordinator #1 on 3/30/16 at 10:15 AM, in the MDS office, confirmed there were no 72 hour bladder and bowel patterns, initial bladder assessments, or quarterly bladder assessments completed. Interview with the DON on 4/1/16 at 10:48 AM, in the conference room, confirmed the facility had failed to complete the Nursing Risk Assessment for Bladder and Bowel and failed to complete a 72 Hour Bladder and Bowel Record for Resident #281. Medical record review revealed Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] revealed the resident scored 13 out of 15 on the BIMS, indicating the resident was cognitively intact. Continued review revealed the resident was frequently incontinent of urine. Medical record review revealed a Bladder and Bowel assessment and a 72 hour Bladder and Bowel Record had not been completed upon admission for Resident #43. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #43 was always incontinent (no episodes of continent voiding) and was not on a urinary toileting program. Interview with MDS Coordinator #1 on 3/30/16 at 10:15 AM, in the MDS office, confirmed there were no 72 hour bladder and bowel patterns, initial bladder assessments, or quarterly bladder assessments completed. Interview with the DON on 4/1/16 at 10:48 AM, in the conference room, confirmed the facility had failed to complete the Nursing Risk Assessment for Bladder and Bowel and failed to complete a 72 Hour Bladder and Bowel Record for Resident #43. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nurse's note dated 6/19/15, revealed .incont (incontinent) of b (bladder) . Medical record review of the Nursing Risk assessment dated [DATE] revealed the resident was assessed as continent of urine. Medical record review of the Admission MDS dated [DATE] revealed the resident had a BIMS score of 6 (indicating the resident had severe cognitive impairment); required extensive assistance of 1 person for toilet use; and was always incontinent of urine. Medical record review of the Quarterly MDS dated [DATE] revealed the resident had a BIMS of 0, was totally dependent on staff for toilet use, and was occasionally incontinent of urine. Medical record review revealed a 72 hour bladder assessment to assess the resident's continence status and patterns was not completed. Medical record review revealed the resident's continence was not reassessed on a quarterly basis per policy. Interview with MDS Coordinator #1 on 4/1/16 at 8:21 AM, in the conference room, confirmed the facility had not completed a 72 hour bladder pattern assessment for the resident. Continued interview confirmed the facility failed to reassess the resident's continence status on a quarterly basis. Interview with MDS Coordinator #1 on 3/30/16 at 10:15 AM, in the MDS office, confirmed there were no 72 hour bladder and bowel patterns, initial bladder assessments, or quarterly bladder assessments completed. MDS Coordinator #1 stated .knew there were problems in that area and they were working on them . Interview with the DON on 4/1/16 at 10:48 AM, in the conference room, confirmed the facility had failed to complete Bladder and Bowel assessments per facility policy. Refer to F-315 and F-323",2019-04-01
1748,BEECH TREE HEALTH AND REHABILITATION,445292,"240 HOSPITAL LANE, PO BOX 300",JELLICO,TN,37762,2018-03-28,600,D,1,1,SP2611,"**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 ensure 1 resident (#74) was free from abuse of 4 residents reviewed for abuse, of 34 residents reviewed. The findings included: Medical record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS- a test for cognitive ability) score was 2 out of a possible 15 indicating the resident was severely cognitively impaired. Continued review revealed the resident required supervision with locomotion on and off the unit. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed the resident's BIMS score was 9 out of a possible 15 indicating the resident was moderately cognitively impaired. Continued review revealed Resident #7 required extensive assistance with bed mobility and transfers and required limited assistance (one person physical assist) with locomotion on and off the unit. Medical record review of nurses' notes from 3/1/18 through 3/11/18 revealed Resident #7 exhibited behaviors of refusing care, yelling at staff and residents and was combative with the staff. Medical record review of the behavior monitoring sheets for (MONTH) (YEAR) revealed Resident #7 exhibited behaviors of anxiety, anger, and agitation on 3/7/18, 3/8/18, 3/9/18, and 3/10/18. Review of a facility investigation dated 3/11/18 revealed Resident #74 was sitting in a wheelchair near the nurses' station when Resident #7 attempted to push Resident #74's wheelchair and said .move (explicative) . then punched Resident #74 in the back with her fist. Further review revealed there were no injuries to Resident #7 or #74. Medical record review of a Nurse Practitioner progress note dated 3/12/18 revealed .has been refusing her [MEDICATION NAME] ([MEDICAL CONDITION] medicine) at times and being combative with her behavior more and more frequently. She throws herself into the floor at times and has angry verbal outbursts . Continued review revealed .Agitation and outbursts .When I asked her about it, she states, 'I did it on purpose' . Interview with Licensed Practical Nurse (LPN) #2 on 3/27/18 at 9:55 AM, on the 200 Hall confirmed she had observed Resident #7 attempt to hit other residents and confirmed the resident would sometimes throw herself in the floor. Interview with Resident #74 on 3/27/18 at 10:30 AM, in the resident's room was not completed because Resident #74's response to every question was yeah. Telephone interview with LPN #1 on 3/27/18 at 7:00 PM, confirmed she had witnessed the altercation between Resident #7 and Resident #74. LPN #2 confirmed Resident #74 was sitting near the nurses' station in a wheelchair when Resident #7 tried to push Resident #74. Resident #7 became agitated and said .move (explicative) . and punched Resident #74 in the back. Interview with the Director of Nursing (DON) on 3/28/18 at 8:25 AM, in the DON's office, confirmed Resident #7 punched Resident #74 in the back.",2020-09-01
2828,FOUR OAKS HEALTH CARE CENTER,445458,1101 PERSIMMON RIDGE RD,JONESBOROUGH,TN,37659,2017-10-04,323,D,1,1,MVC111,"**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 adequate supervision and assistance for 1 resident (#62) of 3 residents reviewed for accidents. The findings included: Medical record review revealed Resident #62 was admitted to the facility on [DATE] and readmitted [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 3 (indicating severe cognitive impairment), and functional status for transfer (how the resident moves between surfaces including to or from bed/chair, wheelchair, standing position) as a 4 indicating total dependence and requiring 2 plus persons physical assistance. Review of the Certified Nurse Aide (CNA) Completed Care Task documentation dated 7/28/17 and 7/29/17 revealed Resident #62 had been transferred on these dates with the assistance of two persons and the assistance of one person. Medical record review of the facility investigation dated 7/29/17 revealed Resident #62 sustained a left tibia/fibula fracture .incident was noted to be of unknown origin . Continued review revealed recommendations/corrective actions included 2 assist c (with) all transfers / mechanical lift c transfers. Medical record review dated 7/29/17 at 12:03 PM, revealed Resident #62 .noted to have swelling, bruising, and warmth to left lower leg mid-calf, noted tightness of muscle with palpation .new order .ultrasound of LLE (left lower extremity) . Further review revealed Resident #62 was transferred to the hospital per family request at 1:34 PM. Medical record review of the emergency department history and physical dated 7/29/17 revealed .X-ray of left lower extremity shows comminuted fracture of the proximal tibia .severe knee osteoarthritis .no surgical interventions planned .no clear cause of the fracture . Interview with Licensed Practical Nurse #1 on 10/3/17 at 10:36 AM, in the Conference Room, confirmed CNA #1 asked her before lunch on 7/29/17 to look at Resident #62's left leg. Further interview confirmed the left leg was swollen and bruised below the knee. Interview with CNA #1 on 10/3/17 at 11:10 AM, in the Conference Room, revealed along with CNA #2, at approximately 10:30 AM on 7/29/17, transferred Resident #62 from the chair to the bed and did not notice any abnormalities of the left leg or any signs or symptoms of pain. Further interview revealed at 11:30 AM, CNA #1 checked the resident for incontinence and noticed a bruise on her left shin. Telephone interview with CNA #2 on 10/3/17 at 11:25 AM, confirmed she transferred Resident #62 on 7/29/17 before breakfast from the bed to the chair without assistance. Continued interview with CNA #2 revealed .I know how to do it . Further interview confirmed prior to transferring her before lunch on 7/29/17 along with CNA #1 she noticed a bruise around the calf area of the left leg. Interview with the Medical Director on 10/3/17 at 5:30 PM, in the Conference Room revealed the leg is not healing because of her comorbidities .dementia .she has weak bones .transfer could have been a factor . Interview with the Director of Nurses on 10/3/17 at 5:50 PM, confirmed Resident #62 was totally dependent with 2 persons plus assist necessary for transfer at the time of the injury. Further interview confirmed Resident #62 was transferred from the bed to the chair with 1 staff member. Continued interview confirmed the facility had failed to ensure adequate supervision and assistance in transferring Resident #62.",2020-09-01
2092,SIGNATURE HEALTHCARE OF GREENEVILLE,445351,106 HOLT COURT,GREENEVILLE,TN,37743,2018-02-21,600,D,1,0,5SLN11,"**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 ensure 2 residents (#1 and #3) were free from abuse of 4 residents reviewed for abuse. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medic record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5 (severe cognitive impairment). Continued review revealed the resident required extensive/total assist with activities of daily living (ADL) with 1-2 person assist. Further review revealed the resident had verbal behaviors daily. Medical record review revealed Resident #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 14 (cognitively intact). Continued review revealed the resident required extensive/total assist with ADL with 1-2 person assist. Further review revealed the resident had verbal behaviors 1-3 days a week. Review of a facility investigation dated 1/17/18 revealed Resident #1 was seated in a reclining wheelchair in the hallway. Continued review revealed Resident #2 exited his room and slapped Resident #1 on the head. Interview with Certified Nursing Assistant (CNA) #4 on 2/21/18 at 4:30 PM, on the 100 hallway, revealed .didn't see it .heard it. (Resident #1) was in the hallway in his (reclining wheelchair) and (Resident #2) came rolling out of his room. (Resident #1) was yelling just as (Resident #2) came by him and I heard a smack . Interview with Registered Nurse #1 on 2/21/18 at 6:00 PM, in the dayroom, revealed .he (Resident #1) told me (Resident #2) hit my head . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the initial MDS dated [DATE] revealed a BIMS score of 15 (cognitively intact). Continued review revealed the resident had verbal behaviors 1-3 days a week. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14-Day MDS dated [DATE] revealed the resident had short and long term memory deficits with wandering behaviors daily. Review of a facility investigation dated 1/11/18 revealed a CNA heard a noise in Resident #3's room on the secure unit. Continued review revealed Resident #3 reported Resident #4 attacked her. Interview with CNA #1 on 2/21/18 at 2:45 PM, on the secure unit, revealed .she (Resident #4) would wander all the time .people would get upset with her so we had to watch her . Interview with Licensed Practical Nurse #2 on 2/21/18 at 3:00 PM, on the secure unit, revealed .she (Resident #4) constantly walked she would walk up to the table and pick up a cup that belonged to someone else and take a drink .we had to constantly keep an eye on her .she just didn't have a clue of her surroundings or others personal space .that's what would get her into trouble . Interview with the Director of Nursing on 2/21/18 at 6:30 PM, in the conference room, confirmed the facility failed to protect Resident #1 and Resident #3 from abuse during resident to resident altercations.",2020-09-01
3785,STARR REGIONAL HEALTH & REHABILITATION,445277,886 HWY 411 NORTH,ETOWAH,TN,37331,2017-02-22,222,D,1,0,IXF411,"**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 ensure a resident was free of chemical restraints used as means of convenience and discipline for 1 resident (#1) of 10 residents reviewed. The findings included: 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 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. Further review revealed Resident #1 required extensive assistance for transfer, dressing, and hygiene/bathing. Medical record review of a nursing progress note dated 11/6/16 at 8:50 PM, written by Licensed Practical Nurse (LPN) #2, revealed .(Resident #1) called to be gotten out of bed right now .it was time to smoke .told by aide it would be a few minutes .got mad and asked to speak to nurse .this nurse did try to explain to resident that other residents were still being put to bed and that we would get him up .stated he didn't care about them that he was going to smoke .stated he was gonna knock my head off and to get out of his way that he was getting up NOW by himself and going to smoke and we couldn't stop him .exhibited actions that suggested he was gonna try to get up and I asked resident to wait .an aide was found and resident was assisted grudgingly to be helped into his chair. Resident came up hall demanding to be let out to smoke .explained it was gonna be a few minutes .Security just happened to be making rounds and resident saw him and stated he 'didn't give a (expletive) if we called the police or not we were not gonna stop him from smoking' and said he would tear up as much as possible till he got what he wanted .new order for [MEDICATION NAME] (sedative medication) 5 mg (milligrams) IM (intramuscular) was received and given . Further review of the progress notes revealed LPN #2 documented [MEDICATION NAME] 5 mg IM was administered at 9:50 PM. Review of the note, documented by LPN #2, revealed the resident's response the medication was .Resident was somewhat calmer 30 minutes after injection. Once he was taken out to smoke. Review of the facility's investigation witness statement dated 11/7/16 and completed by the Occupational Therapist (OT) revealed the resident reported to the OT .The red headed nurse said I couldn't have any coffee, (LPN #2). I went off on them last night .I pushed my call light and waited and waited so I was gonna get up myself .(Resident #1 reported to the therapist) The nurse said 'I have 9 other patients to take care of also.' (Resident #1) reported after dinner he was in dining room and the security guard told him he will be getting a shot because of his behaviors .(Resident #1) reported the nurse stated 'you're going to take that shot no matter what' . Review of the facility's investigation revealed an interview was conducted by the Director of Nursing (DON) with Resident #1 on 11/7/16. Review revealed .(Resident #1) stated the red headed nurse (LPN #2) came in and he told her he wanted up to smoke and get coffee .she (LPN #2) told him no and he said would get himself up .(Resident #1) stated the other girls (Certified Nurse Aides (CNAs)) got him some coffee and he went to the dining room .(Resident #1) stated nurse (LPN #2) came in and told him he was going to get a shot . Resident #1 stated, after two CNAs came in and helped him transfer to his wheelchair, he went up to the nurses desk where he told LPN #2 all she did was sit all night. Resident #1 stated the CNAs got him some coffee and he went to the dining room where he watched TV and the security guard came and sat with him. Later the nurse came in and told him he was going to get a shot and the security guard, two CNAs and LPN #2 gave him the shot. After the shot the security guard sat with him and he continued to watch TV. He stated CNA #4 then took him out to smoke. Review of the facility's investigation witness statement dated 11/7/16, completed by LPN #2, revealed LPN #2 stated the CNAs were putting residents to bed and she was passing medications at 8:50 PM. LPN #2 stated she told Resident #1 he would have to wait to go smoke because they were still putting residents to bed. The resident stated he didn't care and he was going to smoke. LPN #2 stated she asked the resident to be patient but he said to get him up now before he knocked my head off. The resident stated if I didn't get him up he would get up by himself and threw the covers back and started grabbing his legs to pull them toward the edge of the bed. The nurse told him again to be patient because she couldn't get him up by herself. LPN #2 went and got assistance to get Resident #1 out of bed. LPN #2 then went back to the nurses' station, charting, when Resident #1 came up the hall and demanded to go smoke. LPN #2 told the resident again it was going to be awhile. LPN #2 stated the resident then stated if he couldn't do what he wanted to do he was going to mess[***]up. Review of the statement revealed, .(LPN #2) called the physician and got an order for [REDACTED].#2) went and got two CNAs and the security guard and lifted the resident up in a semi-standing position so I could give him the shot . Review of the facility's investigation witness statement dated 11/8/16, completed by the Security Guard, revealed .(Resident #1) was complaining about not having a smoking break and the nurse was saying his smoking was not a priority and other resident needs would have to be taken care of before his break .(Resident #1) became more agitated and swinging his left arm at the nurse who was standing on his left side .(resident) continued to be upset and cursing the nurse and at that time (Resident #1) was notified he had lost his smoking time for the rest of the night .after I returned from my rounds I was requested to assist with the shot .I went to the dining room where (the resident) was sitting .About 5-10 minutes later 3 nurses entered and told (Resident #1) the doctor had ordered a shot .(the resident) resisted vigorously but the nurse was able to administer the shot in his left hip .(the resident) calmed down almost immediately . The security guard stated when he had been sitting and talking with Resident #1, the resident appeared calm. Review of the facility's investigation witness statement dated 11/9/16, completed by CNA #4, revealed .(CNA #10) came to me and said (LPN #2) was ready to give (Resident #1) the shot .(LPN #2) told (Resident #1) she had a shot for him to calm him down .We sat him back down in the chair then (LPN #2) said something like that will teach you a lesson .(LPN #2) then stated there would be no smoking tonight . CNA #4 stated she did take the resident out to smoke. While outside CNA #4 stated she told Resident #1 she was sorry that all this happened. Medical record review revealed no documentation of distress by the resident and no changes in behavior or mood were noted. Review of a psychotherapy note on 11/10/16 revealed the resident was managing his previous symptoms well and there was no change in his mental health. During an interview with CNA #4 on 2/16/17 at 11:30 AM, in the Board Room, CNA #4 stated, at shift change, the day shift nurse stated Resident #1 wanted to get up on the last round to smoke, and LPN #2 replied they were not going to get him up. CNA #4 stated when the resident's call light went off and he wanted up, CNA #4 reported to LPN #2. LPN #2 went into Resident #1's room and CNA #4 went into another resident's room. CNA #4 stated she overheard both of them screaming at each other from Resident #1's room. LPN #2 came and asked CNA #4 to get assistance to get the resident up or he was going to attempt to get up himself. The resident was helped out of bed by two CNAs. The resident requested coffee and the CNAs went to the break area to make fresh coffee. While making the coffee, the CNAs overheard Resident #1 and LPN #2 arguing again. CNA #4 stated later CNA #10 came and got her to give the resident a shot. Resident #1 was sitting in the dining room calmly, and the security guard and CNA #9 assisted with positioning the resident for administration of the shot. After the shot, LPN #2 made a comment you're not in charge or you'll realize who is in charge. Resident #1 continued to sit in the dining room to watch TV. CNA #4 later took the resident out to smoke and then the two CNAs helped him to bed. CNA #4 stated the resident apologized for his behavior to the CNAs, but not for his behavior with LPN #2. Interview with Resident #1 on 2/16/17 at 2:25 PM, in his room, revealed he .got into it with the red headed nurse .after getting out of bed I went to the nurses station and me and (LPN #2) had a few more words .(LPN #2) came in and told me she was giving me a shot to calm down .it took 5 people to give me the shot . Interview with CNA #9 on 2/21/17 at 7:15 AM, in the Board Room, revealed she was at another nurses' station on the evening of 11/6/16, when LPN #2 came to get her for help. Continued interview revealed .(LPN #2) told (Resident #1) he had just earned himself a [MEDICATION NAME] shot .(CNA #9) went into the dining room (Resident #1) was watching TV and when (LPN #2) came in (the resident) said .you are not giving me a (expletive) shot . Interview with the Administrator and the DON on 2/22/17 at 11:15 AM, in the Board Room, confirmed LPN #2 administered a sedative medication ([MEDICATION NAME] - a chemical restraint), to Resident #1.",2020-02-01
3788,STARR REGIONAL HEALTH & REHABILITATION,445277,886 HWY 411 NORTH,ETOWAH,TN,37331,2017-02-22,323,G,1,0,IXF411,"**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 execute a safe transfer using an assistive device (gait belt), which resulted in a fractured right shoulder with pseudosublixation (partial separation) requiring immobilization, for 1 resident (#7), of five residents reviewed for accidents, of 10 sampled residents, which resulted in harm to Resident #7. The findings included: Medical record review revealed Resident #7 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 was severely cognitively impaired and unable to complete the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of two for transfers, and was totally dependent on 2 staff members for dressing and hygiene/bathing. Medical record review of the resident's plan of care dated 11/17/15 revealed .Transfers - Assist X (times) 2 with use of gait belt. Avoid use of lift . Medical record review of an Order Summary Report run on 2/1/17, revealed an order dated 8/23/16, .2 Person assist with Gait Belt (Do not use lift) every shift . Medical record review of a nurse's note dated 1/31/17 at 4:56 PM, revealed .CNAs were putting the resident to the bed when they heard a pop .examined her and it appears the right affected shoulder may have dislocated. I called (physician) and received orders for an xray . Medical record review of the X-ray report dated 1/31/17 revealed, .suspect fracture of the humeral head/neck and inferior subluxation of the humeral head . Review of a facility investigation witness statement dated 1/31/17, completed by Certified Nurse Aide (CNA) #3, revealed, at 4:30 PM, .(CNA #7) and I asked (Resident #7) if she wanted to lay down and she said yes. We took (Resident #7) to her room and changed her into a gown. We picked (Resident #7) up under her arm and by the waist line of her pants. During the middle of her transfer we heard a loud pop and immediately laid her down and checked her, we notified our nurse. I was looking at (Resident #7) shoulders because they looked different and asked my nurse if that was normal . Review of a facility investigation witness statement dated 1/31/17, completed by CNA #7, revealed at 4:30 PM, .Me and my partner took (Resident #7) into her room to lay her down and change her. We put her into a gown we picked her up under her arm and by the pants waist line. During the transfer we heard a loud pop. We layed (Resident #7) down and checked her to make sure everything was alright. We notified .our nurse .Her right shoulder looked different then before . Medical record review of a physician's orders [REDACTED].use a gait belt (with) all transfers - use of 2 (or more) staff . Medical record review of a Progress Noted dated 1/31/17 at 8:16 PM, revealed, .New orders for gait belt to transfer and to use 2 or more staff members . Medical record review of a physician's orders [REDACTED].N.O. (new order) for sling & swath . Medical record review of a computed tomography (CT) report dated 2/1/17, revealed, .Proximal humeral fracture as described with inferior subluxation of the humeral head . Medical record review of a physician's progress note dated 2/1/17 revealed .right shoulder is not dislocated but there is a subluxation noted . Medical record review of a physician's orders [REDACTED].Continue sling to Rt (right) arm .Obtain xray of right shoulder in 7 to 10 days . Observation of Resident #7 on 2/16/17 at 9:30 AM, revealed the resident was up in her wheelchair self-propelling around the dining room. Continued observation revealed the resident was pleasantly confused and unable to answer questions. Telephone interview with CNA #3 on 2/16/17 at 10:55 AM, revealed she and CNA #7 were transferring Resident #7 to the bed when they heard a pop. Continued interview revealed .two CNAs always transfer (the resident) due to she is very fragile and doesn't stand well . Further interview revealed both CNA #7 and #3 had a hand under each of the resident's arms and had hold of the resident's pants waistband to transfer the resident. Continued interview revealed .this is how we transfer (the resident) .did not know we should have used a gait belt . Continued interview revealed CNA #3 was unaware a gait belt was to be used for transfers for Resident #7 and confirmed a gait belt was not used during the transfer of Resident #7 on 1/31/17. Interview with CNA #7 on 2/21/17 at 2:00 PM, in the Board Room, revealed on 1/31/17 the resident was in the hallway and the CNA asked the resident if she wanted to lie down. Continued interview revealed .(Resident #7) can say yes or no .we (CNA #3 and #7) took the resident into her room to lie her down .we raised her good arm to remove the shirt and then removed the shirt from her bad arm and put a clean gown on .we lifted (the resident) up close to the bed with each having 1 hand under an arm and the other hand on the waistband of the (resident's) pants .we stood her up with her left foot touching the floor and heard a pop sound .(the resident) made no sound and had no changed facial expressions .we laid (the resident) down and examined her and went to report to the nurse .(the resident) fell to sleep and did not show any signs of pain .the shoulder just did not look normal .we lifted her the same as we always have lifted her with no problems in the past . Further interview revealed .never thought of using a gait belt before . Interview with the Director of Nursing (DON) on 2/16/17 at 11:00 AM, in the Board Room, confirmed the resident was to be transferred by two staff persons and with use of a gait belt, and the two CNAs failed to use a gait belt while transferring Resident #7 to bed on 1/31/17, resulting in injury to the resident.",2020-02-01
5772,BLOUNT MEMORIAL TRANS CARE CTR,445404,2320 EAST LAMAR ALEXANDER PKWY,MARYVILLE,TN,37804,2015-12-02,309,E,1,1,TFV511,"**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 follow Physician's Orders for 4 (#187, #361, #360, #359) residents of 13 residents reviewed for medications of 29 sampled residents. The findings included: Medical record review revealed Resident #187 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to a Long term Care Facility on 8/28/15. Medical record review of a Physician's Order dated 8/3/15 revealed .change parameters on .Humalog 5 units to hold if BG (Blood Glucose) less than 150 . Medical record review of the Insulin Administration Record dated 8/5/15 revealed .Humalog 5 units tid (three times a day) .Hold if BG less than 150 .1600 (4:00 PM) .BG Level .185 .Units .0 . Review of a facility investigation dated 8/11/15 revealed .Medication order was to change parameters on .Humalog 5 units .Hold if less than 150 .insulin sheet was not re-written when new order was received .suggest to prevent similar occurrences .re-write all changes to insulin orders . Interview with the Director of Nursing (DON) on 12/2/15 at 8:00 AM, in the conference room confirmed the facility failed to follow Physician's orders for the Humalog Insulin. Interview with Licensed Practical Nurse (LPN) #2 on 12/2/15 at 10:45 AM, in the conference room confirmed the original order .was only to give if BG was greater than 200, it was highlighted, then below on same insulin form it had hold if BG less than 150, was not sure which one to go by, and did not check the physician's orders. Medical record review revealed Resident #361 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged home on[DATE]. Medical record review of the Nursing Assessment-Weekly dated 4/17/15 revealed .Denies pain at this time . Medical record review of a Physician's Order dated 4/20/15 revealed .[MEDICATION NAME] to area of pain on back daily, off at HS (bedtime) . Review of a facility investigation dated 4/21/15 revealed .Event Date: 4/21/15 .Medication order: [MEDICATION NAME] Patch to area on back in AM-off in HS .pt (patient) (with) chronic back pain .what caused this occurrence .misplaced medication .nightshift nurse found patients [MEDICATION NAME]es in a lower drawer with an arrival date of 4/20/15 on the package. The two previous shifts had marked the medication as not given, med not available . Medical record review of the back of the Medication Administration Record [REDACTED].[MEDICATION NAME] Patch not available . Medical record review of the Nursing Note dated 4/22/15 revealed .no c/o (complaint of) pain or discomfort . Medical record review of the Nursing Assessment-Weekly dated 4/22/15 revealed .Frequency of pain .occasionally . Medical record review of a Physician's Progress Note dated 4/23/15 revealed .c/o lumbar pain .started during hospital-attributes to uncomfortable beds and chair .[MEDICATION NAME] helped (at) (hospital)-ordered but not available from pharmacy . Medical record review of the Nursing Assessment-Weekly dated 4/29/15 revealed .Denies pain at this time . Interview with LPN #1 on 12/1/15 at 4:15 PM, by telephone confirmed the [MEDICATION NAME] was not available, waited for it to come from pharmacy, was told the [MEDICATION NAME] was found that night or the next day. Interview with the DON on 12/2/15 at 9:00 AM, in the conference room confirmed the Physician's orders had not been followed for the [MEDICATION NAME] Patch. Interview with LPN #2 on 12/2/15 at 10:40 AM, in the conference room confirmed did not apply the [MEDICATION NAME] as ordered by the Physician. Medical record review revealed Resident #360 was admitted to the facility on [DATE] and was discharged on [DATE] to the hospital with [DIAGNOSES REDACTED]. Review of facility, General Event Data, dated 1/19/15 revealed .Event Date: 1/14/15 .Comments: Orders not signed off or faxed pharmacy. Chart placed back in the rack before orders were signed off. Caught on chart check at 0300 (3:00 AM) . Medical record review of the Physician's Orders dated 1/14/15 revealed .D/C (Discontinue) Potassium 99 mg (milligram) order [MEDICATION NAME] (water pill) 40 mg po (by mouth) X (time)1 today- after therapy in am, start [MEDICATION NAME] 20 mg po daily X 5 days KCL (Potassium Chloride) 40 meq (milequivalent) PO X 1 today - after therapy . Medical record review of the MAR for (MONTH) (YEAR) revealed on 1/14/15, Resident #360 failed to receive the [MEDICATION NAME] 40 mg and the Potassium 40 meq after therapy as ordered by the Advanced Practice Nurse (APN). Interview with the Registered Nurse/Administrator on 12/2/15 at 7:45 AM, in the conference room confirmed Resident #360 failed to receive her dose of Potassium and [MEDICATION NAME] as ordered by the APN on 1/14/15. Medical record review revealed Resident #359 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #359 was discharged home on[DATE]. Medical record review of the Physician's Orders dated 2/26/15 revealed .Change times on [MEDICATION NAME] beginning tomorrow to 10 AM & (and) 4 PM . Medical record review of the MAR for (MONTH) (YEAR) revealed .[MEDICATION NAME] TAB (tablet) 20mg Sub (substitute) for: [MEDICATION NAME] 1 tablet PO (by mouth) twice daily . Continued review revealed the 0800 (8:00 AM) was crossed off and 1000 (10:00 AM) was written in, also 2000 (8:00 PM) was crossed through and 1600 (4:00 PM) was written in. Continued review revealed the box to be initialed as given for the 4:00 PM however, the 8:00 PM dose was not initialed as given but had an X in the box indicating the medication should not be given. Interview with the Administrator on 12/2/15 at 7:55 AM, in the conference room revealed the [MEDICATION NAME] order was not transcribed correctly and therefore the 8:00 PM, [MEDICATION NAME] on the 26th was not given as ordered by the APN due to the box having an X in it.",2018-12-01
3787,STARR REGIONAL HEALTH & REHABILITATION,445277,886 HWY 411 NORTH,ETOWAH,TN,37331,2017-02-22,282,G,1,0,IXF411,"**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 implement care plan interventions to prevent injury while transferring a resident, which resulted in a fractured right shoulder with pseudosublixation (partial separation) requiring shoulder immobilization, for 1 resident (#7), of five residents reviewed for accidents, of 10 sampled residents, resulting in harm to Resident #7. The findings included: Medical record review revealed Resident #7 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 was severely cognitively impaired and unable to complete the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of two for transfers and was totally dependent on 2 staff members for dressing and hygiene/bathing. Medical record review of the resident's care plan, initiated 11/17/15, revealed the resident had a self care deficit and an intervention initiated 11/17/15 was, .Transfers - Assist X (times) 2 with use of gait belt. Avoid use of lift . Continued review of the care plan revealed the resident was a fall risk and an intervention for prevention of falls, initiated on 11/29/16, was .2 person lift with gait belt . Medical record review of a nurse's note dated 1/31/17 at 4:56 PM, revealed .CNAs were putting the resident to the bed when they heard a pop .examined her and it appears the right affected shoulder may have dislocated. I called (physician) and received orders for an xray . Medical record review of the X-ray report dated 1/31/17 revealed, .suspect [MEDICAL CONDITION] head/neck and inferior subluxation of the humeral head . Review of a facility investigation dated 1/31/17 revealed Certified Nursing Assistant (CNA) #3 and CNA #7 .stated around 4:30 PM the 2 CNA's went to change (Resident #7) and lay her down to bed .CNAs took the resident to her room and changed her into a gown .picked the resident up under her arm and the waist line of her pants .During the middle of the transfer the CNAs heard a 'loud pop' and immediately laid (the resident) down and checked her .CNAs noted when looking at the shoulders they looked different .CNAs notified the nurse and the Director of Nursing (DON) of the incident . Telephone interview with CNA #3 on 2/16/17 at 10:55 AM, revealed she and CNA #7 were transferring Resident #7 to the bed when they heard a pop. Continued interview revealed .two CNAs always transfer (the resident) due to she is very fragile and doesn't stand well . Further interview revealed both CNA #7 and #3 had a hand under each of the resident's arms and had hold of the resident's pants waistband to transfer the resident. Continued interview revealed .this is how we transfer (the resident) .did not know we should have used a gait belt . Continued interview revealed CNA #3 was unaware a gait belt was to be used for transfers for Resident #7 and confirmed a gait belt was not used during the transfer of Resident #7 on 1/31/17. Interview with CNA #7 on 2/21/17 at 2:00 PM, in the Board Room, revealed confirmed a gait belt was not used to transfer the resident and the CNA .never thought of using a gait belt before . Interview with the DON on 2/16/17 at 11:00 AM, in the Board Room, confirmed the 2 CNAs failed to follow the resident's care plan for use of a gait belt during transfers, resulting in harm to Resident #7 on 1/31/17. Refer to F323",2020-02-01
952,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,225,E,1,0,SMVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of facility investigation, and interview, the facility failed to report timely, thoroughly investigate, and/or report investigative findings within 5 working days to the State Agency for an injury of unknown origin for 2 residents (#4, #7) and allegations of abuse for 1 resident (#5) of 7 residents reviewed for abuse. The findings included: Medical record review revealed Resident #4's Admission notes revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review admission Minimum Data Set (MDS), dated [DATE] revealed the resident was cognitively impaired, and required limited assistance with bed mobility, transfers and walking in her room. The resident had no functional limitations to range of motion, but was not steady in transfers, and was only able to stabilize herself during transfers with staff assistance. She was assessed as at risk for falls. Review of Resident #4's Progress Notes dated 5/14/17 revealed the resident complained of pain to her left leg. No falls were documented in the record, and the Progress Notes included there was no visible injury. Continued review of the Progress Notes dated 5/15/17 revealed the resident was sent out to the hospital for evaluation when the pain worsened. She returned from the hospital the same day with changes to her [MEDICATION NAME] order and a [DIAGNOSES REDACTED]. Review of Resident #4's Progress Notes dated 5/18/17 revealed on 5/17/17 the resident continued to have pain in the left leg. The nurse Noted visual quivering of thigh muscle left. Pt (patient) reports increased pain with muscle spasms. Review of Resident #4's Progress Notes dated 5/19/17 revealed, the resident was sent to the ER (emergency room ) for eval (evaluation) and TX (treatment) r/t (related to) recent x-ray of the left hip. Review of the x-ray report dated 5/19/17 revealed the resident had increased pain, decreased mobility, and the x-ray showed an acute [MEDICAL CONDITION] femoral neck. Review of the Progress Notes the resident was hospitalized from [DATE] - 5/24/17 when she was readmitted to the facility with new [DIAGNOSES REDACTED]. Review of Resident #4's clinical record revealed no evidence as to how the left [MEDICAL CONDITION] occurred. Review of the facility's investigation revealed an investigation was started on 5/19/17 when the x-ray indicated a [MEDICAL CONDITION] and there was no known etiology. The allegation of injury of unknown origin was not reported to the State Survey Agency (SSA) until 3 days later, on 5/22/17. Further review of the facility investigation by the survey team on 9/18/17 revealed no evidence the investigation was completed or that the facility had made a determination as to abuse/neglect which was not reported to the SSA within 5 working days. The investigation was not thorough and did not provide sufficient information to make a determination as to whether abuse/neglect occurred. The investigation contained no evidence of any interviews with staff to determine if they might have knowledge of how the fracture happened. The only interview documented was with the resident. There was no evidence the facility came to a conclusion about the injury of unknown origin, reported the results to the SSA or took action to prevent the potential for further abuse/neglect of the resident. Interview with the Director of Nursing (DON) on 9/18/17 at 2:27 PM verified the packet of information provided to the survey team was the complete investigation into Resident #4's injury of unknown origin. The DON stated the facility became aware of the injury of unknown origin on 5/19/17; however, it was not reported to the SSA until 5/22/17. When asked why the allegation of injury of unknown origin was not immediately reported to the SSA, the DON stated, I think I was trying to figure out what happened. The DON stated, at the time of Resident #4's injury, My understanding was that we had 24 hours (to report). The DON stated she believed the regulation is going to 2 hours in (MONTH) (2018), so we're doing that now. Further interview with the DON revealed she was unaware the changes regarding time frames for reporting had been in effect since (MONTH) 8, (YEAR), and the allegation of injury of unknown origin resulted in serious harm was required to be reported within 2 hours. The DON stated the facility was currently only submitting a follow-up to the SSA within 5 working days if the initial allegation included a named perpetrator of abuse or neglect. She stated she was unaware the 5-day follow-up report was required for all allegations, including injuries of unknown origin, that were reported to the SS[NAME] Further interview with the DON revealed staff should have been interviewed and witness statements should have been completed as part of a thorough investigation. She confirmed there were none present in the investigation file, and stated she could not explain why these were not done. The DON, who stated she was the abuse coordinator, stated, That's my frustration, I've not been shown how to complete an investigation. Interview with the DON on 9/18/17 at 2:35 PM revealed she had additional information about why the allegation of injury of unknown origin had not been reported timely. She stated staff learned of the fracture of unknown source on 5/19/17, which was a Friday. The DON stated the nurse who received the x-ray did not report the fracture to her, and she was unaware of the incident until she returned to work on Monday, 5/22/17. The DON stated when the nurse received the x-ray results indicating a fracture with no known origin, she should have called the DON, Quality Assurance (QA) Nurse, Administrator, or Social Worker. The DON stated any of these 4 staff could have reported the allegation to the SS[NAME] However, No one called and the administrative staff were not aware until the following Monday, when they then reported the allegation to the SS[NAME] Review of facility policy, Abuse Prevention, revised 4/1/17 revealed it did not include correct time frames for reporting abuse. This policy indicated, Any alleged incident of abuse or neglect will be reported immediately to the Administrator/Assistant Administrator and to other officials in accordance with State Law within 5 working days of the event. Further review of this policy revealed Any patient event that is reported to any staff .will be considered as possible abuse if it meets any of the following criteria .Any indication of possible willful infliction of injury to include unexplained bruising. Any partner having any knowledge .is required to report either verbally or in writing to their supervisor, to the facility social worker, the Director of Nursing/ADON (Assistant Director of Nursing) or the Administrator/Assistant Administrator. On 9/19/17 at 10:00 AM, the DON provided a second policy, titled, Abuse, Neglect, Misappropriation Protocol, revised 2/17. Interview with the DON revealed this was the correct abuse policy for the facility, and the policy dated 4/1/17 had been provided in error. Review of the second policy provided by the facility revealed To help with recognition of incidents of abuse, the following definitions of abuse are provided .Injury of unknown source is defined as an injury that meets both following conditions: a. source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of: i. the extent of the injury; or ii. the location of the injury (e.g. the injury is located in an area not generally vulnerable to trauma. The first policy provided time frames for the reporting of reasonable suspicion of a crime, depending on the seriousness of the event that leads to the reasonable suspicion, review of the second policy revealed it did not address time frames for reporting allegations of abuse and neglect to the SS[NAME] Further review of the second policy revealed, The individual conducting the investigation will, as a minimum .Interview staff members on all shifts who have had contact with the resident during the period of the alleged incident; Interview the resident's roommate, family members, and visitors .Witness reports will be reduced to writing, Witnesses will be required to sign and date such reports. Note: A copy of such reports must be attached to the Resident Abuse Investigation Report .The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, and the local police department, if necessary, and other as may be required within five (5) working days of the reported incident. Medical record review revealed Resident #5 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a facility investigation dated 6/27/17 at 2:45 PM revealed Certified Nurse Aide (CNA) #6 was providing incontinence care to Resident #5 when 2 Licensed Practical Nurses (LPN's) and another CNA entered the resident's room and CNA #6 told them she was not catering to her ass, the resident got on her nerves, and she had been on the call light all day. Continued review of a handwritten statement from LPN #5 dated 6/27/17 revealed, .walked into (Resident #5's) room and (CNA #6) was changing her. I overheard her say to (Resident #5) .she doesn't have time for this[***]and I'm not catering to her ass. She gets on my nerves, she's been on the call light all day .(CNA #6) said 'f*** this[***] packed up the dirty linen and left .(Resident #5) was in tears . Continued review revealed handwritten statements from LPN #6 and CNA #8 dated 6/27/17 corroborated the same details. Further review of a statement from Resident #5 taken by the DON on 6/28/17 revealed the resident stated, .(CNA #6) kept yelling at her and saying she cannot keep coming in there and change her .when other staff named (LPN #6, LPN #5, and CNA #8) were in the room that (CNA #6) stated she didn't have time to cater to her ass . Interview with the DON on 9/20/17 at 3:36 PM in the conference room when asked what time the above allegation of abuse was reported to the State Agency, the DON stated, I reported it on 6/27/17 at 6:29 PM. Continued interview confirmed the facility failed to timely report allegations of abuse for Resident #5. Medical record review revealed Resident #7's [DIAGNOSES REDACTED]. Review of the resident's most recent quarterly assessment, dated 8/23/17, revealed the resident was moderately cognitively impaired and totally dependent on staff for transfers and required extensive staff assistance for bed mobility. Medical record review of the Progress Notes revealed on 8/5/17, the resident was noted to have a large brised (bruised) area to right upper chest that was dark in coloration. Unknown etiology, patient is unable to recall. On 8/6/17, the Progress Notes indicated the bruise to the Rt (right) shoulder, upper arm and chest area has gotten worse. The Physician was contacted and ordered x-rays D/T (due to) bruising and [MEDICAL CONDITION] (swelling) and pain. Review of the Progress Notes on 8/7/17 revealed the x-rays were negative for fractures; however, the bruising continues to spread down her rt arm and side. Staff continued to monitor and document the bruising was still present as of 9/18/17. Further review of Resident #7's medical record revealed no evidence the origin of this injury had been identified. Review of the facility investigation revealed no evidence this injury of unknown origin was immediately reported to the SSA when the bruising was identified on 8/4/17 at 7:30 PM. In addition to the failure to immediately make the initial notification of an injury of unknown origin to the SSA as required, the facility also failed to complete and report the findings of an investigation to the SSA within 5 days. Review of the facility's investigation revealed it was not completed within 5 days of its initiation. There was no evidence of any investigative activity after 9/3/17 until 9/18/17 (after intervention by the survey team) when a handwritten note was added to the investigation form that read ecchymosis (discoloration of the skin resulting frombleeding underneath typically caused by bruising) discussed with nursing director - not related to abuse/neglect by facility. Further review of the investigation revealed it was not thorough. Review of Progress Notes dated 8/16/17 indicated the bruising was s/p (status [REDACTED]. The investigation form was marked Yes to indicate Employee statements completed and reviewed. However, review of the investigation reports provided by the facility revealed there were no employee statements documented. Interview with the DON on 9/18/17 at 1:13 PM revealed she was the facility's abuse coordinator. When asked about Resident #7's injury of unknown origin, she stated, It didn't ring a bell and she would have to investigate further. She confirmed she had provided all investigations completed and reported to the SSA since the last standard survey in (MONTH) (YEAR), and Resident #7's injury of unknown origin was not included in them. Additional interview with the DON on 9/18/17 at 2:50 PM confirmed the injury of unknown origin had never been reported to the SSA, and there had been no investigation into the cause of the bruising to Resident #7's chest. At 2:52 PM, the DON then provided different information, by stating the facility's QA Nurse had an open investigation into the injury of unknown origin, and That's why it wasn't reported. At this time, she provided the investigation report. Additional interview with the DON on 9/18/17 at 3:00 PM confirmed the investigation was not thorough or complete. She stated the QA nurse did not have witness statements, saying, She just talked to staff. Further interview with the DON revealed the facility had not reported the allegation because it was still open, there was no evidence of any action being taken to investigate the injury of unknown origin from 9/3/17 until 9/18/17, when the survey team asked for the record. Observation during an assessment on 9/18/17 at 3:00 PM revealed Resident #7 had bruising across her chest. The resident, who had a right [PR[NAME]EDURE], had purple-grey bruising across this area and the tissue was very firm. The bruising then extended from the right breast area, across the midline to the areola of the left breast. From the sternum to the left breast, the area was yellow-green (indicative of old bruising) that was soft-feeling. In addition, there was one dime-sized area by the areola that was dark purple in color. A Nurse Practitioner (NP), who was present during this assessment, palpated the area and stated it felt like there had been a hematoma (a solid swelling of clotted blood within the tissue) that had bled and was now healing. An attempt was made to interview the resident during the assessment; however, she answered nonsensical words to various questions which were asked and could not tell how the bruising had occurred. An additional attempt to interview the resident on 9/18/17 at 5:06 PM was also unsuccessful, as the resident mumbled inaudible words in response to questions. Interview with the QA Nurse on 9/18/17 at 3:05 PM revealed whenever a resident had a bruise, skin tear or other injury, the nurse on the unit would start the investigation paperwork. It would then be reviewed by the Unit Manager, who would, in turn, send it to the QA nurse and Then I look at it. If the nurse can determine what caused them, then I don't have to do an investigation. However, she continued, Resident #7 was completely different. She stated the bruise just showed up out of nowhere and We didn't know how it happened. She stated the facility knew the bruise was not related to a fall because the resident could not get up off the floor without staff assistance and no falls had been reported. The QA Nurse stated she had not documented any interviews with staff. When asked why, she stated if the resident had said someone had been mean, I would have gotten written statements. But I didn't think it was abuse so I didn't. I just get it (written statements) when there is abuse. Further interview with the QA nurse revealed she did not know how the injury occurred and stated, Maybe when they (staff) were turning her - she is prone to bruising. Further interview with the QA Nurse on 9/18/17 at 3:05 PM confirmed she had never reported the injury of unknown origin to the SS[NAME] When asked why, she stated, I hadn't concluded my investigation so it had not yet been reported. The QA Nurse could not provide an explanation as to why the investigation had not been completed in the 46 days since the bruising was first identified. The QA Nurse could also provide no rationale as to why, if it was still being investigated, there had been no action taken from 9/03 - 9/18/17. During this interview, the QA nurse stated, I'll be honest - I did not know what the time frame was for reporting when the investigation was initiated. She added, I do now - we have 2 hours to report. I found that out about 2 weeks ago.",2020-09-01
1158,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2017-07-12,225,D,1,1,33I011,"**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 timely report allegations of abuse for 1 resident (#47) for 35 residents reviewed. The findings included: Medical record review revealed Resident #47 was admitted to the facility on [DATE], readmitted on [DATE], and 1/6/17 with [DIAGNOSES REDACTED]. Review of a facility investigation dated 11/11/16 revealed the following: the date of occurance was 11/8/16 (Tuesday), reported by the Resident to the Social Worker on 11/11/16. The allegation of abuse was reported to the State Agency on 11/18/16 at 3:35 PM by the Administrator. Interview with the Administrator on 7/12/17 at 1:40 PM in the Administrator's office confirmed allegations of abuse reported on 11/11/16 by Resident #47 were not reported to the State Agency until 11/18/16. Continued interview confirmed the facility failed to timely report allegations of abuse.",2020-09-01
2657,MT JULIET HEALTH CARE CENTER,445439,2650 NORTH MT JULIET ROAD,MOUNT JULIET,TN,37122,2017-06-07,157,D,1,0,W48711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of facility investigation, and interviews, the facility failed to notify the physician and the resident representative of a change in condition in physical status for 1 resident (#1) of 3 residents reviewed for notification of change; and failed to notify the physician of a missed medication for 1 resident (#4) of 3 residents reviewed for medication administration of 13 sampled residents. The findings included: 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 the resident scored 09/15 (moderately cognitive impaired) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of one for transfer, dressing, and hygiene/bathing. Review of the facility's investigation dated 2/10/17, not timed, revealed on 2/10/17 at approximately 2:45 PM a Certified Nursing Assistant (CNA) found Resident #1 with her leg elevated on a chair. Continued review revealed .she was complaining about her right leg was hurt .I told the nurse .we put her to bed . Further review revealed the resident's knee was assessed by Licensed Practical Nurse (LPN) #4 and was observed as swollen and LPN #4 instructed the CNA to lay the resident down and elevate the leg on a pillow. Medical record review of a Nurse's note dated 2/10/17 at 3:46 PM revealed the resident complained of pain in her right knee. Continued review revealed there was some swelling in the right knee with no bruising or redness noted. Further review revealed .there is a small scrape on the right knee which appears to be old .no open areas noted .right knee is tender and slightly warm to the touch . denied falling or hurting herself . Medical record review of a Nurse's note dated 2/12/17 at 9:55 PM revealed the resident's right knee was swollen. Continued review revealed .pedal pulses equal and strong .knee elevated with a pillow .note placed in NP (Nurse Practitioner) box and 24 hr (hour) report book .knee is very tender to the touch .denied falling or hurting herself . Medical record review of a NP progress note dated 2/13/17 revealed .right knee that has progressively been bothering her for a couple weeks. It is large, swollen, and quite warm to touch .extremely tender to touch and rom (range of motion) is limited .right knee is approx. twice the size of left knee, very warm to touch, extreme tenderness to palpation - with patient stating she fell 2 weeks ago, and the knee cap is the source of all pain .assessment right knee bursitis probable, right knee pain . Medical record review of the x-ray ordered on [DATE] of the right knee revealed .arthroplasty (knee replacement) at the RIGHT knee .distal femoral diaphyseal fracture displaced laterally by approximately one half bone width .mild overriding of fracture fragments .mild anterior angulation. Prosthesis appears intact .Impression: distal femur fracture . Review of the facility's investigation dated 2/14/17 revealed a written statement by LPN #4. Continued review revealed .CNA stated Friday 2/10/14 the resident's right knee was swollen. She brought the resident to her room and I assessed her and the right knee .the resident showed no signs of distress or SOB (shortness of breath). The right knee was swollen and slightly warm to the touch. The resident denied pain but when I touched it she did complain of some pain .put the resident in bed and elevated the right knee .assessed the resident some more .Pedal pulses were equal and strong. Over the weekend the resident's granddaughter and daughter were in visiting and made aware of swollen knee .daughter informed me that the resident had a past right knee replacement and the knee swells from time to time. The resident denied falling or hurting herself. I asked the resident did she fall or hurt herself and the resident's daughter (named) asked the resident as well. Both times the resident responded, 'No' .over the weekend the resident denied pain. I kept the resident in bed over the weekend with her right leg elevated . Review of facility's investigation dated 2/24/17 staff were counseled related to .Failure to deliver services. Resident change in condition nurse did not follow up. Contact physician, family as appropriate . Interview with the NP on 6/5/17 at 1:00 PM, in the Social Services office, revealed when she saw the resident on 2/13/17 the knee was red, hot, and swollen and an x-ray was ordered. Telephone interview with LPN #4 on 6/6/17 at 1:05 PM revealed Resident #1 did not complain of pain or show signs/symptoms of distress. Further interview revealed LPN #4 kept the resident in the bed over the weekend with the leg elevated. Continued interview revealed, when asked by the writer if LPN #4 should have reported the incident, the LPN replied she would report the incident to the physician based on the level of care the resident required and if the resident showed any signs of distress. Continued interview revealed LPN #4 did not notify the resident's family timely. Interview with the Regional Nurse Consultant on 6/6/17 at 3:05 PM, in the Social Services office, confirmed the nurse did not immediately notify the physician or the resident's family, regarding the change of status for Resident #1. Interview with the NP on 6/7/17 at 10:15 AM, in the Social Services Office, confirmed she would have expected to be notified of the resident's change in condition. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 scored 08/15 (severely cognitive impaired) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required limited assistance for transfer and hygiene/bathing with extensive assistance for dressing. Medical record review of a Patient Medication Profile (physician's recapitulation of Resident #4's medications), not dated, revealed on 7/23/16 a physician's orders [REDACTED].[MEDICATION NAME] (pain medication) 25 MCG (micrograms) APPLY 1 PATCH [MEDICATION NAME] (through the skin) Q (every) 3 DAYS . Medical record review of the paper Controlled Drug Receipt/Record/Disposition Form revealed the [MEDICATION NAME] Patch was signed out on the controlled substance log and administered on 5/7/17, 5/11/17, 5/13/17, and 5/16/17. Further review revealed the medication was due on 5/10/17, but was not given until 5/11/17. Interview with the Interim Director of Nursing (DON) on 6/5/17 at 3:25 PM, in the Social Services office, confirmed the facility failed to administer Resident #4's [MEDICATION NAME] Patch when due on 5/10/17. Further interview confirmed the medication was administered on 5/11/17 (24 hours later) and the nurse should have advised the physician of the missed dose of medication.",2020-09-01
4035,BROOKHAVEN MANOR,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2016-12-07,241,J,1,0,E8N511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of facility investigation, interview, and observation, the facility failed to provide timely incontinence care to maintain dignity for 3 dependent residents (#65, #21, and #45) of 43 residents reviewed. The facility's failure placed residents #65, #21, and #45 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) and was likely to place any resident requiring assistance with incontinence care in Immediate Jeopardy. The facility was cited F-241 at a scope and severity of J which constitues Substandard Quality of Care. The Immediate Jeopardy was effective 2/7/16 and is ongoing. The findings included: Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #65 scored a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. Continued review revealed the resident required extensive assist with transfers and dressing, total assist for hygiene and bathing, and was always incontinent of bowel and bladder. Review of a facility investigation revealed Resident #65 reported on 2/7/16 she told Certified Nursing Aide (CNA) #14 she was soaking wet and requested to be changed. Continued review revealed CNA #14 told the resident he was 2 hours behind, and he could not get to her, and the CNA did not return. Registered Nurse (RN) #2 reported the incident to the Director of Nursing (DON) on 2/8/16. The DON interviewed Resident #65 and the resident confirmed the incident. Interview with Resident #65 on 11/9/16 at 11:40 AM, in the resident's room, revealed .can't remember exactly what he (CNA #14) said .didn't have time or something like that .it made me feel like I wasn't important . Interview with the DON on 12/5/16 at 2:17 PM, in the conference room, confirmed care was not provided to maintain the resident's dignity. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual MDS dated [DATE] revealed Resident #21 had a BIMS Score of 15, indicating the resident was cognitively intact. Continued review revealed Resident #21 was total dependence of one person for mobility, transferring and toileting, and the resident was always incontinent. Medical record review of the Resident's Care Plan dated 10/18/16 revealed .Self Care Deficit r/t (related to) [MEDICAL CONDITION] .Provide Peri care with each incontinent episode .Assist with ADLs (activities of daily living) as needed . Medical record review of the Interdisplinary Progress Notes dated 12/12/15 revealed .Resident is paraplegic and requires total care for ADL's .Incont (incontinent) of B&B (bowel and bladder) c (with) peri care q2 (every 2 hours) + (and) PRN (as needed) . Observation on 11/30/16 at 8:08 PM, on the 400 hall, revealed Resident #21 had a strong urine odor. Continued observation revealed the resident's pants had a wet stain from her groin to the knee. Observation with Licensed Practical Nurse (LPN) #14 on 11/30/16 at 8:12 PM, in the 400 hallway, revealed Resident #21 was in a wheelchair, with a wet saturation on the resident's pants, from the groin to, down the inner thigh, to her knees. Interview with Resident #21 on 11/30/16 at 8:08 PM, on the 400 hall, confirmed .They haven't changed or clean me yet . Interview with CNA #19 on 11/30/16 at 8:09 PM, on the 400 hall, revealed .I haven't changed her yet tonight (shift began at 6:00 PM) . Continued interview confirmed the resident had to wait 3 hours to be provided incontinence care. Interview with LPN #14 on 11/30/16 at 8:12 PM, on the 400 hall, confirmed .She is soiled . Further interview confirmed the resident's dignity was not maintained. Medical record review revealed Resident #45 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 3/25/16 and updated 9/15/16 revealed .Self Care Deficit .Assist with ADL's as needed .Has incontinence bowel & (and) bladder .Incontinence (care) to be provided by staff as needed . Medical record review of the Quarterly MDS dated [DATE] revealed Resident #45 had a BIMS Score of 15, indicating the resident was cognitively intact. Continued review of the MDS revealed the resident was total dependence with toileting. Further review revealed the resident was always incontinent. Medical record review of the Nursing Weekly Summary dated 11/19/16 revealed .ass (assist) x (times) 2 c (with) ADL's + t/f's (transfers) .Incont of B+B peri care PRN + q2 (every 2) .non amb (ambulatory) is in the bed most of the time . Medical record review of a Nurse Aide's Information Sheet undated, revealed .Incontinent .Total care .Geri chair .Lift to chair .(mechanical lift) . Interview with Resident #45 on 11/30/16 at 8:18 PM, in the resident's room, confirmed . I haven't been changed since before supper before 5 (5:00 PM) . Telephone interview with CNA #18 on 12/1/16 at 8:38 PM, confirmed she was assigned to Resident #45 on the night of 11/30/16. Continued interview confirmed she finished her first dry rounds (checking for bowel and urinary incontience needs) after 10:00 PM. Further interview confirmed the resident had to wait more than 3 hours to be changed. Continued interview confirmed Resident #45's dignity was not maintained. Interview with the Director of Nursing on 12/5/16 at 2:17 PM, in the conference room, confirmed she expected the residents to be checked and changed at least every 2 hours. Interview with Resident #45 on 12/7/16 at 9:39 AM in the resident's room, revealed .It is what it is. What can you do about it .",2019-11-01
1690,WILLOW RIDGE CENTER,445284,215 RICHARDSON WAY,MAYNARDVILLE,TN,37807,2018-06-06,600,D,1,1,HNSK11,"**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 prevent abuse for 1 resident (#24) of 3 residents reviewed for abuse, of 28 residents reviewed. The findings included: Medical record review revealed Resident #24 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual Minimum (MDS) data set [DATE] revealed the resident had moderately impaired cognition and required extensive assistance of 1-2 staff with all activities of daily living. Medical record review of the care plan dated 3/20/15, revised 2/11/16, 5/14/18, revealed .Resident was involved in altercation. He was the victim .Mother to sign book at nursing station and nurse to assess if the resident is cursing and/or yelling-mother to visit with resident in lobby. If not cursing and/or yelling -mother can visit with resident in room . Review of the facility investigation revealed on 5/14/18 at 1:00 PM Certified Nurse Assistant (CNA) #1 heard Resident #24 yelling, then heard his mother tell him to .shut up and quit yelling. She looked in room and saw mother slap resident on upper shoulder area .mother said she did slap him because he was yelling and cussing Observation and interview with Resident #24 on 6/6/18 at 8:45 AM in his room revealed he was in his bed, and said he wanted to go home, he could take care of himself, and go back to doing his old job. Interview with CNA #1 on 6/6/18 at 9:30 AM in the conference room confirmed she witnessed Resident #24's mom tell the resident to shut up, and slap his shoulder on 5/14/18. Interview with the Administrator on 6/5/18 at 2:30 PM in the conference room confirmed the incident happened. Continued interview confirmed the mother had slapped Resident #24's shoulder before.",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
1889,HILLCREST HEALTHCARE CENTER,445316,111 E PEMBERTON STREET,ASHLAND CITY,TN,37015,2017-08-10,225,E,1,1,D1L611,"**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 thoroughly investigate an allegation of abuse for Resident #120 and failed to timely report allegations of abuse for 3 residents (#119, #120, #16), and for 1 resident (#24) injury of unknown origin of 14 residents reviewed for abuse or injury injury of unknown origin. The findings included: Medical record review revealed Resident #120 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility investigation revealed the following: On 8/27/16 Resident #120 slapped Resident #57 on the face. On 8/31/16 Resident # 120 slapped Resident #57 on the face. Continued review revealed a guest/visitor witness statement dated 8/27/16 revealed the incident happened in the dining room. There were no witness statements for the 8/31/16 incident. Interview with the Administrator on 8/8/17 at 9:44 AM in the Administrator's office confirmed there were 2 instances of Resident #120 slapping Resident #57. Continued interview revealed the first instance was on 8/27/16 and the second instance was on 8/31/16; both incidents were reported to the State Agency in the same report on 9/2/16. Further interview revealed there was one witness statement documented on 8/27/16 by a visitor and there were no witness statements documented on 8/31/16. Continued interview confirmed the facility failed to report the alleged abuse in the required 24 hour time period for (YEAR) to the State Agency and the facility failed to thoroughly investigate the incident on 8/31/16. Medical record review revealed Resident #119 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility investigation revealed the resident reported the allegation of staff to resident verbal abuse, to the facility staff on 8/21/16 at 11:30 PM and the allegation was reported to the Administrator on 8/22/16 at 9:00 AM. Further review revealed the facility staff failed to report the allegation to the administrative staff immediately. Interview with the Administrator on 8/9/17 at 3:04 PM in the Administrator's office confirmed the allegation of verbal abuse was reported to facility staff on 8/21/16 at 11:30 PM by Resident #119. Continued interview revealed the allegation was reported to the State Agency on 8/23/16. Further interview confirmed the facility failed to timely report an allegation of abuse for Resident #119 in the required time of 24 hours for (YEAR) to the State Agency and failed to report to the facility administration immediately. Medical record review revealed Resident #16 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility investigation report dated 8/2/17 for an allegation of staff to resident physical abuse for Resident #16 revealed the facility reported the allegation to the State Agency on 8/2/17 within the 2 hour required timeframe to the State Agency. Further review revealed the facility failed to complete the investigation within 5 days in (YEAR) as required by the State Agency. Interview with the Administrator on 8/10/17 at 3:38 PM at the nurse's station confirmed the allegation of abuse was reported on 8/2/17 to the State Agency for Resident #16. Continued interview confirmed the facility failed to timely complete the investigation. Medical record review revealed Resident #24 was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nurse's note dated 5/10/17 at 1:57 PM revealed a purple bruise was discovered on Resident #24 on 5/10/17. Continued medical record review revealed administration was notified. Review of the facility investigation revealed the following: On 5/10/17 Resident #24 was found to have a bruise measuring 1 x 3 inches with a scratch down the center of the bruise (an injury of unknown origin). The resident stated it probably happened during transfer, but was unable to tell definitively how it occurred. Continued review revealed the bruise was found on 5/10/17 with no definitive cause. Further review revealed the facility first reported the incident with Resident #24's injury of unknown origin to the state agency on 5/16/17. Interview with the Administrator on 8/8/17 at 8:14 AM in her office revealed when the Administrator was asked when the incident involving Resident #24 took place, she stated on (MONTH) 10. Further interview revealed when asked when the incident was reported to the State Agency, she stated it looks like (MONTH) 16th. When asked if the incident was reported to the State Agency within the required 2 hour period, the Administrator confirmed the facility failed to report Resident #24's injury of unknown origin to the state agency timely.",2020-09-01
1483,TRI STATE HEALTH AND REHABILITATION CENTER,445263,600 SHAWANEE RD,HARROGATE,TN,37752,2019-10-02,600,D,1,0,2TVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of facility investigations, and interviews, the facility failed to ensure 2 residents (#1 and #2) were free from abuse of 6 residents reviewed for abuse. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 8 (moderate cognitive impairment). Continued review revealed the resident required 1 person assist for bed mobility, transfers, and personal hygiene. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #'2s Significant Change in Condition MDS dated [DATE] revealed a BIMS score of 2 (severe cognitive impairment). Continued review revealed the resident required limited assist for bed mobility, transfers, and total dependence for personal hygiene with 1 person assist. Review of a facility investigation dated 9/11/19 revealed Resident #1 was observed seated in his wheelchair and Resident #2 was standing behind Resident #1's wheelchair. Continued review revealed both residents were hitting each other on their forearms. Further review of a witness statement by Laundry Aide #1 revealed .heard what sounded like smacking .saw (Resident #2) had a hold of (Resident #1's) wheelchair as (Resident #1) was trying to get into his (Resident #1) room . Continued review of a witness statement by Registered Nurse (RN) #2 revealed .witness (witnessed) 2 RSDS (residents) fighting . (Resident #1) was seated in a wheelchair and (Resident #2) was standing. Both RSD (residents) where hitting each other's hands and fore-arms . Interview with RN #1 on 10/2/19 at 9:30 AM, in the nurses' station, revealed .(Resident #1) doesn't like people in his personal space .does not like to have his wheelchair pushed . Interview with Certified Nurse Assistant (CNA) #4 on 10/2/19 at 11:00 AM, in the Administrator's office, revealed .(Resident #2) will get aggravated . In summary, Resident #1 and Resident #2 were observed hitting each other on 9/11/19 and the facility failed to protect the residents from abuse.",2020-09-01
2180,STANDING STONE CARE AND REHAB,445363,410 W CRAWFORD AVENUE,MONTEREY,TN,38574,2019-11-07,744,E,1,0,HWML11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of facility investigations, review of facility documents, interview, and observation, the facility failed to provide dementia care to prevent escalation of behaviors for 4 residents (#6, #4, #3, #7) of 9 residents with Dementia reviewed. The findings included: Medical record review revealed Resident #6 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Medical record review of Resident #6's Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The resident had verbal behavioral symptoms directed toward others 1 to 3 days during the assessment period. Medical record review of Resident #6's Comprehensive Care Plan revised 9/22/19 revealed, .Behavioral: At risk and or active behavior problems: Physically Abusive, Verbally Abusive, Resists Care, As evidenced by: yelling at staff, resists eating and taking medication, multiple delusions and swatting at staff .Anticipate needs and provide them before the resident becomes overly stressed .Explain care to resident in advance .Invite and encourage activity programs consistent with residents interest .Re-approach resident later when he becomes less agitated .Reinforce positive behavior . Medical record review of Resident #6's Nurses' Progress Note dated 9/27/19 at 2:32 AM, revealed .Elder has been getting in and out of bed frequently this shift yelling help me, help me, would not let CNA (Certified Nursing Assistant) change bed linens after elder urinated in the bed . Medical record review of Resident #6's Nurses' Progress Note dated 9/27/19 at 10:39 PM, revealed .Elder very agitated, slapping at CNAs when changing elder's clothes, yelling out frequently . Medical record Review of Resident #6's Nurses' Progress Note dated 9/29/19 at 8:32 PM, revealed .Resident had increased anxiety and attempted to follow 2 sons out of room during their visit r/t (related to) wanting to see his spouse .able to redirect resident from seeing spouse and gave nightly medications without complications. Assisted to bed without difficulty . Medical record review of Resident #6's care plan revealed it was revised on 10/8/19 with .Geri-psych (geriatric psychiatric facility) to eval (evaluate) . Medical record review of Resident # 6's Nurses' Progress Note dated 10/9/19 at 8:35 PM, revealed .Resident had one on one contact with his roommate this shift. Resident was screaming and yelling at roommate whom did not understand what all the commotion was and was hit for not responding quickly enough . Review of a facility investigation dated 10/9/19 revealed CNA #5 was walking down the hall and heard a lot of noise coming from a room. CNA #5 entered the room and saw Resident #6 screaming at Resident #5 about the thing spitting cold air and then Resident #6 hit Resident #5 in the chest. Review of an Event Report dated 10/9/19 revealed Resident to resident altercation .resident (#5) was struck by his roommate (Resident #6) .roommate (Resident #5) was yelling at the resident (#6) and the resident (#6) didn't understand and his roommate (Resident #5) struck him .What precipitated the altercation .the air conditioner .Immediate Actions .separation of residents and room change . Medical record review revealed Resident #6's care plan was revised on 10/9/19 with .Consult with telehealth psych (psychiatric) services and medication adjustment provided .Change to a private room . Interview with CNA #5 on 11/4/19 at 12:20 PM, in the conference room, revealed .CNA had asked me to help her. I came out of a room and I heard a commotion in their room (Resident #6 and #5). I think (Resident #5) was up going to the bathroom. I heard (Resident #6) yelling at (Resident #5) to turn that machine that was blowing that cold air out. I looked in the room and saw (Resident #6). (Resident #6) was sitting on the side of his bed and when (Resident #5) walked by him, he hit (Resident #5) in the chest. (Resident #5) didn't understand what (Resident #6) wanted him to do and (Resident #6) was agitated because (Resident #5) didn't understand him . Continued interview revealed (Resident #6) didn't have the strength to hit him hard .he meant to hit him . Medical record review revealed Resident #5 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's Quarterly MDS dated [DATE] revealed a BIMS score of 3, indicating severe cognitive impairment. Interview with the Administrator on 11/7/19 at 2:00 PM, in the conference room, confirmed Resident #6 was witnessed deliberately hitting Resident #5 in the chest. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's Care Plan dated 8/16/17 revealed .Active and/or at risk for Behavior Problems Has hx (history of) and potential for rejection of care, delusions and wandering behaviors .Anticipate care needs and provide them before the resident becomes overly stressed .Invite and encourage activity programs consistent with residents interest .Re-approach resident later, when she becomes agitated .when resident has a delusional episodes, redirect and reorient as able . The care plan was revised on 12/5/17 with . Address wandering behavior by walking with resident, redirect from inappropriate area, and engage in diversional activity . Review of Resident #4's Quarterly MDS dated [DATE] revealed a BIMS score of 6, indicating severe cognitive impairment. The resident had delusions, verbal behavioral symptoms directed toward others, rejection of care, and wandering, occurring 1 to 3 days during the assessment period. Review of a facility investigation dated 10/8/19 revealed Resident #4 hit Resident #3 on 10/8/19. Resident #4 approached the nurse and stated .there was a man in that woman's room and she wanted the cops called. The nurse went to the room and removed Resident #3 from the room. Upon exiting the room Resident #4 hit Resident #3. Review of a facility Incident Report dated 10/8/19 revealed .(Resident #3) was wandering into another resident's room .(Resident #4) noticed this and became agitated, screaming at (Licensed Practical Nurse (LPN) #8) that she needed to get him out and she was going to call the police. As (LPN #8) was assisting (Resident #3) out of other Elder's room and came to doorway (Resident #4) from the hall punched his arm .when interviewed (Resident #3) had stated 'she goosed me and it felt good' . Resident #4's care plan was revised on 10/8/19 with .At risk and/or active behavior problems: Physically/Verbally Abusive, refusing care and wandering as evidenced by: hitting/punching other elders verbally abusive towards staff and others .Intervene as needed to protect the rights and safety of others, approach in calm manner, divert attention, remove from situation and take to another location as needed .Investigate/Monitor need for psychological/psychiatric services .Monitor behavior episodes and attempt to determine underlying causes .Provide non-confrontational environment for care .Place elder on 15 minute checks for 24 hours to monitor behaviors .Obtained order to increase [MEDICATION NAME] (benzodiazepine given for anxiety) . Medical record review revealed Resident #3 was admitted on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's Comprehensive Care Plan dated 6/25/19 and revised 8/21/19 revealed .Behavioral At risk and/or active behavior problems of being combative due to dx (diagnosis) of Dementia .Administer and monitor the effectiveness and side effects of medications .Anticipate care needs and provide them before the resident becomes overly stressed. Provide music for the elder to listen to when becoming overly stressed .divert attention, remove from situation and take to another location as needed . Review of Resident #3's Quarterly MDS dated [DATE] revealed a BIMS score of 3, indicating severe cognitive impairment. Continued review revealed the resident had verbal behavior symptoms directed toward others, other behavioral symptoms not directed toward others, and wandering, occurring 1 to 3 days during the assessment period. Resident #3's care plan was revised on 9/24/19 with .At risk and/or active behavior problems: Verbally abusive and Wandering as evidenced by yelling out loudly cussing .Address wandering behavior by walking with resident; redirect from inappropriate areas; engage in diversional activities .explain care to resident in advance in terms resident can understand .Monitor need for psychological/psychiatric services .Provide non-confrontational environment for care .Re-approach later when he becomes less agitated .Report changes in behavioral status to MD . Observation of Resident #4 on 11/5/19 at 7:00 AM, in the Dining Room on Station 2, revealed the resident seated at a dining room table in a wheelchair. She was seated with 3 other residents and was pleasantly conversing with residents and staff. Observation of Resident #3 on 11/6/19 at 9:20 AM, in the hallway outside of his room, revealed the resident seated in a wheelchair. The resident was pleasant and no fearful or anxious behaviors were identified. The resident was self-propelling small distances in the hall but did not attempt to enter any resident rooms. Interview with LPN #8 on 11/5/19 at 10:55 AM, in the conference room, revealed the LPN was at the nurses' desk when Resident #4 came to the desk and said there is a man in that woman's room and I want the cops called. She (Resident #4) came from station 2 so I went down toward station 2 looking in rooms. The first room I came to (Resident #3) was in the room. He had gotten his wheelchair tangled up with another wheelchair. It looked like he had tried to turn around but got tangled up with a wheelchair in the room. The 2 ladies in the room were both sleeping and neither of them even knew he was in there. I got him untangled. As I was wheeling him out of the door, she (Resident #4) was sitting just out of my sight on the right side, outside the door. When I wheeled him (Resident #3) out, she (Resident #4) came up and with a closed fist and hit him (Resident #3) on his right upper arm. I pushed his wheelchair out of her reach. (Resident #4) said 'I didn't hit him' and I said '(Resident #4) I saw you'. Interview with the Administrator on 11/7/19 at 2:15 PM, in the conference room, confirmed Resident #4 was witnessed deliberately hitting Resident #3. Resident #3 had not been prevented from wandering into other female residents' room. Medical record review of Resident #4's Nurses' Progress Note dated 10/14/19 at 5:41 PM, revealed .Resident (with) increased behaviors of being verbally aggressive towards other residents. Attempted to roll towards another resident threatening to 'throw my hot coffee on you.' Separated and redirected resident away and made attempts to calm. Resident at another time attempted to swing out to hit another resident in the face, did not connect and was removed and redirected away with attempts to calm . Medical record review of Resident #4's Nurses' Progress Note dated 10/19/19 revealed .Res (Resident) (with) increased anxiety this shift. Res pacing hallways (in wheelchair) upset 'looking for her moma (momma) and daddy' .Res crying/yelling out 'oh Jesus come to me, Help me Jesus!' Fretting, wringing hands, frowned expression. Stating 'I'm just so nervous, I don't know what to do!' Res verbally aggressive (with) other res stating 'you don't belong here, Get outta here!' . Review of a facility investigation dated 10/28/19 revealed the Quality of life Director (QOLD) stated .when (Resident #7) was rolling up to the table (Resident #4) stated 'look here, here comes pumpkin head' and she (Resident #4) tried to make a slap at (Resident #7). (Resident #7) then smacked back at her and the two began swatting at each other both making physical contact . Continued review revealed the facility Administrator had viewed the facility camera and it did not appear the residents had hit hard and the residents were not close in proximity to each other. Both residents had been involved in resident to resident altercations previously. Medical record review of Resident #4's Care Plan revealed it was revised on 10/29/19 with .Psych NP (Psychiatric Nurse Practitioner) to eval (evaluate) and treat as indicate .Psych recommendation to discontinue [MEDICATION NAME] (antipsychotic medication) and start Rispirdol ([MEDICATION NAME] - antipsychotic medication) . Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Resident #7's Comprehensive Care Plan dated 5/4/18 revealed .Active and/or at risk for Behavior Problems: History and potential for aggressive behaviors during care d/t (due to) loss of independence wandering noted by nursing .Report to physician changes in behavioral status .Address wandering behavior by walking with resident .redirect from inappropriate area, engage in diversional activity .Provide opportunities for positive interaction, attention stop and talk with him as passing by .Administer and monitor the effectiveness and side effects of medications . Continued review revealed the care plan was revised on 5/17/19 with .altercation with another elder hit her on the arm .separated elder and sent to be evaluated by (geriatric psychiatric facility) . Medical record review of Resident #7's Quarterly MDS dated [DATE] revealed a BIMS score of 6, indicating severe cognitive impairment. The resident had physical behavior directed toward others, rejection of care, and wandering, occurring 1 to 3 days during the assessment period. Interview with the QOLD on 11/4/19 at 1:55 PM, in the conference room, revealed We were getting ready to play Jingo in the Dining Room. (Resident #4) was in the dining room setting at the back table with the other residents, and (Resident #7) entered the dining room, start rolling to the back table. They just don't appear to like each other. I've heard her (Resident #4) tell him (Resident #7) to get out of the dining room before and usually he just ignores her. Occasionally he might say something back, but they haven't been physically aggressive and I keep an eye on them. She said 'look here, here comes pumpkin head.' When she did, his eyes got big and I turned around to start toward them. But by then she had smacked at him, then he smacked back at her. They smacked back and forth and I said 'stop' and they both stopped. Interview with the interim Director of Nursing (DON) on 11/4/19 at 4:10 PM, in the conference room, revealed (Resident #4) was the aggressor. She struck at him first. His was a defensive reaction not an aggressive behavior. Interview with the Administrator on 11/7/19 at 1:30 PM, in the conference room, revealed Resident #4 was witnessed calling Resident #7 an inappropriate name and willfully striking out at Resident #7, and in defending himself they did make physical contact. Continued interview confirmed Resident #4 was the aggressor.",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
5617,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2016-01-05,333,D,1,0,8BJL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of facility policy, review of the facility investigation, and interview, the facility failed to prevent significant medication errors for 1 Resident (#8) of 5 residents reviewed. The findings included: Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of facility policy, Physician Orders, effective 11/30/14 revealed .All information received from the referring facility shall be reviewed .transcribe all orders from the transfer form to the facility Admission Physician order [REDACTED]. Review of the facility investigation dated 9/22/15 revealed during routine chart reviews conducted by the Director of Nursing (DON) and Corporate Nurse, a transcription error was noted on the resident's initial nursing home orders in which the facility had failed to transcribe orders for [MEDICATION NAME] (an injectable anticoagulant) onto the initial Physician's admission orders [REDACTED]. Continued review revealed the facility had received faxed copies of transfer forms and Physician order [REDACTED]. The Unit Manager transcribed the resident's initial nursing home admission orders [REDACTED]. Continued review of the investigation revealed the facility determined the resident had missed 20 doses of [MEDICATION NAME] between 9/2/15 and 9/22/15. Interview with the Corporate Nurse on 12/7/15 at 12:22 PM, in the conference room revealed the facility self-identified the omitted medication and classified it as a significant medication error. Interview with the Administrator on 12/7/15 at 12:31 PM, in the conference room confirmed the Unit Manager had failed to follow facility policy related to transcription of Physician order [REDACTED].#8.",2019-01-01
3395,NASHVILLE CENTER FOR REHABILITATION AND HEALING LL,445512,832 WEDGEWOOD AVENUE,NASHVILLE,TN,37203,2018-12-20,660,J,1,0,E5NC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of hospital and home health records, staff interviews and facility policy review, the facility failed to ensure 2 of 8 sampled residents (#10 and #18) had a safe and effective discharge. Cognitively-impaired Resident #10 was discharged from the facility after completion of skilled services. The resident was unable to perform activities of daily living (ADLs) independently, before she was discharged home. Resident #10 was not provided additional community resources, such as food, home and community-based services, and 24/7 caregiver support, to ensure Resident #10 was safe to be discharged back to the community. These failures resulted in Immediate Jeopardy when Resident #10 was admitted to the hospital 3 days after discharge from the facility and an additional resident (#18) was placed at risk for more than minimal harm that was not Immediate Jeopardy when the facility failed to provide clear discharge planning and referrals to community services. On 12/20/18 at 10:57 AM in the conference room, the Administrator was notified verbally that Immediate Jeopardy began on 4/24/18, when cognitively-impaired Resident #10 with a [DIAGNOSES REDACTED]. Three days later, the resident was transported from home to a local hospital due to an increase in confusion. The Immediate Jeopardy was removed onsite after receipt of an acceptable Allegation of Compliance on 12/20/18 at 5:13 PM when the facility implemented corrective actions and was effective from 4/24/18 - 12/20/18. A partial extended survey was completed on 12/20/18. The findings include: Review of the facility policy, Discharge Planning undated, noted .Residents of the facility will be evaluated for discharge potential and plans upon admission, and discharge planning will be initiated at that time. Discharge planning will be part of the comprehensive care plan and will be addressed during Interdisciplinary Care Plan Meetings, based on significant change in resident's medical condition, or at any other time requested by the resident/representative .Consideration will be given to care-giver support person's availability and capacity/capability to perform required care to ensure the safety of the resident .The resident/representative will be involved in discussion regarding the results of the evaluation . Medical record review of the Admission Record revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Brief Interview for Mental Status (BIMS) on the 14 day Admission Mental Data Set (MDS) revealed a score of was 3 out of 15. During Resident #10's stay, she received skilled services such as physical and occupational therapies. Per review of the Progress and Skilled Therapy Notes, there was no indication the staff instructed the resident with medication management or the preparation of food in anticipation of her return home. There was no information a home visit was made by the therapy department as well to ensure a safe discharge home. Medical record review revealed there was no discharge plan identified in the medical records for Resident #10. There was no evidence the resident, or her family member were involved in the development of a discharge plan during her stay in the facility. There was no documented evidence that additional community services were set up to assist the resident in a successful transition back home. There was no evidence in the clinical record social services or the interdisciplinary team (which includes staff from skilled therapy) met with the resident and her representative to identify that she might be more appropriate for long-term care placement verses being discharged home alone. Review of the Physical Therapy .Progress Report dated 3/27/18 revealed a Physical Therapy Assistant (PTA) noted a discharge plan for Resident #10 was yet to be determined. Medical record review dated 4/3/18 revealed the Physical Therapist (PT) documented the anticipated discharge plan was unknown due to the cognitive decline Resident #10 experienced and there was a decrease in safety limiting her ability to return home alone. Medical record review revealed the Physical Therapist documented on 4/10/18 that the anticipated discharge plan for the resident was possible nursing home placement with psych services or a memory care unit. Medical record reveiw revealed the Physical Therapy Assistant documented on 4/17/18 the anticipated discharge plan for the resident was yet to be determined. Medical record review of a Physical Therapy note dated 4/23/18, by the Physical Therapist revealed the resident was to be discharged home with her boyfriend with 24 hour supervision and noted the prognosis to maintain her current level of functioning was good with .strong family support . Review of a Care Plan dated 4/11/18 identified Resident #10 with impaired mobility. The goal identified was for the resident improve in her ADL status. Further review revealed the resident's placement was indentified as short term, placement. The goal for Resident #10 was for her to be safely discharged with eligible community services/resources. The interventions included to assist the resident with application for community resources; to educate the resident and/or designated representative about community resources; to identify community support for the resident; to make appropriate referrals as needed, such as homecare; provide resident and/or designated representatives with teachings as needed such as medications, diet or adaptive equipment; and, social worker to meet with the resident and/or designated representative to identify needs for discharge. There was no evidence in the medical record interventions were established for the resident to be safely discharged to her own home. Review of a Transfer/Discharge Report dated 4/24/18 identified multiple medications were prescribed to Resident #10, including an antipsychotic for her [DIAGNOSES REDACTED].ambulates w/ (with) assist (assistance), ext (extensive) assist with ADLs . There was no staff name identified on this document. Medical record review of Resident #10's revealed the Home Health records dated 4/24/18 revealed the Registered Nurse who made the home visit documented, .NUTRITION .Probably inadequate - rarely eats a complete meal and generally eats only about 1/2 of any food offered .malnourished .impaired decision-making . Continued review of the Home Health records dated 4/26/18 revealed the PT who went to the resident's home noted, .She is referred to home health .There is a friend .who lives in the building and checks on her. Otherwise, she lives in her apartment by herself . Medcial record review of hopsital records revealed 3 days after discharge, Resident #10 was transported to the Emergency Department (ED). The ED notes dated 4/27/18 stated, This patient is an [AGE] year-old female past medical history of [REDACTED]. The patient is unable to give a history .It is unclear what the relationship was with a family member who dropped her off. All he told people in triage was that her nerves are bothering her .The patient's friend return (sic) to the emergency department. He states that she has been in a nursing home for the past 4 or 5 weeks. She was discharged from the nursing home to her home on Tuesday. He states that she lives alone. He states that she has been having difficulty walking and inability to take care of herself. He states that she does not make her feed (sic). He tried to bring her fever (sic) when he can. He states that she has had no complaints up until today and all she said is that she is nervous and needs to go see a doctor . Review of another ED note dated 4/27/18 revealed, .History is obtained from the chart given no family is present and the patient is unable to provide information. It appears that the patient was recently admitted ,[DATE]-[DATE] for acute [MEDICAL CONDITION] (abnormal levels of electrolytes, water, and vitamins that possibly affect brain function) which was thought to be secondary to a Urinary Tract Infection [MEDICAL CONDITION]. At that time, she had a Montreal Cognitive Assessment (M[NAME]A) which is a screening tool to determine mild cognitive function. The results of the M[NAME]A were 5 out of 30 which indicated the resident had severe dementia. She was discharged to a SNF (skilled nursing facility). Reportedly, she recently got back home on 4/24 to her house where she lives alone. The friend told the ED that she has had difficulty getting around the house, has not been eating, and is unable to care for herself . Interview with the Director of Social Services on 12/18/18 at 11:09 AM in the social service office with the Social Service Aide #148 revealed the Director of Social Services verified Resident #10's male friend (who was not the resident representative or next of kin) was the person who would prepare the resident meals and stayed with her occasionally. The Director of Social Services stated there was a meeting with the resident and the male friend. The Director of Social Services said the man would make decisions for the resident. The Director of Social Serives stated the resident did have cognitive issues, but she was able to give permission to speak with her friend. She confirmed she did not have information on the meeting that was held with the resident and her friend. Per Director of Social Services, she said the man said the resident (#10) was the one who cared for her and would prepare her meals and stay with her occasionally. The Director of Social Services was asked about discharge planning and stated there was no other information other than the baseline care plan. The Director of Social Services provided a typed, undated written document, which was not part of the electronic medical record. The information contained in this note revealed the resident was referred to a home health agency on 4/20/18 and the home health agency performed a home visit on 4/24/18. The note further stated home health discharged her since the resident was admitted to the hospital on [DATE]. This document was signed by the Director of Social Services. Interview with the Director of Social Services, the Physical Therapist #112 and the Rehabilitation Director #109 on 12/19/18 at 10:59 AM in the conference room the Utilization Review (UR) process and the Interdisciplinary (IDT) meets and goes over the entire case load and anticipates discharges and any anticipated needs. Per members in this interview, they said they discuss safe discharges. Rehabilitation Director #109 said that her staff did note the resident had cognitive impairments and identified the resident had a friend who stayed with her and both were adamant about returning home. Per Physical Therapist #112, the friend did not participate in caregiving training before the resident was discharged back home. Both Rehabilitation Director #109 and Physical Therapist #112 could not provide a reason why care giving training was not provided to the friend. All present during this interview said that if Resident #10 was left by herself there would be safety issues. They stated a home visit was not completed by therapy prior to the resident's discharge. Per Rehabilitation Director #109, the discharge was not safe based on the resident's cognition. An interview was conducted with the interim Director of Nursing (DON) #11 on 12/20/18 at 1:20 PM in the conference room revealed her expectation for the discharge process was all IDT members were all in agreement with the discharge. Review of the job description for the Director of Social Services, undated revealed there was no date identified on the document. The job description specifically stated, .assess all new residents upon admission and complete the social service initial admission notes, social history, social assessment, and discharge planning when appropriate .Coordinate discharge planning for appropriate residents .Document referral information and discharge disposition for the medical record .make referrals to other social service agencies such as home delivered meals and homemaker services as needed .create discharge packet with information for patients and families . Review of the job description for Physical Therapist, undated revealed there was no date noted on this document. The document specifically documented, .Recognizes and identifies patients' needs for imitations (sic) of services from other disciplines and consult with other professionals as needed .Provides advisory and consultative services to staff .Participates in patient care conferences and discharge planning . Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Care Plan initiated on 10/4/18 for impaired skin integrity and another care plan developed on 10/8/18 for nutritional problem for Resident #18. A baseline care plan was initiated on 10/5/18 and noted the resident was to be discharged back home to live with his family. Review of a Social Services Evaluation completed on 10/9/18 noted Resident #18's Brief Interview for Mental Status score was 6 out of 15 which indicated he was severely cognitively impaired. Review of the Progress Notes dated 10/30/18, revealed the Director of Social Services entered the following information into the clinical record, Resident #18, .was admitted to the facility on [DATE] with dx (diagnosis) of Benign (sic) neoplasm of meninges, [MEDICAL CONDITION], weakness, difficult walking, dysphasia, aftercare following surgery on the nervous system, and [MEDICAL CONDITION]. He was discharged home with wife on 10/16/18. He was alert and fairly well oriented at the time of discharge .Resident was scheduled to see is PCP (primary care physician) on day of discharge .Wife visited daily and was very supportive . There was no documentation that showed the resident might need home health or additional services after discharge, or if the resident's wife was the sole caregiver in the home. Interview with the interim DON #11 on 12/19/18 at 9:10 AM revealed her expectation is social services was to anticipate residents' needs, set-up home health and to prepare the resident to go home. The DSS was interviewed on 12/20/18 at 4:11 PM in the social service office regarding Resident #18. The DSS stated that she did not remember if home health was set-up for him. She said the resident wanted to be discharged home earlier than planned and he had a doctor's appointment scheduled on the date of his discharge which was on 10/16/18. The DSS stated, I would anticipate that physician would set up those services. The Immediate Jeopardy was removed onsite after receipt of an acceptable Allegation of Compliance (A[NAME]) on 12/20/18 at 5:13 PM when the facility implemented the following corrective actions: On 12/20/18, immediately after notification of the Immediate Jeopardy, the facility completed an audit on the residents due to be discharged from 12/19/18 through 12/20/18 for proper indications for discharge. The audit revealed no residents were scheduled to be discharged . On 12/20/18 at 11:48 AM, an in-service was provided to all administrative staff, regarding appropriate indications for discharge. One of the documents/training aides Criteria Determining the Need for Resident or Discharge or Transfer (Phase I) dated as revised 11/7/16, was provided to the staff for training. The document specifically stated .The facility must permit each resident to remain in the facility, and not transfer or discharge the resident unless .The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility .The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility .The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident .The health of individuals in the facility would otherwise be endangered .The resident has failed, after reasonable and appropriate notice, to pay (or to have paid under Medicare or Medicaid) a stay at the facility .The facility ceases to operate . The Administrator attached all educational materials and sign-in sheets provided to the staff during this period. An interview was conducted on 12/20/18 at 4:15 PM, with the Administrator. Also present was the interim Director of Nursing (DON) #11, current DON #12, the Rehabilitation Director #109, a Regional Director, Registered Nurse/Unit Managers (RN) #23 and RN #22. The Administrator said the staff present had completed re-education on the A[NAME]. The training was also provided during the morning meeting (12/20/18) and with all Unit Managers. All residents scheduled for discharge would be evaluated for potential barriers, such as unsafe discharge. If the facility determined an unsafe discharge, the physician, local police, and Adult Protective Services (APS) would be notified. The facility provided evidence that in-service training was provided to all administrative staff, to all staff included in discharge planning, and to the nursing staff. Social Services would follow up with all discharged residents or responsible party within 24 hours, then 72 hours, 14 days, and finally after 28 days as part of the facility's philosophy. During interview with DON #12 on 12/20/18, she verified the discharge training was discussed and implemented in the morning meeting (12/20/18) and with all Unit Managers. The Administrator or designee will conduct audits five times a week for eight weeks. The audit will then continue three times a week for four weeks, then weekly for four weeks. The results of the discharge audits will be discussed during the Clinical Start up meetings weekly and will be ongoing. Audits will be discussed in monthly Quality Assurance Performance Improvement meetings for six months.",2020-09-01
2188,HARRIMAN CARE & REHAB CENTER,445368,240 HANNAH ROAD,HARRIMAN,TN,37748,2020-01-15,623,D,1,0,JJIZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of hospital documentation, and interview, the facility failed to notify a resident/family in writing of a transfer and discharge for 1 of 5 (Resident #3) reviewed for discharge. Review of the medical record, showed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly Minimum Data Set ((MDS) dated [DATE], showed the resident had a Brief Interview of Mental Status Score (BIMS) of 15 indicating the resident was cognitively intact. Continued review showed the resident was on oxygen therapy. Review of the medical record showed Resident #3 was transferred to a local hospital for evaluation and treatment due to a change in mental status, difficulty waking and decreased blood pressure. Resident #3 was admitted to the hospital. Review of electronic communication between the facility and the hospital showed on 12/2/2019 the facility communicated to the hospital the facility would not accept Resident #3 back to the facility due to not being able to meet the resident's needs. During an interview on 1/15/2020 at 11:15 AM, Registered Nurse #1 confirmed she transferred Resident #3 to the hospital on [DATE]. Registered Nurse #1 confirmed the facility failed to provide the resident/ family with written notice of the resident's transfer. During an interview on 1/15/2020 at 3:12 PM, the Director of Nursing (DON) confirmed the facility failed to provide Resident #3 or Resident #3's family written notice of her transfer and discharge from the facility.",2020-09-01
3394,NASHVILLE CENTER FOR REHABILITATION AND HEALING LL,445512,832 WEDGEWOOD AVENUE,NASHVILLE,TN,37203,2018-12-20,622,J,1,0,E5NC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of hospital records, and staff interviews, the facility failed to ensure 1 of 8 residents (#10) had appropriate criteria to be discharged from the facility. Cognitively-impaired Resident #10 was discharged from the facility without documented overall improvement in the resident's cognition or functional status prior to her discharge home to live alone. The resident was unable to perform activities of daily living (ADLs) independently before she was discharged home. These failures resulted in Immediate Jeopardy when Resident #10 was admitted to the hospital 3 days after discharge from the facility. On 12/20/18 at 10:57 AM, the Administrator was notified verbally that Immediate Jeopardy began on 4/24/18, when Resident #10 was discharged home without proper indications for a facility-initiated discharge. Resident #10 had no improvement in her health including functional or cognitive status, was not a danger to herself or others, and the facility was capable of meeting her documented physical and emotional needs. Three days after discharge from the facility, Resident #10 was admitted to the hospital. The Immediate Jeopardy was removed onsite after receipt of an acceptable Allegation of Compliance (A[NAME]) on 12/20/18 at 5:13 PM. F-622 and F660. A partial extended survey was completed on 12/20/18. The findings include: Medical record review revealed Resident #10 was admitted to the facility on [DATE] from a local hospital with [DIAGNOSES REDACTED]. Continued review revealed the a sister as a contact with the facility. Review of a hospital General Medicine Discharge Summary dated 3/20/18 revealed Resident #10 was admitted to the hospital on [DATE] with Weakness and Altered Mental Status. The emergency department (ED) determined the resident had a Urinary Tract Infection [MEDICAL CONDITION] and began treatment with antibiotics. During the resident's hospitalization , she had a speech cognitive evaluation that revealed a low Montreal Cognitive Assessment (M[NAME]A) which is a screening tool to determine mild cognitive function. The results of the M[NAME]A were 5 out of 30 which indicated the resident had severe Dementia. Review of an admission Progress Note dated 3/20/18, revealed Resident #10 was admitted from a local hospital and presented to the facility with Generalized Weakness and Altered Mental Status. Continued review revealed the resident required extensive assistance with all ADLs and was incontinent of both bowel and bladder. Medical record review of the Care Plan initiated on 3/21/18 revealed Resident #10 was combative with staff, such as grabbing, slapping, and hitting them. The care plan identified the resident would wander into other resident rooms and would come out of her room naked. The interventions noted were to distract the resident with activities, to notify the physician of negative behaviors, redirect the resident, and for staff to approach the resident in a calm manner. Review of Physical Therapy (PT) Notes revealed on 3/21/18, Resident #10 had a friend who assisted the resident for years with transportation and documented the resident lived in an apartment alone. Review of Progress Notes on 3/26/18, revealed Resident #10 would yell and scream as loud as she could and would wander into other resident rooms and the resident had one-on-one monitoring during the day by staff. Review of a 14-day Admission Minimum Data Set (MDS) assessment for Resident #10 dated 3/27/18 revealed a Brief Interview for Mental Status (BIMS) score was a 3 of 15 and determined the resident was severely cognitively impaired. Continued review revealed the resident was normally understood by others and usually understood others. Further review revealed Resident #10 required extensive assistance with bed mobility and transfers with the assistance of 1 staff member, was noted to need limited assistance with eating with the assistance of 1 staff member, was able to move around in her room and the corridor, and required extensive assistance from 1 staff member. Medical record review of the Nursing Progress Notes dated 3/31/18 revealed Resident #10 was getting in and out of bed constantly, and exhibited behaviors such as kicking, yelling, spitting, going in to other resident rooms yelling and was difficult to redirect. Medical record review of a Nurse Practitioner (NP) note dated 4/6/18, revealed Resident #10 was sleeping better at night but remained agitated and combative with caregivers during the day. Medical record review of a Nurse Practitioner (NP) progress note dated 4/9/18 revealed .poor insight. Mental Status: confused and abnormal affect. Orientation: not oriented to time and place and to person. Memory: recent memory abnormal and remote memory abnormal . The NP noted the resident had a [DIAGNOSES REDACTED]. The NP also documeted Resident #10 was still agitated but there was some improvement noted. Review of a care plan initiated 4/9/18, revealed Resident #10 with cognitive impairment related to dementia. The goal noted the resident would be able to communicate basic needs daily. Review of a National Health Rehabilitation note written by a physician, noted to also be a Physiatrist (a physician who specializes in physical medicine and rehabilitation), wrote a note dated 4/10/18, documented Resident #10 required 1 on 1 supervision and that the resident was slightly less confused. The physician diagnosed the resident with failure to thrive while at home and she was appropriate for a secured dementia unit and could not participate meaningfully in therapy. The physician noted to continue physical and occupational therapy for conditioning. On 4/12/18, this same physician noted that he saw the resident on this date. The physician wrote the resident continued with a 1 on 1 sitter and would be appropriate for placement on a secured dementia unit. He noted a functional update in which the resident was able to ambulate .45 separate trials with contact guard assist and a rolling walker for 42 feet, 17 feet, 15 feet, 10 feet, and 84 feet. She performed sit to stand from her wheelchair to rolling walker with min (minimal) assist . The physician ordered to continue physical and occupational therapies for conditioning. On 4/17/18, the physician documented the resident's last therapy treatment was scheduled for 4/23/18 and her identified barriers were dementia, impulsivity, decreased safety awareness, and weakness. Review of the 30-day MDS assessment dated [DATE], revealed Resident #10 with no improvement in the BIMS score. The BIMS score was 3 out of 15 which determined the resident was severely cognitively impaired. Continued review revealed Functional Status identified the resident had improved; however, still required limited assistance of 1 staff member for bed mobility. For transfers, the resident required extensive assistance with 1 staff member. For walking in room and in corridor the resident required supervision with oversight and cueing by staff. For eating, the resident required set-up and 1 person assistance with meals. Record review of a NP progress note dated 4/19/18 revealed Psychiatric .poor insight. Mental Status: confused and abnormal affect. Orientation: not oriented to time, place or person. Memory: recent memory abnormal and remote memory abnormal . Continued medical record review of a progress note at 6:10 AM on 4/20/18, noted Resident #10 had not slept all night and needed to be redirected and offered activities. Medical record review of the progress notes dated 4/22/18, stated Resident #10 needed supervision with dressing, eating and drinking which included encouragement and cueing. Medical record review of the Progress Notes revealed Resident #10 was assessed by a Nurse Practitioner (NP) on 4/23/18, and documented the resident's insight was poor and that she was confused and not oriented to time, place, and person. Medical record review of the Physical Therapy Discharge Summary dated 4/23/18 revealed Resident #10's short and long-term goals were: required minimal assistance with bed mobility with 100 percent verbal cues; required functional transfers with minimal assistance with 100 percent verbal cues; would walk 20 feet with minimal assistance and 100 percent verbal cues; the resident's dynamic standing was fair with minimal assistance and was unable to shift her weight; and the resident was unable to follow commands. Record review of the Occupational Therapy Discharge Summary dated 4/23/18 revealed Resident #10's short and long-term goals were: to stand during activities of daily living (ADLs), the resident was fair to minimal assistance and unable to shift her weight. For lower body dressing, the resident was at maximum assistance with verbal cues at 50 percent. To manipulate fasteners, the resident was unable to perform this function and it was noted that this treatment was discontinued on 4/9/18. Bi-lateral upper body strength, the resident was able to move part through full range against gravity and moderate resistance. This note documented the resident reached potential achievement and her prognosis was to maintain current level of function since she had good strong family support. Review of a hospital Ethics Consult dated 4/30/18 compiled to address Resident #10's decision making and placement was written by a Registered Nurse Juris Doctor (RN/JD) revealed, .Likely patient will need a conservator for long term placement and management of her affairs since there really is no one else and she cannot return home alone. Of note .has been consulted to determine a decision maker and need for .conservator . Interview with the Director of Social Services and the Social Services Aide #148 in the Social Services office on 12/18/18 at 11:09 AM revealed the Director of Social Services stated she had a conference with the resident and a son (friend - residnet did not have a son). She said the son was the one who made the resident's decisions. Per Director of Social Services even though the resident had cognitive issues, she was able to give permission to speak with this person. She went on to state this person was the one who provided care for the resident and prepared her meals. The Director of Social Service was unable to provide the name and number of the man that Resident #10 was discharged home with and confirmed there was no information in the clinical record to support this information that she provided. She stated the facility wanted to keep the resident or place her on a dementia unit but could not provide a reason why the facility did not, other than the resident wanted to return home. Interview with Registered Nurse (RN) #23 who was also a Unit Manager in the conference room on 12/19/18 at 9:28 AM revealed RN #23 stated there was a young man who was identified as possibly living full-time with Resident #10. RN #23 stated the resident really wanted to return home. Per interview with the RN, the resident was adamant about going home. Interview with the Administrator on 12/19/18 at 1:02 PM in the conference room revealed he was recently hired in (MONTH) (YEAR). The Administrator stated prior to his arrival, there were issues. He continued to state, he had identified concerns around the discharge process and noticed the length of stay was short. Currently, he stated if there is a belief the resident needs long-term care, we need to reinforce this with the resident and their representative. A telephone interview was completed with Resident #10's friend on 12/19/18 at 1:27 PM in the conference room. He confirmed he had known the resident since the 1980's. He said that they were good friends and he did not live with the resident. He specifically stated she has her own place. The friend said he would only check on her. Interview with the Administrator, Director of Social Services, Rehabilitation Director #109, and PT #112 on 12/19/18 at 2:45 PM in the conference room revealed PT #112 stated Resident #10 had no improvement in her goals and her therapy levels would vary. The Director of Social Services stated there were multiple discussions with the resident's friend. The Administrator stated there was no documentation, in the record, that was specific to the friend. The staff stated that if there was a resident who did not meet their therapy goals, they would discharge them if there was stable support in the home. Interview with a night shift Licensed Practical Nurse (LPN) #40 on 12/20/18 at 9:40 AM revealed Resident #10's ADL status was up and down. There were some days the resident could help herself, but other days she could not and needed staff to assist her. LPN #40 stated the resident was alert, but could not say she was oriented. LPN #40 explained the resident would revert back and sundown (late evening confusion). The resident could feed herself, but sometimes she needed assistance because she would not eat. She said the resident's friend visited 2 to 3 times per week and would sit with her. Whenever he would sit with her, the resident was calm. When he left, she would become confused and combative. She stated the Resident #10's friend felt she could do more for herself whenever she was at home, but it was her belief the friend did not understand the resident's decline in status. She stated the resident could not cook for herself and she needed someone to be with her 24 hours a day. She did not believe the friend understood dementia, and the care the resident would need at home. She stated prior to the resident coming to the facility, this friend lived with her. She thought the friend was living in the resident's home while she was at the facility as well. It was her understanding that they would be living together again once she was discharged . The LPN #40 said the resident was not safe to be discharged home. The Immediate Jeopardy was removed onsite after receipt of an acceptable Allegation of Compliance (A[NAME]) on 12/20/18 at 5:13 PM when the facility implemented the following corrective actions: On 12/20/18, immediately after notification of the Immediate Jeopardy, the facility completed an audit on the residents due to be discharged from 12/19/18 through 12/20/18 for proper indications for discharge. The audit revealed no residents were scheduled to be discharged . On 12/20/18 at 11:48 AM, an in-service was provided to all administrative staff, regarding appropriate indications for discharge. One of the Policy/Training aide entitled Criteria Determining the Need for Resident or Discharge or Transfer (Phase I) dated 11/7/16, was provided to the staff for training. The document specifically stated .The facility must permit each resident to remain in the facility, and not transfer or discharge the resident unless .The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility .The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility .The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident .The health of individuals in the facility would otherwise be endangered .The resident has failed, after reasonable and appropriate notice, to pay (or to have paid under Medicare or Medicaid) a stay at the facility .The facility ceases to operate . The Administrator attached all educational materials and sign-in sheets provided to the staff during this period. An interview was conducted on 12/20/18 at 4:15 PM, with the Administrator. Also present was the interim DON #11, current DON #12, the Rehabilitation Director #109, a Regional Director, Registered Nurse/Unit Managers (RN) #23 and RN #22. The Administrator stated the staff present had completed re-education on the A[NAME]. The training was also provided during the morning meeting (12/20/18) and with all Unit Managers. All residents scheduled for discharge from the facility will be evaluated for potential barriers, such as unsafe discharge. If the facility determined an unsafe discharge, the physician, local police, and Adult Protective Services (APS) would be notified. The facility provided evidence that in-service training was provided to all administrative staff, to all staff included in discharge planning, and to the nursing staff. Social Services will begin to follow up with all discharged residents or responsible party within 24 hours, then 72 hours, 14 days, and finally after 28 days as part of the facility's action plan. Interview with DON #12 on 12/20/18, confirmed the discharge training was discussed and implemented in the morning meeting (12/20/18) and with all Unit Managers. The Administrator or designee will conduct audits 5 times a week for 8 weeks. The audit will then continue 3 times a week for 4 weeks, then weekly for 4 weeks. The results of the discharge audits will be discussed during the Clinical Start up meetings weekly and will be ongoing. Audits will be discussed in monthly Quality Assurance/Performance Improvement meetings for 6 months.",2020-09-01
1152,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2018-03-21,558,D,1,0,5EU311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of the Grievance/Concern/Comment Report form, observation, and interview, the facility failed to ensure water was within reach for 1 of 6 residents reviewed (Resident #2). Findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Grievance/Concern/Comment Report form dated 9/13/17 revealed the water was not in reach of Resident #2. The facility actions were to in-service staff immediately to ensure the over bed table was close to the resident and choice of beverage was available. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #2's Brief Interview for Mental Status (BIMS) score was 7/15, indicating severe cognitive impairment. Resident #2 had no episodes of [MEDICAL CONDITION], mood, or behavior during the review period. Resident #2 had a delusional psychotic episode during the review period. Resident #2 required Activity of Daily Living (ADL) assistance of extensive 2 person assistance with bed mobility and transfers; extensive 1 person assistance with dressing, toileting, and hygiene; and total dependence with 2 person assistance with bathing. Medical record review of the Annual MDS dated [DATE] revealed Resident #2's BIMS score was 5/15, indicating severe cognitive impairment. Resident #2 exhibited feeling down/depressed for 2-6 days and delusions during the review period. The resident required the same care assistance for ADLs as in the 11/4/17 assessment with the exception of total 2 person assistance for transfers. Observation on 3/19/18 at 12:26 PM revealed Resident #2 in the bed lying on her right side facing the window. Further observation revealed the filled water pitcher and a container of apple juice was on the the over bed table on the door side of the resident therefore it was out of reach of the resident. Observation on 3/20/18 at 7:48 AM revealed Resident #2 in bed lying on her right side facing the window. Further observation revealed the filled water pitcher was on the over bed table on the door side of the resident therefore it was out of reach of the resident. Interview with Licensed Practical Nurse (LPN) #4 on 3/20/18 at 7:50 AM in Resident #2's room confirmed he was assigned to the resident. Further interview confirmed Resident #2's water pitcher was not in reach of the resident. Further interview confirmed the resident was capable of reaching for and drinking from the water pitcher.",2020-09-01
1151,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2018-03-21,550,D,1,0,5EU311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of the Grievance/Concern/Comment Report form, observation, and interview, the facility failed to maintain the dignity by ensuring clean clothes were worn daily for 1 of 6 residents reviewed (Resident #2). Findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Grievance/Concern/Comment Report form dated 10/27/17 revealed Resident #2 was not getting clothes changed. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #2's Brief Interview for Mental Status (BIMS) score was 7/15, indicating severe cognitive impairment. Resident #2 required Activity of Daily Living (ADL) assistance of extensive 1 person assistance with dressing. Medical record review of the Annual MDS dated [DATE] revealed Resident #2's BIMS score was 5/15, indicating severe cognitive impairment. Resident #2 exhibited feeling down/depressed for 2-6 days and delusions during the review period. The resident required the same care assistance for ADLs for dressing as in the 11/4/17 assessment. Observation on 3/19/18 at 9:09 AM revealed Resident #2 was in the bed in a gown. Observation at 2:40 PM revealed the resident in bed with clean hair and a clean top. Observation on 3/20/18 at 7:48 AM, 9:30 AM, 11:58 AM and at 5:00 PM revealed Resident #2 was wearing the same top as she was wearing on 3/19/18 at 2:40 PM. Observation on 3/21/18 at 7:50 AM revealed Resident #2 was wearing the same top she was wearing on 3/19/18 at 2:40 PM. Observation at 12:10 PM revealed Resident #2 was in bed with clean hair and wearing a clean top. Interview with the Administrator in the Social Service office on 3/21/18 at 2:15 PM revealed the resident had duplicate clothing items per the CNAs. The Administrator and surveyor went to the resident's room and the top worn, as identified by the surveyor from 3/19/18 at 2:40 PM through 3/21/18 at 7:50 AM, was in a clear plastic bag in the resident's closet . Further observation revealed no duplicate top in the closet as was worn from 3/19/18 to 3/21/18. Further interview with the Administrator confirmed the top in question was not duplicated and was stored in a clear bag in the closet for the family to pick up to do laundry. Further interview confirmed the resident was not in clean clothing on 3/20/18.",2020-09-01
1153,GLEN OAKS HEALTH AND REHABILITATION,445234,1101 GLEN OAKS ROAD,SHELBYVILLE,TN,37160,2018-03-21,561,D,1,0,5EU311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of the Grievance/Concern/Comment Report form, review of the B-Side Showers form, observation, and interview, revealed the facility failed to provide showers as scheduled for 1 of 6 residents reviewed (Resident #2). Findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Grievance/Concern/Comment Report form dated 10/27/17 revealed Resident #2 was not getting showers on scheduled day of shower Monday, Wednesday, and Friday. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 Brief Interview for Mental Status (BIMS) score was 7/15, indicating severe cognitive impairment. Resident #2 had no episodes of [MEDICAL CONDITION], mood, or behavior during the review period. Resident #2 had a delusional psychotic episode during the review period. Resident #2 required Activity of Daily Living (ADL) assistance of extensive 2 person assistance with bed mobility and transfers; extensive 1 person assistance with dressing, toileting, and hygiene; and total dependence with 2 person assistance with bathing. Review of the B-Side Showers form for (YEAR) revealed Resident #2 was to receive showers on Mondays, Wednesdays, and Fridays during the day shift. Review of the Documentation Survey Report form for Resident #2's Monday/Wednesday/Friday shower on the day shift revealed the following: For 10/2017-There was a total of 13 opportunities for showers. The resident received 1 shower, 6 bed bath, 1 partial bath, and 5 undocumented events. For 11/2017-There was a total of 13 opportunities for showers. The resident received 7 shower, 5 bed bath, 0 partial bath, and 1 undocumented event. For 12/2017-There was a total of 13 opportunities for showers. The resident received 6 shower, 5 bed bath, 1 partial bath, and 1 undocumented event. Medical record review of the nursing notes revealed no documentation in 10/2017 regarding why showers were not provided. Observation on 3/19/18 at 9:09 AM revealed Resident #2 was in the bed in a gown. Observation at 2:40 PM revealed the resident in the bed with clean hair and wearing a clean top. Observation on 3/20/18 at 7:48 AM, 9:30 AM, 11:58 AM and at 5:00 PM revealed Resident #2 wearing the same top as she was wearing on 3/19/18 at 2:40 PM. Observation on 3/21/18 at 7:50 AM revealed Resident #2 wearing the same top she was wearing on 3/19/18 at 2:40 PM. Observation at 2:20 PM revealed Resident #2 was in the bed with clean hair and wearing a clean top. Interview with the Administrator on 3/20/18 at 4:00 PM in the Social Service office revealed during (MONTH) and (MONTH) (YEAR) the facility was using a lot of agency and was in process of training them. Further interview confirmed after reviewing the Documentation Survey Report form for 10/2017 for Resident #2 confirmed .appears no shower as scheduled on Monday, Wednesday, and Friday .",2020-09-01
3885,LAURELBROOK SANITARIUM,4.4e+201,114 CAMPUS DRIVE,DAYTON,TN,37321,2018-08-29,760,D,1,0,ELCE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of the facility investigation and interview, the facility failed to avoid a significant medication error for 1 resident, Resident #1, of 3 residents reviewed for medication management. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] under Hospice Care with [DIAGNOSES REDACTED]. Resident #1 was care planned as cognitively impaired and dependent for activities of daily living. Medical record review, investigative interviews and review of the facility investigation revealed on 8/11/18, Resident #1 was to receive [MEDICATION NAME] Oral Solution 5 milligrams (mg) once every 4 to 6 hours for pain. The medication was contained in reusable vial form at a concentration of 20 mg per 1 milliliter (ml). Continued review revealed the nurse (RN #1) misread the Physician order [REDACTED]. (5mg) as listed on the MAR. Further medical record review revealed the nurse upon realizing the error a short time later, contacted the Physician and administered [MEDICATION NAME] (a narcotic antagonist, to reverse effects of [MEDICATION NAME]). Resident #1 received a second dose of [MEDICATION NAME] in the nursing home and was transferred to a local hospital for additional evaluation where she received a third dose of [MEDICATION NAME] prior to discharge back to the nursing home. Interview with the Director of Nursing (DON) on 8/28/18 at 5:06 PM at the nursing station confirmed the facility had failed to avoid a significant medication error for Resident #1.",2020-02-01
739,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2018-02-28,600,D,1,0,VR3611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of the facility investigation, and interview the facility failed to intervene and protect from abuse 1 (#2) of 4 sampled residents. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 1/19/18 Quarterly Minimum Data Set (MDS) revealed Resident #1 was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 8 of 15. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #2 was cognitively intact with a BIMS score of 15 of 15. Review of the facility investigation revealed on 1/28/18 Resident #1 and Resident #2 were together outside of the Bedford Corner dining room. Continued review revealed staff heard Resident #2 state loudly Resident #1 was going to hit (Resident #2). Continued review revealed three staff, including Certified Nurse Assistant (CNA) #1 rushed to reach Resident #1 and Resident #2 to separate them. Further review revealed Resident #1 struck Resident #2 in the chest/upper arm area 3 times before the staff reached Resident #1 and #2. Continued review revealed Resident #1 and Resident #2 were examined for injury and Resident #2 was found to have a hand print mark on her right breast. Interview with CNA #1 on 2/27/18 at 5:05 PM at Nurse Station 1 revealed she had witnessed the altercation between Resident #1 and Resident #2 on 1/28/18. Continued interview revealed CNA #1, just prior to the altercation, had walked through the Bedford Corner dining room and observed and heard Resident #1 and Resident #2 bickering. Continued interview revealed CNA #1 had told Resident #1 and Resident #2 to stop bickering and to separate from one another. Continued interview revealed she left Resident #1 and Resident #2 before ensuring they had separated and she continued down the hallway. Continued interview revealed she heard Resident #2 state Resident #1 was trying to hit (Resident #2). Continued interview revealed she turned and saw Resident #1 strike Resident #2 three times before staff could separate the two residents. Interview with the Director of Nursing (DON) on 2/28/18 at 8:45 AM in the conference room revealed the staff was expected to immediately separate residents who were engaged in any type of altercation. Continued interview confirmed CNA #1 failed to separate Resident #1 and Resident #2 when she witnessed the two residents arguing. Continued interview revealed the facility's failure to separate Resident #1 and Resident #2 resulted in failure to protect Resident #2 from physical abuse from Resident #1.",2020-09-01
1349,HARTSVILLE CONVALESCENT CENTER,445256,649 MCMURRY BLVD,HARTSVILLE,TN,37074,2017-09-12,157,D,1,0,9I4J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of the facility investigation, and interview, the facility failed to notify the Responsible Party of a non-abusive allegation timely for 1 resident (#1) of 3 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility investigation and a Nurse's Note dated 3/5/17 at 8:25 PM revealed Resident #2 had his pants down and was found on top of Resident #1 in bed. Further review of the facility investigation revealed Social Progress Notes dated 3/6/17 .This writer along (with) DON (Director of Nursing) called resident's daughter .this afternoon (although the event took place 3/5/17 at 8:25 PM) to let her know about the situation that happened last PM around 8:25 in her room (with) a male resident . Interview with Resident #1 on 9/11/17 at 8:48 AM and 2:00 PM in her room revealed the resident recalled Resident #2, nodded her head Yes when asked if she had affection for him and was ok with him being on top of her and doing what he did. When asked if the resident was ever afraid while he was on top of her, if he had hurt her, and if he had done anything she did not want him to do, she shook head No to each question. Interview with the Abuse Coordinator, the Social Service Director (SSD), with the DON and Administrator present, on 9/11/17 beginning at 9:30 AM in the conference room revealed the SSD informed both resident's Responsible Parties of the event. Further interview confirmed the facility failed to notify Resident #1's Responsible Party timely.",2020-09-01
2373,SIGNATURE HEALTHCARE OF MONTEAGLE REHAB & WELLNESS,445393,26 SECOND STREET,MONTEAGLE,TN,37356,2017-08-09,323,D,1,0,XYDR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of the facility investigation, and interview, the facility failed to provide supervision for 2 residents (#11 and #12) of 17 residents reviewed for behaviors, on 1 of 4 wings obsreved. The findings Included: Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #11 with a Brief Interview of Mental Status (BIMS) score of 12/15 (moderate cognitive impairment). Continued review revealed the resident had a history of [REDACTED]. Medical record review revealed Resident #12 was readmitted to the facility from an acute psychiatric hospital on [DATE] with [DIAGNOSES REDACTED]. Review of an admission MDS dated [DATE] revealed Resident #12 with a BIMS of 3/15 (severe impairment). Continued review revealed the resident had a history of [REDACTED]. Review of a facility investigation dated 6/13/17 revealed around 7:00 AM Resident #12 ambulated into the main dining room in her wheelchair, rolled by Resident #11, and struck him on the hand with an empty plastic coffee cup without provocation. Continued review revealed Resident #11 forcibly took the coffee cup away from Resident #12, and the two residents separated themselves, moved to tables adjacent to one another with their backs turned to each other. Further review revealed at the time of the incident, staff members had opened the dining room to permit residents to enter in preparation for the morning meal, but left Resident #11 and Resident #12 unsupervised. Continued review revealed the incident was reported to staff members by a third resident (Resident #15) when staff returned to the dining hall (5 minutes after the incident occurred). Further review revealed Resident #11 and Resident #12 sustained minor abrasions to the upper extremities in the altercation and Resident #11 sustained a superficial skin tear (less than 1 centimeter on the hand), which required minor first aid by the nurse (band aid). Interview with Occupational Therapist (OT) #3 on 8/7/17 at 5:45 PM, in the Admissions Office, he entered the dining room with another resident to assist them with the morning meal and Resident #15 informed him of the altercation. Continued interview revealed no staff members were present in the dining room and when he asked Resident #11what happened, Resident #11 informed him Resident #12 struck him and he (Resident #11) took the coffee cup used to strike him away from Resident #12. Further interview revealed the two residents had separated themselves and were seated 6 to 8 feet from each other with their backs turned to one another. Interview with Resident #11 on 8/7/17 at 6:20 PM, in the resident's room, revealed no staff members were present in dining room when the altercation occurred. Interview with LPN #8 on 8/8/17 at 9:25 AM, in the Admissions office, revealed at the time of the incident, she didn't know where the staff members assigned to monitor the dining room were and she was unaware the dining hall was opened and unsupervised. Interview with the Director of Nursing (DON) on 8/7/17 at 6:05 PM, in the Admissions Office, confirmed no staff members were present in the dining area at the time the altercation occurred and Resident #12 required supervision during meals and social interactions with others. Further interview revealed staff had unlocked the dining area, permitted residents to enter the dining room, and left the area unsupervised. Continued interview confirmed staff members residents were not allowed in the dining area unsupervised and the facility failed to provide adequate supervision to prevent the resident to resident altercation.",2020-09-01
3267,WEST HILLS HEALTH AND REHAB,445501,6801 MIDDLEBROOK PIKE,KNOXVILLE,TN,37919,2017-07-18,225,D,1,0,GCFU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of the facility investigation, and interview, the facility failed to report an allegation of abuse timely for 1 (#1) resident with an allegation of abuse of 1 resident with an allegation of abuse reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum (MDS) data set [DATE] revealed the resident had score of 8 on Brief Interview for Mental Status indicating the resident had moderately impaired cognitive skills for daily decision making, and the resident had delusions. Medical record review of the Psychiatric Notes dated 5/2/17 revealed .Resident has long hx (history) of depression .Resident alert with confusion. Confabulates .increase Trazadone (antidepressant) 100mg (milligrams) (at) HS (bedtime) . Review of a statement dated 7/10/17 obtained by the facility from Registered Nurse (RN) #2 revealed .Approximately 5:00 PM on 7/10/17, I responded to residents call light .requested a pain pill stating 'I hurt down there' (pointing to peri area) .Resident then stated 'two men messed with me down there last night.' Resident medicated per request .assessed .based on her complaints on visual examination no redness, bruising, abrasions, bleeding or other sign of injury were noted to thighs or genitalia. Review of the facility investigation dated 7/10/17 revealed .Resident verbalized two men raped her and c/o (complained of) pain above bladder to floor nurse .Head to toe assessment, to include thighs and genitalia . Medical record review of the Departmental Notes dated 7/10/17 8:21 PM revealed .This social worker and administrator spoke with resident's granddaughter .regarding recent allegation made by resident .(granddaughter) reports that she spoke with her grandmother around 4pm and her grandmother voiced no concerns .voices concern that her grandmother has been obsessively calling and she feels that this report could potentially be for attention from her family . Medical record review of the Departmental Notes from the Director of Nursing (DON) dated 7/10/17 at 8:45 PM revealed .At approximately 5:30 pm this afternoon, it was reported to me by the charge nurse that the resident had made an allegation. A head to toe assessment was completed. There were no redness, bruising, or open areas noted .The resident has a history of delusions and is care planned .She sometimes has confusion as well . Review of the Resident Interview Form for Resident #1 dated 7/10/17 at 5:30 PM obtained by the Social Worker revealed .Two men came in my room (and) raped me I was asleep (and) they woke me up. One man was on top of me. He said 'Be quiet [***] ' the other man said 'Go ahead and finish up what you're doing'. I didn't say anything because I was afraid they would hurt me.' .It was dark outside. Resident is unable to report date/time .Resident refused to give description. She does state, 'They are staff members (and) I recognize them' .were there witnesses? 'No they closed the door' . Review of the Resident Interview Form for Resident #1 dated 7/10/17 at 5:50 PM obtained by the DON revealed .Last night I was asleep (and) 2 men woke me up (and) one took one leg (and) the other one took the other (and) one of them said they were going to rape me .one held her (and) the other one raped her. She did not see them because it was dark in her room (and) there was only a small amount of light coming thru the window then they left . Review of a witness statement dated 7/10/17 obtained by the facility from Certified Nursing Assistant (CNA) #1 revealed .I took care of (Resident #1) last night Sunday 7/9/17 changed her brief a couple of times. She did not say anything about anybody coming in room. She has talked about different things that did not make sense before when I took care of her. She did mention she was not feeling well today. Her light was on Sunday night . Review of the Summary of Investigation dated 7/10/17 revealed .Resident reported on 7/10/17 at approximately 5:30 PM that she was raped by two men. The alleged incident was reported to have occurred the night before. The resident had no description to provide of the two men .allegation of abuse could not be substantiated. There was no evidence of bruising, redness, abrasion, bleeding or other signs of injury noted to resident's thighs or genitalia. No statement from other residents or employees indicated a concern .Allegation reported to state .on 5/11/17. Medical record review of the Physician's Progress Note dated 7/11/17 revealed .Chief Complaint .urinary discomfort .patient continues to complain of urinary discomfort .started giving her [MEDICATION NAME] (pain reliever for urinary tract) last night .The patient had a rape allegation. After thorough investigation it appears to have been a hallucination .she has no recollection of this .Dementia with behaviors . Medical record review of the Psychiatric Notes dated 7/11/17 revealed .staff requested recheck due to patient allegation that 'men were in her room last night and raped' her. No 1:1 personal care with male CN[NAME] Has recent episode of UTI (Urinary Tract Infection) Also has had elevated sugar, now on oral med and insulin .Dementia with Depression .Resident in room, alert, up in chair, eating lunch .When asked about allegation, she states 'you got that right!' But does not have any specific descriptors or recollection of event. No fearfulness or anxiety. Does have some pain at urethra, dysuria. Per staff, patient has not had any statements about alleged incident today .probable delusions/[MEDICAL CONDITION] related to elevated blood sugar and UTI . Medical record review of the Interdisciplinary Team Meeting Notes dated 7/13/17 revealed .Confusion noted throughout the day . Interview with Resident #1 on 7/17/17 at 8:30 AM, in the resident's room revealed 2 men came in room and woke her up, 1 got on top of her and pulled his penis out and stuck in her vagina. It was dark I couldn't see, don't remember the day or time. Interview with the Director of Nursing (DON) on 7/17/17 at 12:30 PM, in the conference room, confirmed the resident saw CNA #1 who had taken care of her the night before and called him by name and said I like him. Continued interview revealed unable to substantiate due to history of delusions and no indication of rape from assessment. Interview with the Nurse Practitioner on 7/17/17 at 1:30 PM, in the conference room, revealed performed a visual exam the next morning and there was no indication the resident had been raped. The resident had no recollection of the incident. Continued interview revealed would expect to see some trauma the next day when examined if resident had been raped. Interview with Resident #1 on 7/17/17 at 2:10 PM in the resident's room revealed Resident #1 did not remember if the door was open or closed, the other man was standing to the side of the bed, they were African American, she did not know them and had never seen them before. Interview with CNA #1 on 7/17/17 at 2:45 PM, in the conference room, revealed the lights were on all night in the resident's room, and she has a history of saying things that are not true. Interview with RN #1 on 7/17/17 at 3:30 PM by telephone, revealed he only administers the resident's medications, the resident's door is usually open and you can see what is going on. Interview with the DON on 7/17/17 at 2:30 PM, in the conference room, confirmed the allegation of abuse was not reported to the state agency until 7/11/17.",2020-09-01
438,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2019-11-27,725,D,1,0,Y85H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of the facility staffing schedules, review of the time detail reports, observation, and interview, it was determined the facility failed to provide sufficient staffing to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 6 of 27 (11/3/19, 11/11/19, 11/13/19, 11/15/19, 11/23/19, and 11/24/19) days in Novenber. The facility had a census of 55 residents. The findings include: 1. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a BIMS score of 14, which indicated no cognitive impairment. Interview with Resident #1 on 11/26/19 at 12:50 PM, in Resident #1's room, Resident #1 was asked if there was enough staff at the facility to give her the care she needed. Resident #1 stated, I'm blind so I have a hard time getting to the bathroom at night .I believe they need more help. Observation on 11/26/19 at 11:25 AM and 12:50 PM in Resident #1's room, revealed Resident #1 with hair that appeared oily and there was a urine odor in her room. 2. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Interview with Resident #2 on 11/26/19 at 5:20 PM, in Resident #2's room, Resident #2 was asked if there was enough staff to give her the care she needed. Resident #2 stated, There is not enough staff here and they don't answer the call lights timely on days or nights . 3. Observations on 11/26/19 at 12:03 PM at the East Nurses Station, revealed a family member of Resident #4 complaining to the staff member at the desk that his sheets were dirty and the room smelled of urine. Observations of Resident #4's room revealed the sheets had yellowish stains visible and the room did have an odor of urine. Interview with Resident #4 and 2 of his family members on 11/26/19 at 12:09 PM, in Resident #4's room, the family member stated, .came to take (Resident #4) out for Thanksgiving dinner and he (Resident #4) was upset because his sheets are dirty and the room smells of urine. 4. Review of the Certified Nursing Aide (CNA) schedule for 11/3/19 revealed that CNA #7 and #8 were scheduled for the night shift (11:00 PM - 7:00 AM) on 11/3/19. The actual time detail revealed only 1 CNA (CNA #8) worked on the night shift. The facility had a census of 59 residents. Review of the CNA schedule for 11/11/19 revealed that CNA #5, #12, and #13 were scheduled for 3:00 PM - 11:00 PM shift. Review of the actual time detail revealed 2 CNAs (CNA #5 and #12) worked the 3:00 PM - 11:00 PM shift on 11/11/19. The facility had a census of 53 residents. Review of the actual time detail revealed one CNA (CNA #12) worked on 11/13/19 on the 3:00 PM - 11:00 PM shift. The facility had a census of 52. Review of the CNA schedule for 11/15/19 revealed that CNA #10 and #11 were scheduled for 11:00 PM - 7:00 AM. Review of the actual time detail revealed only 1 CNA (CNA #11) worked on 11/15/19 for the 11:00 PM - 7:00 AM shift. The facility had a census of 52. Review of the CNA schedule for 11/23/19 revealed that CNA #9, #10, and #11 were scheduled on the night shift. Review of the actual time detail revealed only 1 CNA (CNA #11) worked the night shift on 11/23/19. The facility had a census of 56. Review of the CNA schedule for 11/24/19 revealed CNA # 8, #9, and #11 were scheduled on the night shift. Review of the actual time detail revealed only 1 CNA (CNA #11) worked the night shift on 11/24/19. The facility had a census of 55. 5. Interview with CNA #1 on 11/26/19 at 1:12 PM, in the Conference Room, CNA #1 was asked if there was enough staff for the residents to receive the care they needed. CNA #1 stated, .no not always enough time to complete everything .not enough staff for all the residents to get showers, just bed baths. They don't get the care they need. CNA #1 was asked how many residents she was assigned today. CNA #1 stated, today 12 .responsible for 18 sometimes .Laundry is only here 8 hours and we often run out of sheets, washcloths, and towels. The first weekend of November, I worked 25 hour shift due to no one showing up for third shift . Interview with CNA #2 on 11/26/19 at 1:42 PM, in the Conference Room, CNA #2 was asked if there was enough staff for the residents to receive the care they needed. CNA #2 stated, No need more CNAs . CNA #2 was asked how many residents she was assigned today. CNA #2 stated, .I have 13 .I stay over until 7:00 PM, if they have a call in. We do run out of clean sheets and washcloths due to laundry only doing one shift . Interview with CNA #3 on 11/26/19 at 2:05 PM, in the Conference Room, CNA #3 was asked if there was enough staff for the residents to receive the care they needed. CNA #3 stated, No, no residents on 700 hall had showers today, they got bed baths. CNA #3 was asked how many residents she was assigned today. CNA #3 stated, Today 12 .I have worked West (hall) by myself with 22 residents Interview with CNA #4 on 11/26/19 at 2:27 PM, in the Conference Room, CNA #4 was asked if there was enough staff for the residents to receive the care they needed. CNA #4 stated, Not enough staff to give care needed .last week 3 days I was by myself on second shift on West (hall) with 22 residents . CNA #4 was asked how many residents she was assigned today. CNA #4 stated, 12 today. Interview with CNA #5 on 11/26/19 at 2:53 PM, in the Conference Room, CNA #5 was asked if there was enough staff for the residents to receive the care they needed. CNA #5 stated, Absolutely short staffed to give the care these residents need .I have stayed over when only one CNA on third shift . Interview with the Administrator on 11/26/19 at 3:40 PM, in the Conference Room, the Administrator was asked about the working schedule. The Administrator stated, I had to take over the scheduling in mid-November. The person that had been doing the schedule had been doing it since (MONTH) and had been doing really good. But then she was making a hot mess of it, she didn't have them accurate. She was leaving people off the assignments sheets and schedule . Interview with Licensed Practical Nurse (LPN) #1 on 11/26/19 at 3:50 PM, in the Conference Room, LPN #1 was asked if there was enough staff for the residents to receive the care they needed. LPN #1 stated, No I don't. LPN #1 was asked if the residents appeared clean when she arrived or if she noticed any odors. LPN #1 stated, .I have noted oily hair on residents and odors occasionally. Interview with CNA #6 on 11/26/19 at 5:04 PM, on the 300 Hall, CNA #6 was asked if there was enough staff for the residents to receive the care they needed. CNA #6 stated, .I was on East (hall) with 30 residents by myself .worked 2 nights by myself. Interview with CNA #7 on 11/27/19 at 6:00 AM, in the Conference Room, CNA #7 was asked if there was enough staff for the residents to receive the care they needed. CNA #7 stated, No there is not enough staff .we run out of linens regularly most nights lately . CNA #7 was asked how many residents she was assigned. CNA #7 stated, 22. Interview with CNA #8 on 11/27/19 at 6:20 AM, at the East Nurses Station, CNA #8 was asked if there was enough staff for the residents to receive the care they needed. CNA #8 stated, No not enough for the residents to get care needed .often one CNA for the whole building .",2020-09-01
5280,SIGNATURE HEALTHCARE OF GREENEVILLE,445351,106 HOLT COURT,GREENEVILLE,TN,37743,2016-04-25,425,D,1,0,LII611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of the facility's pharmacy services agreement and interview, the facility failed to ensure the pharmaceutical service provided an intravenous (IV) antibiotic as ordered by the physician for 1 resident (#3) with a Methicillin-resistant Staph Infection (MRSA) of the Cerebrospinal Fluid (CSF) of 12 residents reviewed. The findings included: Resident #3 was admitted to the facility from the hospital on Monday, 10/12/15 at 3:30 PM with [DIAGNOSES REDACTED]. Medical record review of the physician's hospital discharge orders which were reviewed and approved by the facility's Nurse Practitioner on 10/12/16 revealed, Vancomycin (antibiotic used to treat MRSA) 1 GM (gram) vial (Vancomycin HCL) give intravenous every eight hours .stop date 10/19/15 .Dx (diagnoses) MRSA . Medical record review of the facility's History and Physical dated 10/13/15 revealed the resident was evaluated by Infectious Disease (while in the hospital) for a positive .CSF .culture .was started on IV Vancomycin for the infection .was positive for staph . Medical record review of the Medication Administration Record [REDACTED]. Medical record review of a nursing assessment (dated 10/12/15) by the Assistant Director of Nursing (ADON #1) revealed, .Unable to give 10 PM dose of Vancomycin IV on 12/12/15 .due to pharmacy not bringing medication .Pharmacy was notified of medication need and stated back up pharmacy was bringing medication. Called pharmacy/back up pharmacy numerous times during the night and morning/afternoon requesting Vancomycin IV. Was told it was on its way .Received medication around 2 PM on 10/13/15 .Unable to administer IV Vancomycin as ordered due to unavailability from pharmacy . Medical record review of a nurse's note dated 10/13/15 revealed the resident did not receive the 6:00 AM dose of Vancomycin on 10/13/15 because the resident had been transferred to the hospital at 3:00 AM to have the Percutaneous Intravenous Central Catheter (PICC) replaced. Review of the facility's pharmaceutical agreement dated 4/28/15 revealed, .Pharmacy will provide and deliver .prescription and nonprescription medications, biologicals, and parenteral nutrition, and intravenous solutions, supplies and equipment .in accordance with the orders of the Residents' attending physicians or other appropriately licensed prescribers .Pharmacy will also provide .stat (urgent or immediate) delivery services .Pharmacy will also provide back-up pharmacy services from other pharmacies to satisfy emergency Product needs .Provide IV Drug Therapy Services on an emergency basis, as needed, subject to availability . Interview with the ADON (#1) on 4/12/16 at 6:40 AM in the conference room confirmed the resident was admitted to the facility on [DATE] at 3:30 PM. Continued interview revealed the pharmacy usually delivered medications between 10:00 PM and 11:00 PM. The Vancomycin was not received during the regularly scheduled delivery. Continued interview revealed staff started calling the pharmacy and was told the medication would be delivered stat. The medication was not received, and a return call was made to the pharmacy. Continued interview confirmed the scheduled dose of Vancomycin was not administered at 10:00 PM on 10/12/15 as ordered by the physician because the medication had not been delivered by the facility's pharmacy.",2019-04-01
4144,MT PLEASANT HEALTHCARE AND REHABILITATION,445374,904 HIDDEN ACRES DR,MOUNT PLEASANT,TN,38474,2016-11-03,278,J,1,0,J51L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of the hospice forms, and interview, the facility failed to accurately assess the swallowing impairment on the 6/16/16 Minimum Data Set (MDS) and failed to accurately assess the hospice status on the 9/29/16 MDS for 1 resident (#1) of 11 residents. The failure to assess Resident #1 for a swallowing impairment placed Resident #1 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death of a resident). The Administrator, Director of Nursing and the Quality Assurance Nurse were informed of the Immediate Jeopardy on 11/2/16 at 3:00 PM in the Administrator's office. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician telephone Orders dated 4/24/16 revealed .ST (Speech Therapy) to eval (evaluate) + (and) tx (treat) as indicated .ST Clarification: ST to see 2 x wk (week) x 6 wks for cognitive deficit and swallowing secondary to dementia . Medical record review of the Progress Notes revealed the following: 6/8/16 .Holds fluids in mouth at times though no cough or choking noted. Takes meds crushed . 6/9/16 at 9:19 AM .Takes meds crushed in applesauce with extreme encouragement . and at 10:25 PM .Continues to have difficulty swallowing at times . 6/11/16, 6/12/16 .meds administered crushed in applesauce . or .takes meds crushed . 6/14/16 at 9:59 AM .Takes meds crushed in applesauce with extreme encouragement . and at 11:47 PM .has difficulty swallowing at times . 6/16/16 .Takes meds crushed . Medical record review of the 60 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had no swallowing disorder. Medical record review of the Physician telephone Orders dated 9/16/16 revealed .Code Status changed to DNR (Do Not Resuscitate) .Comfort Measure .Admit to .Hospice effective this day . Review of Hospice Informed Consent form revealed the effective date of services was 9/16/16. Medical record review of the Significant Change MDS dated [DATE] revealed the facility failed to accurately assess the hospice services provided. Interview with Registered Nurse (RN) #2, responsible for the accuracy of the MDS information, on 10/25/16 at 10:18 AM, in the conference room when asked how the RN obtained the information to complete the MDS the RN stated .checked the nursing notes, laboratory data .every piece of paper in the chart .the hospice notes .and interviewed staff . Further interview revealed the documentation the RN reviewed and the interviews .had no mention of swallowing or pocketing issues . The facility failed to accurately assess the swallowing status on the 6/16/16 MDS. Further interview confirmed the MDS failed to accurately address the hospice status of the resident. Refer to F154 J, F155 J, F157 J, F224 J SQC, F225 J SQC, F226 J SQC, and F241 J SQC.",2019-11-01
528,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2018-07-19,806,D,1,0,0VM311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on menu review, tray card review, medical record review, observations and interviews, the facility failed to ensure nourishing, palatable meals, honoring resident preferences were served to 1 of 3 (Resident #1) sampled residents reviewed for nutrition. The findings included: Medical record review for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The record revealed Resident #1 with an order dated 6/15/18 for a Mechanical Soft Diet. Resident #1 was assessed on the 1/26/18 Annual and the 4/25/18 Quarterly Minimum Data Set (MDS) with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated Resident #1 was independent with decision making skills and required extensive assistance with Activities of Daily Living (ADLs). Further medical record review revealed the only Dietary Progress note to date in (YEAR) was dated 6/14/18 and documented Resident #1 had a 3% (percent) weight loss that month and a recommendation to liberalize her diet was noted. A Nurse's note dated 6/19/18 documented, Patient complaint of meal not being what she wants .she wants to talk to dietary supervisor . There was no documentation in the medical record the Dietary Manager or the Registered Dietician had conducted a follow up visit to address the 6/19/18 request made by the resident. There were no dietary notes in the medical record documenting the frequent trips to the grocery or attempts to accommodate Resident #1's food preferences. The Care Plan did not address Resident #1's food complaints/preferences/attempts to accommodate. Review of the Noon meal Menu for 7/15/18 revealed Roast Beef, Mashed Potatoes, Capri Mix Vegetables, Banana Cream Pie, and Dinner Roll to be served. The Noon meal Menu for 7/16/18 revealed Baked Chicken, Greens, Cornbread, and Strawberries with topping to be served. Observations on 7/15/18 at 12:20 PM of the noon meal revealed Resident #1 served Roast Beef, Vegetable Medley, and a Baked Sweet Potato. The Roast Beef and Sweet Potato were listed on the tray card as dislikes. The resident was observed to be eating the Sweet Potato and stated, .had one last night, get them frequently, have to eat something . Observations on 7/16/18 at 12:50 PM of the noon meal revealed Resident #1 served Baked Chicken, Greens, and a Baked Sweet Potato. The Sweet Potato was listed on the tray card as a dislike. The resident was observed to be eating the Sweet Potato and stated, .3 days in a row for Sweet Potatoes . Review of the tray card used in dietary to plate each meal for Resident #1 revealed the following foods listed as dislikes: No milk, juice, bread, chicken and dumplings, yams, roast beef, gravy or pork. Interview with the Dietary Manager on 7/11/18 at 10:30 AM, in the Conference room, the Dietary Manager stated, .(Named Resident #1) has given me a long list of dislikes on her tray cards .she is very picky, complains a lot about the food .we make frequent trips to the grocery for her meals . Interview with Resident #1 on 7/11/18 at 12 Noon, in the resident room, Resident #1 stated, .I have given the dietary manager a list of my likes and dislikes but they can't get that right . Interview with the Dietary Manager on 7/15/18 at 12:05 PM, in the Conference room, the Dietary Manager was asked to provide evidence such as notes and receipts of foods purchased to address the complaints/preferences of Resident #1 and stated, I don't have any receipts where I've bought food for her . Interview with the Director of Nursing (DON) on 7/18/18 at 11:15 AM, the DON was asked who completed the care plans related to dietary/food issues and stated, .Dietary would put those on the care plan. The DON was asked the care plan expectations regarding Resident #1's frequent food complaints and stated, I would expect all her dietary complaints, preferences and all that has been done to address them to be on the care plan. The facility failed to provide evidence the food complaints/preferences of Resident #1 were addressed, failed to ensure that food preferences were honored for Resident #1, and failed to ensure a variety of foods were served to Resident #1.",2020-09-01
4379,STANDING STONE CARE AND REHAB,445363,410 W CRAWFORD AVENUE,MONTEREY,TN,38574,2016-10-26,441,D,1,1,3DE711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview the facility failed to maintain a sanitary manner for 3 of 14 resident bedpans observed. The findings included: Observation on 10/26/16 from 9:35 AM to 9:45 AM on the 100, 200, 300, 400, and 500 halls revealed 14 bedpans in various resident bathrooms in plastic bags labeled with resident name and ready for use. Continued observation revealed 1 bedpan in room [ROOM NUMBER] bathroom with dried brown debris. Further observation revealed 2 bedpans in room [ROOM NUMBER] bathroom with dried yellow debris. Interview and observation with the Director of Nursing (DON) on 10/26/16 at 9:50 AM in room [ROOM NUMBER] bathroom confirmed 1 bedpan had dried brown debris. Interview and observation with the DON on 10/26/16 at 9:53 AM in room [ROOM NUMBER] bathroom confirmed 2 bedpans had dried yellow debris and the facility had failed to maintain the bedpans in a sanitary manner.",2019-10-01
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
1477,AHC CUMBERLAND,445262,4343 ASHLAND CITY HIGHWAY,NASHVILLE,TN,37218,2018-11-07,761,D,1,0,Y07M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to ensure medications were secure and inaccessible to unauthorized staff and residents. The findings include: Observation of room [ROOM NUMBER]A during facility tour on 11/5/18 revealed the previous resident had been discharged . Continued observation of the bedside table top drawer revealed one prefilled syringe labeled as Normal Saline and a second prefilled syringe labeled as [MEDICATION NAME] Flush. Both syringes were available to staff, residents, and/or visitors. Interview with Registered Nurse #1 on 11/5/18 at 3:10 PM at the nurses' station confirmed the syringes should not be left at the resident's bedside and should have been removed when the resident was discharged .",2020-09-01
1540,GREEN HILLS CENTER FOR REHABILITATION AND HEALING,445267,3939 HILLSBORO CIRCLE,NASHVILLE,TN,37215,2017-10-31,441,E,1,0,EO0911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to handle and store linen to prevent the spread of infection, failed to provide sanitized water pitchers for 10 of 11 residents, and failed to perform appropriate handwashing. The findings included: Observation on 10/23/17 at 10:15 AM in the 3rd floor linen room revealed the following on the floor of the 3rd floor linen room: 1 white plastic clothes hanger with the hook broken off, 1 mens knit shirt, 2 pairs of mens trousers, 17 shoes-some pairs and some singles, 1 purple 10 x 10 inch square fleece throw pillow, 1 leather belt, 4 foam wedges/positioning devices, 2 flat sheets and 2 bath towels. Observation on 10/24/17 at 2:05 PM of the 3rd floor linen room revealed the same items lying about the linen room floor. Observation on 10/25/17 at 5:50 PM of the 3rd floor linen room with Registered Nurse (RN) #5 revealed the same items lying about on the linen room floor. Interview with RN #5 on 10/25/17 at 5:52 PM in the 3rd floor linen room confirmed the linen room floor had several items including clean linens on it. Continued interview confirmed the 3rd floor linen room floor should be clear of items and linens should be stored to prevent the spread of infection. Observation on 10/24/17 at 6:00 PM at the 3rd floor nurses station revealed 30 clothing protectors in a plastic bag located under the second chair opening of the nurses station desk. Continued observation revealed Certified Nurse Aides (CNAs), were assisting residents for dinner and were obtaining clothing protectors for the residents from the plastic bag. Continued observation revealed 2 clothing protectors partially spilled out of the plastic bag onto the floor and were pushed back into the bag for resident use. Interview with RN #5 and CNA #3 on 10/24/17 at 6:05 PM at the 3rd floor nurses station confirmed 2 clothing protectors spilled onto the floor and were pushed back into the plastic bag. Continued confirmation by RN #5 revealed the facility failed to handle the clothing protectors to prevent the spread of infection. Interview on 10/25/17 at 9:15 AM with Licensed Practical Nurse (LPN) #7 confirmed Residents #6, #7, #9, #10, #11, #12, #13, #14, #15, #16's water pitchers were placed out of reach of residents. Continued interview with LPN #7 confirmed the water pitchers were dirty (dirty fingerprint smears and brown-black debris on the tops and sides) and were cleaned, .usually when needed and at least weekly . Observations on 10/23/17, 10/24/17 and 10/25/17 revealed the water pitchers were dirty for Residents #6, #7, #9, #10, #11, #12, #13, #14, #15, and #16. Interview with LPN #7 on 10/25/17 at 7:55 AM on the 3rd floor south hall confirmed the water pitchers for Residents #6, #7, #9, #10, #11, #12, #13, #14, #15, and #16 had not been cleaned and sanitized daily. Interview with the Director of Nurses (DON) on 10/30/17 at 6:15 PM confirmed the facility failed to ensure the water pitchers were clean and sanitized for Residents #6, #7, #9, #10, #11, #12, #13, #14, #15, #16 and the facility failed to ensure regular sanitizing of the water pitchers. Observation on 10/25/17 at 7:45 AM on the 3rd floor, south hall, revealed CNA #4 exited a resident room with dirty laundry in ungloved hand, touched the lid of the dirty linen cart in the hallway and deposited the dirty linen. Continued observation revealed the CNA returned to the resident's room knocked on the door, touched the door knob and entered the resident's room without washing or sanitizing her hands. Interview on 10/25/17 at 7:50 AM on the 3rd floor, south hall with CNA #4 confirmed she failed to sanitize her hands after carrying dirty linens to the linen cart. Continued interview confirmed the CNA touched the dirty linen cart and proceeded to room [ROOM NUMBER], knocked on the door and provided resident care without sanitizing her hands. Interview with LPN #7 on 10/25/17 at 7:55 AM on the 3rd floor, south hall confirmed the facility failed to maintain infection control protocols by failing to wash or sanitize hands after contact with dirty linens.",2020-09-01
4461,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2016-09-06,465,E,1,0,T33N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to maintain 4 of 4 first floor showers of 8 total showers and 1 Resident (#1) room of 32 occupied rooms on the first floor in a safe manner. The findings included: Medical record review revealed Resident #1 was admitted on [DATE] abd readmitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 8/22/16 at 8:55 AM and 12:18 PM, revealed Resident #1 in bed in his room, a tube feeding formula was being administered via a bag on a pole with 3 rusted legs. Further observation revealed the wall, to the right side of the heater/air conditioner unit was wrinkled and wet to the touch from the bottom of the window sill to the floor. Interview with the Director of Nursing on 8/22/16 at 9:43 AM, in Resident #1's room confirmed the wall was wet and wrinkled to the right of the heater/air conditioner unit. Interview with the Maintenance Director on 8/22/16 at 11:55 AM, in the Business Office Manager office stated .there was a roof leak and that's why the wall is wet . Observation on 8/22/16 during the initial facility tour revealed the following: 1.) At 8:45 AM-The shower rooms on 1 East. The shower room closest to room 125 was not occupied, had feces in the commode, and a brown stain on the floor in front of the commode. The second shower room closest to the nursing station on 1 East was not occupied, had a dead winged insect on the floor and a wadded up glove on the sink. 2.) At 8:50 AM-The shower rooms on 1 West. The shower room on the right was not occupied and had soiled linen on the floor and a brown stain on the shower seat. The shower room on the left, closest to the nursing station on 1 East, was not occupied, had urine in the commode, and soiled towels on the floor. Interview with the Director of Nursing, on 8/22/16 beginning at 9:45 AM, after observing both 1 East showers and 1 unoccupied shower on 1 West, confirmed the facility failed to maintain the environment in a safe manner.",2019-09-01
1478,AHC CUMBERLAND,445262,4343 ASHLAND CITY HIGHWAY,NASHVILLE,TN,37218,2018-11-07,842,E,1,0,Y07M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to maintain medical records which are complete and accurately documented in accordance with acceptable professional standards of practice for 21 records of 24 records reviewed. The findings include: Medical record review of Nursing Notes of 21 residents who were treated for [REDACTED]. Medical record review of Nursing Notes of 21 residents who were treated for [REDACTED]. Continued review of the same records revealed documentation Ivermectin (anti-scabies) was ordered by the Nurse Practitioner but failed to state the reason for the order. Medical record review of Nursing Notes of 21 residents who were treated for [REDACTED]. Further review of Nursing Notes revealed staff had documented [MEDICATION NAME] was administered on 10/17/18 for Residents #16, #19, #20, #21, #22, and #23. Continued review revealed the administration of Ivermectin on 11/1/18 was not documented until 11/6/18. Interview with the Administrator on 11/7/18 at 3:00 PM in the conference room confirmed there was inaccurate and missing documentation in the medical record.",2020-09-01
3271,"THE WATERS OF SMYRNA, LLC",445502,202 ENON SPRINGS ROAD EAST,SMYRNA,TN,37167,2018-01-16,584,D,1,0,POU411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to provide a clean, sanitary environment for 2 residents (#13, #15) of 16 residents reviewed. The findings included: Observation on [DATE] at 12:46 PM revealed Resident #13's room had an approximately 1-inch wide area of black grime surrounding the floor mat (used to prevent injuries in falls) which was positioned to the left side of the resident's bed. Food, including half-eaten crackers were noted under the resident's bed. Unidentifiable dried food was noted under and around the bed. Dried liquid splotches stained the floor. Food packaging was noted under and around the bed. A round disc was stuck to the floor behind the resident's bed and surrounded by a ring of grime. An attempt was made to interview the resident, but he was not interviewable and could not answer basic screening questions. Observation on [DATE] at 12:25 PM revealed the room was still in the same state as observed the previous day. Half-eaten orange crackers were still in the same place under the resident's bed. The grime around the floor mat was still present, as were the dried splotches of food and liquid. Interview with the Director of Nursing (DON) on [DATE] at 12:30 PM in Resident #13's room revealed the DON stated, He's a slob, eats in bed, and she added that there was constant food on the floor. The DON was then informed her current observations of the room, including old food, dried stains and grime were also present the previous day. She stated, If you say this was here yesterday, no, they're not cleaning thoroughly. When looking at the grime surrounding the floor mat, she stated, They're obviously not moving the mat or cleaning around it. The DON looked at the round disk that was stuck to the floor and pulled it up, leaving behind a round black ring of grime to indicate where it had been. Further interview with the DON revealed that she would inform Housekeeping Staff that the room needed cleaning. Observation on [DATE] at 5:00 PM revealed no change in Resident #13's room, which was still in need of cleaning. Observation on [DATE] at 7:15 AM revealed no change in Resident #13's room, which was still in need of cleaning. Observation and interview with the Housekeeping Supervisor on [DATE] at 10:45 AM in Resident #13's room confirmed the room needed cleaning. Continued interview with the Housekeeping Supervisor and Housekeeper #1 in the 100 Hall outside the room revealed Housekeeper #1 stated the room was cleaned every day; however, it was still a mess because the resident ate in bed. She stated it was also hard to clean the resident's room because he was routinely in the bed. Further interview with the Housekeeping Supervisor revealed that a new housekeeper had been working on [DATE]. She stated that the new housekeeper did not get started on cleaning Resident #13's hall until late in the afternoon and it appeared the room was missed based on the observations made on [DATE], [DATE] and [DATE]. She related that Resident #13 was moved to a different room that morning, and once his bed was out of the room, it could easily be seen that the floor was filthy. Observation on [DATE] at 12:55 PM in Resident #15's room revealed the floor in the room was sticky, with unidentified dried spills staining the floor. Continued observation revealed one dried substance on the floor was rusty colored red and had the appearance of a dried blood splatter. Interview with Certified Nurse Aide (CNA) #4 on [DATE] at 12:55 PM in Resident #15's room revealed the resident was admitted on [DATE] and placed in this room. Interview with the Maintenance Supervisor, who was present in the room during the [DATE] observation at 12:55 PM revealed, This room was supposed to be deep cleaned a couple of days ago, after the previous resident died . He confirmed the floor was dirty, sticky and in need of cleaning. Further observation of Resident #15's room, on [DATE] at 12:55 PM, revealed the floor on the roommate's side of the room was also littered with trash, stained with unidentifiable substances, and covered in half-eaten food. Interview with the DON on [DATE] at 10:30 PM in the conference room, confirmed the room of Resident #15 was in need of cleaning and it was not cleaned on a daily basis.",2020-09-01
4457,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2016-09-06,253,D,1,0,T33N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility housekeeping services failed to maintain 1 Resident's room (#6) in a sanitary manner of 32 occupied rooms on the first floor. The findings included: Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 8/22/16 at 9:23 AM, in the hallway outside the room of Resident #6 revealed a very strong urine odor. Further observation revealed the floor between the bed and the heater unit was sticky when walked on and black debris was present. Interview with the Director of Nursing on 8/22/16 at 9:35 AM, in Resident #6's room, confirmed the room smelled strongly of urine, the floor was sticky and the DON notified housekeeping.",2019-09-01
3714,GREYSTONE HEALTH CARE CENTER,445242,181 DUNLAP ROAD,BLOUNTVILLE,TN,37617,2017-03-15,241,D,1,0,NWOR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interviews the facility failed to maintain the dignity for one resident (#12) of twenty-one residents reviewed. The findings included: Medical record review of the Admission Record revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15, with 15 being the highest attainable score for intact cognition. Continued review revealed he was totally dependent on nursing staff for assistance with all Activities of Daily Living (ADLs). Further review revealed the Resident required a suprapubic urinary catheter for urinary elimination. Observation of Resident #12 on 2/15/2017, at 8:10 PM, in the Resident's room, confirmed he was lying in bed with his suprapubic urinary catheter tubing attached to a drainage bag. Continued observation confirmed the uncovered drainage bag was attached to the Resident's left side of the bedframe and visibly faced the open door toward the hallway. Further observation confirmed the uncovered bag contained 425 milliliters of medium-yellow colored urine. Continued observation confirmed multiple individuals were walking back and forth in the hallway, to include staff, other residents, and visitors. Further observation at 9:00 PM, in the presence of the Director of Nursing (DON) confirmed the bag remained uncovered. Interview with Resident #12 on 2/15/2017, at 9:05 PM, in his room, confirmed the Resident preferred the bag to be placed in a privacy bag. Interview with the DON on 2/15/2017, at 9:10 PM, in the Family Conference Room, confirmed the facility failed ensure the drainage bag was placed in a privacy bag and failed to maintain the Resident's dignity.",2020-03-01
3715,GREYSTONE HEALTH CARE CENTER,445242,181 DUNLAP ROAD,BLOUNTVILLE,TN,37617,2017-03-15,309,D,1,0,NWOR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interviews the facility failed to provide wound care for one Resident (#12) of five Residents reviewed. The findings included: Medical record review of the Admission Record revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15 and he was totally dependent on nursing staff for assistance with all Activities of Daily Living (ADLs). Medical record review of a Weekly Wound assessment dated [DATE] revealed Resident #12 had an acquired (developed in the facility) Stage II Pressure Ulcer on his right lower buttock in the gluteal fold. Continued review revealed the Pressure Ulcer measured 4.6 centimeters (cm) long (L) by 1.8 cm wide (W) by 0.1 cm in depth (D) and had a moderate amount of serosanguinous exudate. Medical record review of Physician's Monthly Recapitulation Orders dated 1/2017, revealed, .Right Lower Buttock-gluteal fold (horizontal groove marking the lower limit of the buttock) .Remove old dressing, clean with wound cleanser, apply epc (extra protective cream) cream to periwound (around the wound), then apply [MEDICATION NAME] gauze to wound, cover with abd (abdominal) pad, daily . Medical record review of a Nurse's Note dated 1/16/2017, (no time), and completed by Licensed Practical Nurse (LPN) #1, revealed, .Resident wound care not done due to limited staffing . Medical record review of the 1/2017 Treatment Administration Records (TARs), revealed LPN #1 initialed the block dated 1/16/2017 and circled the initials, indicating the daily wound treatment was not done. Medical record review of a Weekly Wound assessment dated [DATE] revealed the Pressure Ulcer measured 3.0 (L) by 1.6 (W) by 0.2 cm (D) with moderate serosanguinous exudate; and on 1/31/2017 measured 2.8 (L) by 1.5 (W) by 0.1 cm (D) with light serosanguinous exudate. Review of the Nursing Daily Staffing Sheets, Time Sheets, and Daily Census, dated 1/16 to 1/17/2017 revealed four nurses (LPN #1, two other LPNs, and one Registered Nurse) worked the night shift beginning on 1/16 at 6:30 PM, to the end of the shift on 1/17 at 6:30 AM. The census included a total of 79 residents, of which LPN #1 was assigned to a total of 15 with an intermediate level of care (a lesser acuity of care required). Observation of Resident #12 on 2/15/2017, at 8:28 PM, in the Resident's room, confirmed a Stage II Pressure Ulcer was present on his right buttock, in the gluteal fold Telephone interview with LPN #1 on 2/28/2017 at 9:25 PM, confirmed three additional nurses besides LPN #1 worked the night shift beginning on 1/16 at 6:30 PM, to 1/17/2017 at 6:30 AM. Continued interview revealed LPN #1 did not attempt to obtain assistance from any of the licensed nursing staff and did not attempt to notify the DON. Further interview with LPN #1 revealed she did not have any medical emergencies or emergency events to occur during the night shift beginning on 1/16 at 6:30 PM, to 1/17/2017 at 6:30 AM. Continued interview with LPN #1 confirmed she was assigned to 15 residents who required an intermediate level of care. Further interview with LPN #1 confirmed she failed to provide the wound treatment to Resident #12 on the night of 1/16/2017. Interview with the DON on 3/11/2017, at 6:10 PM, in the Family Conference Room, confirmed the facility failed ensure wound treatment was provided on 1/16/2017, resulting in a 24-hour delay in treatment.",2020-03-01
995,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2018-09-20,584,E,1,0,4QHC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and review of facility maintenance records, the facility failed to maintain clean, comfortable and home like conditions on 3 of 4 resident units observed for physical environment. The findings include: Observations of facility dining area and front lobby during initial tour revealed it was closed due to renovations in progress. Observations during the initial tour revealed the front lobby, front hallway, dining area and common seating areas adjacent to the lobby were cordoned off by a black, vinyl curtain with a zipper and sign that informed viewers that section of the facility was closed due to renovation. Continued observation revealed the dining room appeared to be renovated with new flooring, wall coverings and carpet. Rolls of new flooring materials were in the floor near the wall adjacent to the kitchen door of the dining room and the dining room appeared to have been unused for a substantial period of time as evidenced by dust on a few of the tables near the rear of the dining room adjacent to the kitchen. Staff offices in the construction area were in use, including the medical records department, admissions office, conference room and Administrator's Office. Interview with the Director of Nursing (DON) and construction foreman during the initial tour revealed the dining area and a major portion of the West Wing had been under renovation since (MONTH) (YEAR), and residents had been required to dine in their rooms or on the unit hallways since then. Observations of the East Wing, H Wing Hallway and portions of the West Wing still in use, with the DON, on 9/18/18, from 2:39 PM to 3:30 PM revealed the following: East Wing 1. A pervasive odor of urine was present in the hallway, attributed to the carpet, between rooms 205-212. room [ROOM NUMBER] was closed for renovations and was reported to have a pervasive odor prior to renovation due to odors absorbed by the wall coverings. 2. Crusty matter which appeared to be dried food particles were present ground into the carpet in front of the East Wing Nursing Station between rooms [ROOM NUMBERS]. 3. There was a pervasive odor of urine at the distal end of the East Wing again attributed to carpeting in the hallway in the vicinity of room [ROOM NUMBER], which extended to the exit door at the end of the unit. 4. Observations of the carpeting revealed the carpet was worn with multiple bare spots near the carpet edges, and heavy black staining throughout the East Unit. 5. The tile floors of rooms, 203-209, 223, 226, 230 and 231, were heavily scuffed with black marks, and appeared heavily worn, dirty and dull. 6. The wall covering near the door in room [ROOM NUMBER] was visibly stained and dirty. The wall covering around the air condition unit in room [ROOM NUMBER] was in a state disrepair, scuffed and dirty. 7. Observations of the East Wing Shower room revealed the metal box which contained the thermostat was hanging open. A single used vinyl glove was inside the lid of the box which hung by the hinges below the box. The plastic thermostat cover was lying in the hanging portion of the box. The thermostat mechanism itself with single red and white wires visible, was exposed to open air. A paper clip was noted to be present protruding from the lock mechanism on the upper front portion of the box which was inoperable. The box could not be closed by the DON who attempted secure it and it would fall open when attempts to close it were made. Continued observations of the H Hallway (between the East and West Units) revealed the following: 1. The H Hallway carpet was heavily worn and stained with a black stain that appeared water like in pattern, throughout the entire length of the hallway. A pervasive, musty odor was present the length of the hallway between the East and West units. There was dirt and debris ground into the carpet near the nursing stations at either end of the hallway. 2. Observations of the flooring in the H Hallway shower room revealed it to be in a state of disrepair. Sections of the flooring were loose and appeared to have become detached from the sub flooring beneath. The DON reported the shower had been out of use for several months due to the flooring issues and the owners of the facility had ordered it closed in lieu of repair, due to planned renovation. The DON reported at the time, the facility used the 2 remaining shower rooms (East wing shower at the other end of the H Hallway, and another shower room on the main hall entrance to the East Wing) for all 65 residents who remained in the facility. Observations of the West Wing revealed the following: 1. The carpet on the unit from the nursing station to the end of the unit was heavily worn and soiled with black stains similar to those noted on both the East and H Hallways. 2. A pervasive musty odor was present at the far end of the West Hallway. 3. The tile floors in the resident rooms were noted to be heavily scuffed, dirty and worn in rooms 122, 123, 125 and 131. The threshold of room [ROOM NUMBER] was noted to be covered with gray duct tape, which was torn at the edge adjacent to the door frame, wood fragments were noted to be in the floor atop the duct tape, which appeared to have flaked off the finish of the room door. Interview with the interim Housekeeping Supervisor (HS) revealed she had been in the position for 2 weeks. The HS reported the facility did not own a floor cleaner or tile buffer and the tile floors had not been cleaned other than routine mopping. The HS reported the facility did not own a carpet cleaner as well and staff attempted to keep the carpets clean via sweeping it or vacuuming it after meals. The HS confirmed for several months residents had taken meals in the hallways or their rooms as the dining hall had been closed due to renovations. The HS reported her predecessor had advised her and other members of the housekeeping staff, the facility owners did not wish to spend money on carpet or floor cleaning equipment or commercial carpeting cleaning services, due to the costs of ongoing renovations and plans to change the flooring. The HS reported the facility carpets had not been deep cleaned since before the last annual survey sometime in (YEAR). Review of the facility carpet cleaning receipts revealed the facility had not contracted for carpet cleaning since (MONTH) of (YEAR). There were no receipts for tile floor cleaning. Interview with the DON on 9/18/18 at 5:00 PM, in the conference room confirmed the facility did not own a tile floor buffer or carpet cleaner other than a standard vacuum cleaner, and confirmed the facility had not contracted for cleaning services for the floors since (MONTH) (YEAR) per the receipts. The DON confirmed the facility dining hall had been closed for 10 consecutive months due to renovations and confirmed the facility failed to maintain a clean, comfortable and homelike environment on the East Wing, H Hallway and West Wings as identified during observations.",2020-09-01
5053,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2016-05-25,431,D,1,0,TE8F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and policy/procedure review, the facility failed to ensure all opened vials of insulin were labeled with dates. The facility also failed to remove 1 expired vial of insulin from the supply for resident administration in 1 of 6 medication storage carts. The findings included: Review of facility policy, Medications with Special Expiration Date Requirements, revealed Humalog Insulin vials in use and not refrigerated were good for 28 days. Lantus Insulin vials that are in use and not refrigerated were also good for 28 days. Review of facility policy, Storage of Medication, revealed opened insulin vials should have the date noted when first used. Observation on [DATE] with Licensed Practical Nurse (LPN) G with medication carts on the Harriman Unit revealed 1 multi-dose vial of Lantus Insulin for an un-sampled resident was not labeled with an open date to calculate expiration. Continued observation revealed there were no other vials of Lantus Insulin for the un-sampled resident in the cart. Observation revealed 1 opened multi-dose vial of Humalog Insulin for a different un-sampled resident with an open date of [DATE] and was past its 28 day expiration. Interview with LPN G at the time of the observation confirmed the vial of Lantus was not labeled and the Humalog was expired and still in use. LPN G indicated it was the Nurse's responsibility to label opened vials and check for expiration dates prior to use.",2019-05-01
4491,CUMBERLAND HEALTH CARE AND REHABILITATION INC,445262,4343 ASHLAND CITY HWY,NASHVILLE,TN,37218,2016-09-21,332,D,1,0,KCHW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, medical record review, manufacturer's specifications review, and interview, the facility failed to administer the correct medication per the physician's orders [REDACTED].#8) of 4 residents observed during a medication pass of 25 medications administered, resulting in a medication error rate of 8%. The findings included: Observation of Licensed Practical Nurse (LPN #1) on 8/29/16 at 9:05 AM, in room [ROOM NUMBER]A revealed the LPN administered Calcium 600 milligrams (mg) plus D3 (Vitamin) 200 mg 1 tablet by mouth. Continued observation revealed the LPN administered [MEDICATION NAME] 160-4.5 mg inhalation medication 2 puffs consecutively one right after another to Resident #8. Medical record review of of a physician's orders [REDACTED]. Review of manufacturer's specifications for [MEDICATION NAME] with a revision date of 10/15 revealed, .If your prescribed dose is 2 puffs, wait at least one minute between them . Interview with LPN #1 on 8/29/16 at 10:40 AM, in the Conference Room confirmed she administered Calcium 600 mg with D3 200 mg instead of Calcium [MEDICATION NAME] 600 mg as prescribed by the Physician to Resident #8. Continued interview confirmed the LPN failed to wait at least one minute between each puff of [MEDICATION NAME] administered to Resident #8. Interview with the Director of Nursing (DON) on 8/29/16 at 11:00 AM, in the Conference Room confirmed there was no Calcium [MEDICATION NAME] 600 mg in stock in the facility at the present time. Continued interview confirmed [MEDICATION NAME] administration instructed users to wait at least one minute between each puff. Continued interview with the DON confirmed the facility failed to achieve a less than 5% medication error rate during the observation of med pass in the facility.",2019-09-01
3106,MCKENDREE VILLAGE,445491,4347 LEBANON ROAD,HERMITAGE,TN,37076,2018-01-19,803,E,1,0,7CQJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, review of facility menu, resident interview, review of the No Concentrated Sweets Diet policy and procedure, and staff interview, the facility failed to follow the menus for Residents #6, #10, and #12 on No Concentrated Sweet diets, for Resident #13 on a regular fortified nutrition diet, and for Residents #15 and #16 on mechanical soft fortified nutrition diets. This affected 6 of 51 residents (Residents #6, #10, #12, #15, and #16) who eat on the 1-East unit. Findings include: 1. Interview with the Food Service General Manager on 1/16/18 at 11:50 AM regarding facility menus. He stated the difference between the regular diet and the No Concentrated Sweets (NCS) diet was the NCS diet received a diet dessert and sugar substitute. On 1/16/18 multiple random observations were conducted on the 1-East unit between 12:20 PM to 1:20 PM while the noon meal was being served. The following residents on NCS diets were observed to have received the regular cake versus the diabetic substitute of the cake: a. On 1/16/18 at 12:40 PM Resident #6 was sitting in bed eating. Her menu slip stated she was on a NCS diet. She had a piece of chocolate cake with icing on her tray. At 12:42 PM the Food Service General Manager also checked the tray and verified the cake was regular and not the diet substitution of the cake. He replaced the cake with the diet chocolate cake. Review of Resident #6's Face Sheet in her medical record revealed a [DIAGNOSES REDACTED]. Review of her physician's orders [REDACTED]. At the time of the observation Resident #6 stated she often gets regular desserts on her trays. b. On 1/16/18 at 12:45 PM Resident #10 was sitting in his room eating. Review of the menu slip sitting next to his tray stated he was on a NCS diet. He had a piece of chocolate cake with icing on his tray. The Food Service General Manager was present at the time of the observation and verified the resident had received the regular chocolate cake and not the No Concentrated Sweets substitution of the chocolate cake. Review of his Face Sheet in his medical record revealed Resident #10 had a [DIAGNOSES REDACTED]. Resident #10's medical record contained a Telephone physician's orders [REDACTED]. c. On 1/16/18 at 12:50 PM Resident #12 was sitting in her room eating. Review of the menu slip sitting next to her tray indicated she was on a NCS diet. She had a piece of chocolate cake with icing on her tray. The Food Service General Manager was present at the time of the observation and verified the resident had received the regular chocolate cake and not the no concentrated sweets substitution of the chocolate cake. Review of her Face Sheet revealed Resident #10 had a [DIAGNOSES REDACTED]. At 12:50 PM the Food Service General Manager stated all the room trays were served from the main kitchen and not from the steam table located in the 1-East dining room. On 1/18/18 at 3:16 PM Registered Dietitian #1 was interviewed in the conference room. She verified the residents on the NCS diet should have received the diet substitution of the chocolate cake at the noon meal on 1/16/18. She stated she checked into it and found there was a misprint on the menu slips and as a result the staff in the kitchen served regular cake to some of the residents on the NCS diet. Review of the undated No Concentrated Sweets Diet policy and procedure stated, The NCS diet is a regular, nutritionally adequate diet that omits foods that are high in simple sugars (concentrated sweets). Carbohydrates that are unrefined and high in fiber are substituted for highly refined foods whenever possible and acceptable to the individual. Review of the Census List the facility had 51 residents residing on the first floor. Review of the List of Residents and Diets for Crosscheck provided by the facility revealed 5 residents on 1-East unit were on NCS diets. 2. On 1/16/18 at 12:30 PM Food Service Employee #1 was observed serving the noon meal from the steam table located in the 1-East Unit dining room. Mash potatoes, country fried steak, gravy, collard greens, biscuits, green beans, hash browned potatoes, hot dogs, and hamburgers were observed on the steam table. After Food Service Employee #1 served eight residents he was asked what utensil sizes he was using to serve the food and he stated he did not know. He stated, I just give them about the amount you would give a four-year-old. At 12:32 PM the Food Service General Manager was asked what utensil sizes were being used to serve the food items located on the steam table. He checked each utensil and stated Food Service Employee #1 was using a 2-ounce scoop for the ground meat, a 4-ounce scoop for the green beans, a 2-ounce (#16) scoop for the fortified mashed potatoes, a four-ounce scoop for the hash brown potatoes a four-ounce scoop for the collard greens, and a 4-ounce scoop for the gravy. Food Service Employee #1 continued to serve the entire meal using the same size utensils. Review of the menu revealed the residents on all diets were supposed to receive four ounces of either mashed, fortified, or hash browned potatoes. At 1:00 PM observations in the dining room revealed the following: a. Resident #13's menu slip stated she was on a Regular Fortified Nutrition Plan diet. She had a 2-ounce scoop of Fortified Nutrition Plan mashed potatoes on her plate. The menu slip stated 4-ounces of fortified potatoes. Review of her physician's orders [REDACTED]. Review of her Plan of Care with a problem onset date of 3/20/17 and a goal date of 3/22/18 revealed she had a [DIAGNOSES REDACTED]. The Plan of Care included an intervention to provide high calorie fortified foods Fortified Nutrition Plan. b. Resident #16's menu slip indicated she was on a mechanical soft Fortified Nutrition Plan diet. The menu slip indicated she should have received 4-ounces of fortified mashed potatoes and a Mighty Shake. The residents plate contained a 2-ounce scoop of potatoes and there was no Mighty Shake on the tray. The Food Service General Manager in addition to Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #4 were all present at the time of the observation and all stated the resident should have had the Mighty Shake on her tray when it was served to her. Review of the physician's orders [REDACTED]. Review of her Nutritional Plan of Care revealed she has a [DIAGNOSES REDACTED]. One of the interventions of the plan of care was to provide mighty shakes with meals three times a day. c. Resident #15's menu slip indicated she was on a mechanical soft Fortified Nutrition Plan diet. The menu slip indicated she should have received 4-ounces of fortified potatoes and a Magic Cup with her meal. The residents plate contained a 2-ounce scoop of potatoes and there was no Magic Cup on the tray. The Food Service General Manager, RN #1, and LPN #4 were all present at the time of the observation and all stated the resident should have had the Magic Cup on her tray when it was served to her. Review of the (MONTH) physician's orders [REDACTED]. At 1:30 PM the menu was reviewed with the Food Service General Manager. He verified a 2-ounce scoop was used to serve the Fortified Nutrition Plan mashed potatoes and verified a 4-ounce scoop should have been used to provide the Fortified Nutrition Plan correct size serving as ordered by the Physician. This citation resulted from information discovered during the complaint investigation TN 144.",2020-09-01
3360,LIFE CARE CENTER OF OOLTEWAH,445511,5911 SNOW HILL ROAD,OOLTEWAH,TN,37363,2018-03-05,583,D,1,0,U6GO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on of facility policy review, facility documentation, and interviews the facility failed to maintain personal privacy and confidentiality of a medical record for 1 resident #5 of 3 residents reviewed for privacy. The findings included: Review of facility policy, Safeguarding and Storage of Medical Records, revised 8/1/08 revealed .The facility must maintain medical records .The medical record is a legal document that contains confidential resident information and should be safeguarded against loss, tampering, or unauthorized use at all times . Medical record review revealed resident #5 was admitted to the facility on [DATE] and discharged on [DATE] with the [DIAGNOSES REDACTED]. Review of a Minimum Data Set ((MDS) dated [DATE] for Resident #5, revealed a Brief Interview of Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. Review of the facility's documentation for the HIPPA Case File Breach dated 8/7/17 revealed .Date of Report 8/7/17 .Date of Alleged Incident 6/15/17 .Date case closed 8/15/17 .Details of Alleged Incident: A discharge audit was done on a medical record and it was found that the (MONTH) (YEAR) MAR's (Medication Administration Record) and TAR's (Treatment Administration Record) were missing from the record . Interview on 3/5/18 at 8:55 AM, with the Health Information Manager, in her office, revealed Health Information completed a discharge audit on all medical records when a resident was discharged from the facility. Continued interview confirmed when the audit was completed on Resident #5's medical record the MAR and TAR for (MONTH) (YEAR) were missing. Further interview revealed the MAR and TAR contained information including the resident's name, medical diagnoses, admitted , medication list, and the location of the facility he had resided. Interview on 3/5/18 at 10:45 AM, with Resident #5, via telephone revealed the facility had notified him of the missing information from his medical record. Continued interview revealed he had no issues as a result from the missing MAR and TAR from (MONTH) (YEAR). Interview on 3/5/18 at 2:43 PM, with the Executive Director, in the private dining room confirmed the MAR and TAR for (MONTH) (YEAR) were missing from Resident #5's medical record, and the facility failed to safeguard and protect the confidentiality and privacy contained in the medical record.",2020-09-01
918,"NHC HEALTHCARE, HENDERSONVILLE",445191,370 OLD SHACKLE ISLAND RD,HENDERSONVILLE,TN,37075,2017-06-28,155,D,1,1,QJYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on patient rights review, medical record review, and interview, the facility failed to allow 1 Resident (#59) of 32 residents reviewed the right to refuse dental services. The findings included: Review of the Patient Rights handbook provided to each resident in the facility revealed, .You have the right to accept or refuse any medication or treatment .You are entitled to explore various options available to you and to choose the treatment option you prefer . Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].>Telephone interview with Resident #59's family conservator on 6/28/17 at 12:53 PM revealed she had revoked her consent for dental care in (YEAR). Continued interview revealed she had verbalized this to the Social Worker (SW) who stated she would call the dental office and tell them to take the resident off the list to be seen at the facility. Continued interview revealed the family conservator learned the resident received dental services on 1/5/17 after receiving a bill from the dental clinic. She called the facility and spoke with the SW and was told she would call the dental clinic again and make sure the resident was no longer on the list for cleanings or any further dental care. Medical record review revealed a Dental Progress Note dated 1/5/17 indicating that a dental exam, cleaning, and x-rays had been completed by the dental clinic for Resident #59. Interview with the SW on 6/28/17 at 2:05 PM in the classroom confirmed the family conservator had requested no dental services to be performed for the resident. Continued interview revealed the resident was placed on the exam list by the dental clinic in error, and the resident did receive dental services on 1/5/17. The SW stated, I just overlooked her being on the list when he showed it to me. The SW confirmed the facility failed to honor the resident's right to refuse dental services.",2020-09-01
5328,SERENE MANOR MEDICAL CTR.,4.4e+252,970 WRAY ST,KNOXVILLE,TN,37917,2016-04-08,226,D,1,0,GQVT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on personnel file review, facility's policy review, medical record review, review of facility investigation, and interview, the facility failed to timely report an allegation of abuse for 1 resident (#1) of 3 facility reported incidents reviewed and failed to provide training to the staff after a report of unwanted physical contact for 1 resident (#7) of 7 residents reviewed for Abuse. The findings included: Review of facility Resident Abuse Policy dated (MONTH) (YEAR) revealed .Alleged violations will be thoroughly investigated .the results of that investigation reported to the Administrator or his/her designated representative and to the other officials in accordance with State law, including the state survey and certification agency within 5 working days of the incident . 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 the resident scored 06/15 (severely cognitive impairment) on the Brief Interview for Mental Status (BIMS) and required limited assistance for ambulation in the room, dressing, and bathing. Review of a facility investigation revealed on 12/27/15 at 6:30 PM, the staff heard Resident #2 yelling for a Certified Nursing Assistant (CNA) and stated .they are in a fight . When the staff arrived Resident #1 and #3 were in a fight. Resident #3 stated Resident #1 was in the dayroom when he bumped into Resident #1's wheelchair. Resident #3 told Resident #1 .he was sorry and Resident #1 said you're sorry again and then started whacking on him with his grab bar . Resident #1 took the grab bar away and started hitting Resident #3 at which time Resident #2 started hitting Resident #1 to get him to quit hitting Resident #3. Resident #3 was kicking Resident #1. Resident #1 sustained a bruise to the left side of the nose at corner of the eye. An ice pack was applied to the nose of Resident #1 and an X-ray was ordered with negative results for fracture. Review of the Incident Reporting System (IRS) revealed the resident to resident incident occurred on 12/27/15 and was not reported to the state agency until 1/5/16 (6 working days after the incident). Interview with the Administrator on 4/6/16 at 8:10 AM, in the Administrator's office, confirmed the Administrator was aware the altercation on 12/27/15 was not reported until 1/5/16 (6 working days) and stated I realized it was late. Review of the personnel file of CNA #4 revealed on 10/12/15 the CNA signed the facility's Professional Conduct Policy and Prohibition Against Harassment which stated Each employee must exercise his or her own good judgment to avoid engaging in conduct that may be perceived by others as harassment. Forms of harassment include 3. Physical: included unwanted physical contact including touching . 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 the resident scored 12 (cognitive intact) on the BIMS. Continued review revealed the resident required extensive assistance of 2 for transfer and the assist of 1 for dressing and hygiene/bathing. Review of the Administrator's investigation related to the allegation of 3/22/16 revealed it was reported a CNA had spanked Resident #7 8 times on his bottom and did not stop when he told her to stop. The resident confirmed the CNA patted him on the bottom and he did not wish her to do this and when he had told her to stop she did. Resident #7 stated the CNA did not do this to harm or hurt him in any way and he did not feel threatened, scared or intimidated by the accused CNA or any other staff member. The Administrator and the Director of Nursing (DON) talked with the accused CNA and explained her action was not professional even though the resident stated it was all in fun and games, the resident must be treated with dignity and respect and this type of incident must not happen again. Interview with the resident on 4/7/16 at 7:45 AM, in the resident's room revealed the incident on 3/22/16 did happen but in a jovial way when he was coming out of the shower room and CNA #4 had patted him 1 time on the bottom and when he told her to stop she stopped. Telephone interview with the accused CNA (#4) on 4/7/16 at 1:25 PM revealed when the incident occurred they (resident and CNA) were just messing around. The resident was in the shower room with another CNA (#2) present and while the resident was being let down from the shower lift into the whirlpool chair she patted the resident on the bottom and he told her to stop at which time she stopped. The CNA stated she meant no harm either physical or mental and would never do it again. Interview with the Administrator on 4/8/15 at 9:15 AM, in the Administrator's office confirmed only CNA #4 (accused CNA) was in-serviced following the incident related to the facility's Professional Conduct Policy concerning unwanted physical contact including touching and in-service with other staff members did not occur.",2019-04-01
3941,BEECH TREE HEALTH AND REHABILITATION,445292,"240 HOSPITAL LANE, PO BOX 300",JELLICO,TN,37762,2017-01-12,225,D,1,0,IM2S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review review, medical record review, review of facility documentation, and interview, the facility failed to report allegation of verbal abuse for 1 resident (#1) of 4 residents reviewed for abuse. The findings included: Review of the facility policy, Abuse, Neglect, Exploitation and Misappropriation of Resident Property, no date, revealed .Staff should report all incidents/allegations immediately to the Administrator or designee . 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 the resident was moderately impaired for daily decision making. Review of facility documentation dated 12/13/16 revealed facility staff did not immediately report an allegation of verbal abuse involving Resident #1 and a Certified Nursing Assistant (CNA). Interview with CNA #1 on 1/9/17 at 11:10 AM, on the 300 Hall, revealed she witnessed an incident where CNA #2 was .verbally rough . with Resident #1. Continued interview confirmed CNA #1 did not immediately report the incident. Interview with the Director of Nursing (DON) on 1/9/17 at 2:10 PM, in the conference room, confirmed the the incident was not immediately reported by facility staff and the facility failed to follow facility policy.",2020-01-01
1091,THE KINGS DAUGHTERS AND SONS,445221,3568 APPLING ROAD,BARTLETT,TN,38133,2019-07-17,609,D,1,0,GL8F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, Facility Reported Incident (FRI) review, medical record review, and interview, the facility failed to report an allegation of abuse and neglect within 2 hours for 1 of 3 (Resident #1) sampled residents reviewed. The findings include: Review of the undated facility Abuse Prevention Policy documented, .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified time frames: a. Immediately, but not later than 2 hours after the allegation is made . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Assessment revealed Resident #1 scored a 12 on the Brief Interview of Mental Status (BIMS) which indicated the resident was cognitively intact for decision making. Review of the Event Report dated 7/8/19 documented, .Administrator was notified of allegation of abuse on 7/8/19 at approximately 12 PM by (named person) MDS Coordinator .Ms. (Resident #1's) daughter reported that on 6/24/19 a certified nursing assistant (CNA) had come into her mother's room to put her to bed and grabbed her by the arm and the back of the pants, attempting to transfer her without a lift. She stated that in doing this she dropped her on the floor. She stated the certified nursing assistant then roughly picked her mother up off the floor and put her back in the bed and never told anyone the incident occurred . Review of the FRI revealed the incident was reported to the State Agency on 7/9/19 at 5:44 PM. Interview on 7/17/19 at 10:30 AM in the conference room, the MDS Coordinator confirmed her witness statement. She stated, .( (Resident #1's daughter) came to me on 7/8/19 at approximately 12 noon and informed me that (Resident #1) had been abused on 6/24/19 by a CNA because she was yanked on the arm and put in the bed .I immediately informed the Administrator there was an allegation of abuse . Interview on 7/17/19 at 2:00 PM with the Assistant Director of Nursing (ADON) in the conference room, the ADON confirmed the abuse allegation was reported to the State Agency by the Administrator on 7/9/19, 24 hours after the facility received the allegation of abuse. The ADON stated, .The Administrator said she thought she had 24 hours .",2020-09-01
4170,AHC HARBOR VIEW,445428,1513 N 2ND STREET,MEMPHIS,TN,38107,2016-12-22,309,G,1,0,XY5611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, Job Description NURSING ASSISTANT AND ORDERLY, medical record review, and interview, the facility failed to provide care and treatment for constipation for 3 of 6 (Resident #1, 3, and 4) sampled residents. The facility failed to provide recommended and ordered interventions for Resident #1, resulting in avoidable pain, constipation, and hospitalization requiring manual removal, which resulted in actual harm to Resident #1. The findings included: 1. The facility's PHYSICIAN STANDING ORDERS policy documented, .Physician standing orders or protocol orders are pre-authorized orders conditioned upon the occurrences of certain clinical events . The facility's Care Plans policy documented .Care Planning is an essential part of healthcare providing a road map of sorts, to guide all who are involved with the patient's care . The facility's Job Description NURSING ASSISTANT AND ORDERLY documented, .The following job functions have been determined to be essential to the position of nursing assistant .3. Report changes in the resident's condition to the charge/staff nurse as soon as possible. Document in records . 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented Resident #1 had severe cognitive deficits, required extensive assistance with activities of daily living (ADLs), was always incontinent of bowel and bladder, and received antidepressant and antibiotic medications. The quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #1 had moderate cognitive deficits, and was always incontinent of bowel and bladder. The care plan dated 7/5/16 documented Resident #1 was at risk for constipation related to decreased mobility, with interventions to assess and document Resident #1's usual bowel movement history to include medication use, laxative use, diet, fluids, exercise, and personal remedies, and intervene with laxatives or stool softeners as ordered. The Physician order [REDACTED].Q (every) pm with supper .7/14/16 Multivitamins (1) tablet oral .QD (everyday) .8/4/16 [MEDICATION NAME] .25 mg (1) tablet oral .QID (four times daily) .8/4/16 [MEDICATION NAME] 5-325 mg (1) tablet oral .bid (twice daily) PRN (as needed) .8/9/16 [MEDICATION NAME] .0.1 mg (1) tablet oral .QID PRN . These medications have the side effect of constipation. The Clinical Pathway (physician's standing orders) dated 7/20/16 documented, .Constipation: Check Bowel Movement record; Notify Provider of any abdominal distention. If no abdominal distention and no BM (bowel movement) in last 3 days: Milk of Magnesia (MOM) 30 cc (cubic centimeters) po (by mouth) .prn (as needed) constipation; or [MEDICATION NAME] tablet 1 po .or 1 suppository PR (per rectum) daily prn constipation. Fleets enema if MOM or [MEDICATION NAME] not effective in 24 hours .Notify provider if Fleets enema not effective within 24 hours . The ADL Verification Worksheets were requested and provided for Resident #1. The ADL Worksheet did not document that Resident #1 had a bowel movement on 8/19/16, 8/20/16, 8/21/16, 8/22/16, and 8/23/2016. The facility was unable to provide documentation the bowel protocol was followed. The ADL Verification Worksheets were requested and provided for Resident #1. The ADL Worksheet did not document that Resident #1 had a bowel movement on 8/25/16, 8/26/16, 8/27/16, 8/28/16, and 8/29/2016. The facility was unable to provide documentation the bowel protocol was followed. A Clinical Note dated 8/29/16 documented, .1200 Resident complained of abdominal pain. Resident's family called wanting (Resident #1) to be transported to ER (emergency room ) immediately. Nurse Practitioner called and gave verbal order to send resident to the hospital . A Physician Telephone Order dated 8/29/16 documented, .Send resident to ER for evaluation for complaints of abdominal pain . The (Named Hospital Emergency Department) Physician Documentation dated 8/29/16 documented, .Diagnosis: [REDACTED].History of Present Illness .The patient presents with abdominal pain. The course/duration of symptoms is constant. The character of symptoms is crampy. The degree at onset was moderate .The degree at present is moderate .Review of Symptoms .Gastrointestinal Symptoms: Abdominal pain, nausea, vomiting. No diarrhea .Differential Diagnosis: [REDACTED]. The (Named Long Term Care (LTC) Facility) Vital Signs/Pain assessment dated [DATE] at 13:33 (1:33 PM)documented, .Pain .Yes .Pain Intensity .5 .Primary pain location .Other: ABD (abdominal) pain/buttocks pain .Primary pain character .Aching .Primary pain onset .gradual .Primary pain pattern .Constant . The (Named Hospital) History Forms dated 8/29/16 documented, .Chief complaint .pt (patient) brought in by (Named Ambulance Service) from (Named Long Term Care Facility) for c/o (complaints of) ABD pain. pt has history of ABD aneurysm . The (Named LTC Facility) Clinical Data Flowsheets .GASTROINTESTINAL assessment dated [DATE] at 14:15 (2:15 PM) documented, .Stool Character .Hard .GI symptoms .Constipation . The (Named LTC Facility) Clinical Data Flowsheets .GASTOINTESTINAL assessment dated [DATE] at 18:06 (6:06 PM) documented, .Stool Character .Hard .GI (Gastrointestinal) symptoms .Constipation . The (Named Hospital) History Form dated 8/29/16 documented, .this nurse removed a very large, formed stool from patient's rectum . Interview with Certified Nursing Assistant #2 (CNA) on 12/20/16 at 2:30 PM, in the conference room, CNA #2 was asked who was responsible for charting bowel movements. CNA #2 stated, .the CNA's . The facility failed to provide recommended and ordered interventions for Resident #1, resulting in avoidable pain, constipation, and hospitalization , which resulted in actual harm to Resident #1. 3. Medical record review revealed Resident #3 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 #3 was cognitively intact and always incontinent of bowel. The care plan dated 11/28/16 documented Resident #3 was always incontinent of bowel related to [DIAGNOSES REDACTED]. The ADL Verification Worksheets were requested and provided for Resident #3. The ADL Worksheet did not document that Resident #3 had a bowel movement on the following days: 8/2/16, 8/3/16, 8/4/16, 8/5/16, 8/6/16, and 8/7/16. The facility was unable to provide documentation the bowel protocol was followed. The ADL Worksheets were requested and provided for Resident #3. The ADL Worksheet did not document that Resident #3 had a bowel movement on the following days 8/9/16, 8/10/16, 8/11/16, 8/12/16, and 8/13/16. The facility was unable to provide documentation the bowel protocol was followed. The ADL Worksheets were requested and provided for Resident #3. The ADL Worksheet did not document that Resident #3 had a bowel movement on the following days 10/4/16, 10/5/16, 10/6/16, 10/7/16, 10/8/16, 10/9/16, and 10/10/16. The facility was unable to provide documentation the bowel protocol was followed. 4. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #4 was cognitively intact and occasionally incontinent of bowel. The annual MDS dated [DATE], revealed Resident #4 had moderate cognitive impairment and was occasionally incontinent of bowel. The care plan dated 11/29/16 documented Resident #4 was at risk for constipation related to history of constipation, with interventions to monitor and document Resident #4's bowel movements, intervene with stool softeners and laxatives and to have a bowel movement every three days. The ADL Verification Worksheets were requested and provided for Resident #4. The ADL Worksheet did not document that Resident #4 had a bowel movement on the following days: 8/5/16, 8/6/16, 8/7/16, 8/8/16, 8/9/16, and 8/10/16. The facility was unable to provide documentation the bowel protocol was followed. The ADL Verification Worksheets were requested and provided for Resident #4. The ADL Worksheet did not document that Resident #4 had a bowel movement on the following days: 8/12/16, 8/13/16, 8/14/16, and 8/15/16. The facility was unable to provide documentation the bowel protocol was followed. The ADL Verification Worksheets were requested and provided for Resident #4. The ADL Worksheet did not document that Resident #4 had a bowel movement on the following days: 8/17/16, 8/18/16, 8/19/16, 8/20/16, 8/21/16, and 8/22/16. The facility was unable to provide documentation the bowel protocol was followed. The ADL Verification Worksheets were requested and provided for Resident #4. The ADL Worksheet did not document that Resident #4 had a bowel movement on the following days: 9/5/16, 9/6/16, 9/7/16, 9/8/16, 9/9/16, 9/10/16, 9/11/16, 9/12/12, and 9/13/16. The facility was unable to provide documentation the bowel protocol was followed. The ADL Verification Worksheets were requested and provided for Resident #4. The ADL Worksheet did not document that Resident #4 had a bowel movement on the following days: 9/20/16, 9/21/16, 9/22/16, 9/23/16, 9/24/16, 9/25/16, 9/26/16, 9/27/12, 9/28/16, and 9/29/16. The facility was unable to provide documentation the bowel protocol was followed. 8. Interview with the Director of Nursing (DON) on 12/20/16 at 7:00 PM, in the conference room, the DON was shown the ADL records of Resident #1 and was asked if she would say that the nursing staff followed the Resident #1's care plan. The DON stated, No. The DON was asked if she considered the Clinical Pathways physician orders. The DON stated, .standing orders .yes they would be considered physician orders [REDACTED].#1 and was asked if her nursing staff had followed the physician's orders [REDACTED].I don't see any documentation where they did . The DON was shown the ADL records for Resident #1's oral care and baths. The DON was asked if the nursing staff had followed Resident #1's care plan. The DON stated, No. The DON was asked how the CNA's knew what they were to do for their assigned residents. The DON stated, .the kiosk lists the resident care needs and it's updated as things change for the resident . The DON was asked what the blanks on the ADL records meant. The DON stated, The blanks mean the care was not given or it wasn't documented that it was given.",2019-11-01
2865,AHC PARIS,445462,800 VOLUNTEER DRIVE,PARIS,TN,38242,2019-09-06,689,J,1,0,EU6411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, National Weather Service Records, review of a police report, medical record review, observation, and interview, the facility failed to ensure adequate supervision to prevent elopement (unsupervised wandering off of the grounds of the facility) for 2 of 6 (Resident #1 and #2) cognitively impaired, vulnerable, residents reviewed for wandering/exit seeking behaviors. The failure of the facility to supervise and monitor residents with exit-seeking behaviors placed Resident #1 and #2 in Immediate Jeopardy when these residents eloped from the facility and were found in the turning lane of a heavily traveled street. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Regional Nurse Consultant were notified of the Immediate Jeopardy on 9/4/19 at 3:22 PM, in the Conference Room. F-689 was cited at a scope and severity of [NAME] F-689 J is Substandard Quality of Care. A partial extended survey was conducted on 9/4/19-9/6/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on 9/5/19 at 12:05 PM, and the A[NAME] was validated onsite by the surveyor on 9/5/19 and 9/6/19 through review of assessments, policies related to active exit seeking behaviors, staff interviews, and in-service training records. The IJ was effective from 8/11/19 to 9/5/19. The findings include: 1. The facility's Elopements and Wandering Patients policy with a revision date of 11/2017 documented, .The facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents .Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff .Adequate supervision will be provided to help prevent accidents or elopements . 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a ELOPEMENT RISK assessment dated [DATE] revealed Resident #1 was a low risk for elopement. Medical record review of a Nursing Clinical Note dated 7/30/19 documented, .up in wheelchair wandering hallways at this time . Medical record review of a Nursing Clinical Note for Resident #1 dated 8/2/19 documented, .observed pt. (patient) wandering in and out of other rooms . Medical record review revealed there was no risk assessment completed when Resident #1 displayed these wandering behaviors prior to the elopement. Medical record review of the 14 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was assessed to have a Brief Interview of Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. Resident #1 needed extensive assistance with transferring and walking and used an assistive device for mobility. A Police Report dated 8/11/19 documented, .WELFARE CHECK .CALL INFORMATION DISPATCHED DATE/TIME 08-11-2019 16:04 (4:04 PM) .ELDERLY FEMALE IS PUSHING AN ELDERLY MALE SUBJECT IN A WHEELCHAIR IN THE MIDDLE OF THE STREET .08-11-2019 16:18 (4:18 PM) .THE STAFF FROM (Named Nursing Home) HAS THESE SUBJS (subjects, Resident #1 and #2) . Medical record review of a ELOPEMENT RISK assessment dated [DATE] revealed Resident #1 was a high risk for elopement and interventions of Wanderguard bracelet initiated Care plan initiated/updated to reflect elopement risk and interventions implemented . Medical record review of the Care Plan Report revised on 8/11/19 documented, .At risk for elopement from facility due to wandering Actual attempt was successful to exit building 8/11/19 .Resident will not exit building without proper supervision .Offer diversional activities as needed .All visits with wife in her room and common areas .Monitor resident's location and presence of wanderguard .Assess potential physical causes for wandering (need of toilet, water, food, pain relief) .Provide diversional activities (folding, rummaging box, packing/unpacking . Medical record review of a Nursing Clinical Note dated 8/12/19 documented, .At approximately 16:10 (4:10 PM on 8/11/19) a police officer called to notify us (facility staff) there was a man (Resident #1) in a wheel chair stating he lived at our facility in the road .staff escorted both (Resident #1 and #2) back into the building . Medical record review of a Nursing Clinical Note for Resident #1 dated 8/14/19 documented, .wanderguard intact to right ankle, resident continues to wander off and nurse has pulled resident out of 2 different residents room so far this shift. Resident also keeps attempting to stand up with very unsteady balance . Observation and interview in Resident #1's room on 9/5/19 at 3:20 PM, revealed Resident #1 wanted to know where his wife (Resident #2) was at the time. He could not remember his wife was residing in another area of the facility. He could not remember the location of the Secure Unit. Staff assisted Resident #1 to visit with his wife in the Secure Unit. 3. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Nursing Clinical Note dated 8/3/19 documented, .confused tonight. She (Resident #2) wanders in and out of other residents rooms and has asked this nurse to help find (her husband, Named Resident #1) . Medical record review of a Nursing Clinical Note for Resident #2 dated 8/4/19 documented, .overheard pt (patient) telling her husband (Resident #1) 'they are letting us go, and we have to go' then proceeded to help him (Resident #1) out of bed. Aide notified nurse that pt (Resident #2) was telling husband (Resident #1) they need to escape . Medical record review of a Nursing Clinical Note dated 8/5/19 documented, .wonderguard (wanderguard) placed to lt (left) ankle for wondering (wandering) behavior moving in and out of rooms searching for husband .redirected numerous times and continued searching through rooms . Medical record review of a ELOPEMENT RISK assessment dated [DATE] revealed Resident #2 was a high risk for elopement and interventions of Wanderguard bracelet initiated . Medical record review of a Nursing Clinical Note for Resident #2 dated 8/7/19 documented, .earlier this am (before midday) pushing husband in w/c (wheelchair) down hallway . Medical record review of the admission MDS dated [DATE] revealed Resident #2 was assessed to have a BIMS score of 3, which indicated severe cognitive impairment. Resident #2 did not require any assistive devices and walked independently with supervision. Resident #2 exhibited wandering behavior daily. Review of the Care Plan Report revised 8/11/19 documented, .Problems .(Named Resident #2) has exhibited Wandering Behavior .Assess potential physical causes for wandering (need for toilet, water, food, pain relief) .Provide diversional activities (folding, rummaging box, packing/unpacking) .Redirect (Named Resident #2) behavior/activity when wandering (8/11/19) Place in Special Care Unit. Ensure all door alarms/locks are armed to reduce the risk of (Named Resident #2) leaving secure area .Elopement 8/11/19: Placed on one on one observation, then placed in secure unit . Medical record review of a ELOPEMENT RISK assessment dated [DATE] revealed Resident #2 was a high risk for elopement and interventions of Wanderguard bracelet initiated . Medical record review of a ELOPEMENT RISK assessment dated [DATE] revealed Resident #2 was a high risk for elopement and interventions of Care plan initiated/updated to reflect elopement risk and interventions implemented . The National Weather Service records revealed the recorded high temperature for the facility area on 8/11/19 (the day of the elopement from the facility) was 93 degrees Fahrenheit. Review of the facility's security video monitor footage date and time stamped 8/11/19 at 16:09 (4:09 PM) revealed Resident #2 propelling Resident #1 in his wheelchair across the front parking lot and into the turning lane of the street, headed North. The couple was unsupervised and traffic was constant in both side lanes of the street. Review of Licensed Practical Nurse (LPN) #1's written statement dated 8/11/19 and verified by LPN #1 documented, .At around 4:10 (PM) the phone rang and an officer stated that he (Officer) had a gentleman in a w/c (wheelchair) at the (Named Elementary School) parking lot stating he (Resident #1) was from here (Nursing Home) but could not give a name . Review of LPN #2's written statement dated 8/11/19 documented, .Nurse took the phone call stating a resident (Resident #1) in a wheelchair was in the road between the facility & (and) Elementary School . Medical record review of a Social Services Clinical Note for Resident #2 dated 8/13/19 documented, .Resident does wander on secure unit and will go to doors . Observations in Resident #2's room on the Secure Unit on 9/3/19 at 1:15 PM, revealed Resident #2 was walking around in her room. She ambulated independently with good balance. Resident #2's husband (Resident #1) was visiting in her room. Resident #2 would follow Resident #1's directions for pushing him (Resident #1) in his wheelchair to go out into the hallway and to the dining area Interview with the Administrator on 9/3/19 at 2:50 PM, in the Conference Room, the Administrator was asked how Resident #1 and #2 exited the building. The Administrator stated, .went out exit door at end of service hall by the Secure Unit. Only door with alarm is front door. We (Administrative staff) reviewed the camera recording that evening. Two staff from dietary were on break outside and 1 of the staff punched in the code to open the door .They (dietary staff) helped them (Resident #1 and #2) out the door. They (dietary staff) came back in to work . Interview with Licensed Practical Nurse (LPN) #2 on 9/3/19 at 4:00 PM in the Conference Room, LPN #2 was asked if Resident #2 had displayed wandering behavior on 8/11/19. LPN #2 stated, .Wife (Resident #2) pushed him (Resident #1) in wheelchair down 300 cubby (short end of hall) and back up .It was routine for her to push him around .She would push him on all halls. They would look out doors some . Telephone interview with Dietary Aide #1 on 9/3/19 at 4:32 PM, Dietary Aide #1 was asked if he knew how Resident #1 and #2 had exited the building on 8/11/19. Dietary Aide #1 stated, .on my way in toward the dietary door, I noticed a lady and gentleman (Resident #1 and #2) at the door tapping on the glass. I went ahead and put the code in .I told them (Resident #1 and #2) they could go around to the front and sit under the awning. She (Resident #2) said okay and started pushing him (Resident #1) in the wheelchair toward the front. I knew he (Resident #1) was a resident, but I thought she (Resident #2) was a visitor . Interview with LPN #1 on 9/4/19 at 2:09 PM in the Dogwood Lane Hall, LPN #1 was asked what she would do to monitor and supervise residents at risk of wandering with exit seeking behaviors. LPN #1 stated, We did 15 minute checks on residents with wanderguards. We don't do that anymore. Nothing really. Interview with the Administrator and the Director of Nursing (DON) on 9/4/19 at 2:50 PM in the Administrator Office, they were asked what facility action was taken to ensure supervision was adequate for cognitively impaired residents with wandering/exit seeking behaviors. The Administrator stated, .changed the door codes. We did 15 minute checks for 72 hours on all residents with wanderguards. Nurse Managers did a risk assessment on all residents . The Administrator and the DON confirmed there were no new interventions currently in place for staff supervision of residents after the elopement of Resident #1 and #2 and the Care Plans of Resident #1 and #2 were updated on 8/11/19 with no new care plan interventions in place for supervision. The facility is located across the street from a small lake, near several businesses and an Elementary School. The street is a heavily traveled by traffic. The surveyor validated the A[NAME] by: 1. All entry/exit door codes were changed on 8/11/19. On 8/12/19 the Director of Nursing ensured signage was placed at each entry/exit door on red paper stating Attention Family, Staff and Residents: You must check in with the nurse of the resident before you can let someone leave the facility or go outside. Family, residents, and visitors must enter/exit through front door. The surveyor viewed the signage on each entry/exit door. 2. The Maintenance Director checked all entry/exit doors for proper functioning on 8/11/19 and 8/12/19, and weekly checks were ongoing. The surveyor reviewed the door check logs. 3. Residents wearing wanderguard bracelets will be checked every shift by a nurse to ensure placement of the wanderguard bracelet is maintained beginning on 8/11/19. Wanderguard transmitter functionality will be verified each day per Nursing Staff. The surveyor reviewed the documented check logs and interviewed staff on each shift. 4. All wanderguard transmitters were checked on 8/11/19, then daily by the nursing staff. The surveyor made observations and reviewed the daily wanderguard transmitter check logs. 5. A Wanderguard Identification Book was verified for accuracy on 8/11/19 by Nurse Managers. A Wanderguard Identification Book was placed in Dietary, Laundry, Receptionist Office, Activity Department, and Therapy Department on 8/12/19. The book will be updated as needed by the Social Worker. The surveyor reviewed the Wanderguard Book in each department for accuracy and placement. 6. Elopement risk assessments on all residents were completed on 8/12/19. The surveyor reviewed each assessment. 7. The Quality Assurance and Performance Improvement (QAPI) committee met on 8/12/19 to review and discuss specifics of plan of correction to prevent elopement and ensure resident safety. The QAPI committee completed a Community Risk Assessment and Evaluation on Elopement Prevention and Response on 8/12/19. The surveyor reviewed the assessment and the minutes of the QAPI meeting. 8. Facility Staff education was provided by the Administrator and Nurse Managers on facility elopement and wandering patients policy to all staff which began 8/11/19 and was completed 8/16/19. The surveyor reviewed the education sign-in forms and verified each staff member participation. The surveyor interviewed staff on each shift. 9. Elopement drills on all 3 shifts were conducted and completed by Maintenance Staff by 8/15/19 and will be ongoing weekly for one month for 2 months, then twice a year and as needed by Maintenance Staff. Discussions of drills will be ongoing during monthly staff meetings. The surveyor reviewed the elopement drills. 10. All staff were provided education for supervision of cognitively impaired residents with exit seeking behavior to prevent accidents and outcomes with serious injury. The education began 9/4/19 for on-duty staff and all off-duty staff to be educated before returning to work. The surveyor reviewed the education and sign-in forms and interviewed staff on each shift. 11. Nurses will implement interventions based on the elopement risk assessment. Cognitively impaired residents with exit seeking behavior not residing in the Secure Unit will have every 15 minute visual checks for 72 hours and other interventions implemented as appropriate may include but not limited to: placement on the Secure Unit, redirection, wanderguard bracelet, diversional activities, and referrals to other disciplines/departments. The surveyor observed interventions implemented and interviewed staff on each shift. 12. Beginning 9/5/19, the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinators, and Medical Records Nurse will audit staff education and supervision of cognitively impaired residents with exit seeking behavior every shift for one week, daily for one week, weekly for four weeks, monthly for two months, then quarterly ongoing. The surveyor reviewed the education audits and interviewed staff on each shift. 13. Results of the findings from the audits of staff education and supervision of cognitively impaired residents with exit seeking behaviors will be reported to the QA Committee. Noncompliance of F-689 continues at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.",2020-09-01
2957,DICKSON HEALTH AND REHAB,445477,901 N CHARLOTTE,DICKSON,TN,37055,2019-08-29,689,J,1,1,K4RM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, National Weather Service record, medical record review, observation, and interview, the facility failed to ensure adequate supervision and monitoring for 4 of 4 (Resident #38, #44, #272, and #422) cognitively impaired, vulnerable residents who had wandering and exit seeking behaviors. The failure of the facility to ensure a safe environment and adequately supervise residents placed Resident #38 in Immediate Jeopardy. Resident #38 was a cognitively impaired resident with prior wandering and exit seeking behaviors, who was missing for approximately 15 minutes before staff saw the resident outside the facility unsupervised and realized he had eloped from the facility. Resident #38 was found by a staff member in his wheelchair on a heavily traveled street beside the facility. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 8/27/19 at 7:21 PM, in the Assistant Director of Nursing (ADON) Office. F-689 was cited at a scope and severity of [NAME] F-689 is Substandard Quality of Care. An extended survey was conducted on 8/28/19 through 8/29/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on 8/29/19 at 1:50 PM and the A[NAME] was validated onsite by the surveyor on 8/29/19 through review of assessments, policies related to exit seeking behavior, in-service training records, and staff interviews. The IJ was effective from 8/20/19 to 8/28/19. The findings include: 1. The facility's Elopement policy, revised (MONTH) (YEAR), documented, .Elopement occurs when a resident leaves the premise (premises) or a safe area without authorization .and/or any necessary supervision to do so .For residents requiring increased monitoring of wandering, the Licensed Nurse will initiate, 'Elopement / Wandering' supervision for a specific period of time identified in the care plan or physician orders [REDACTED].documented in the Nurses Notes as to effect of interventions . The facility's Wandering, Unsafe Resident policy, revised (MONTH) (YEAR), documented, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement . The facility's Safety and Supervision of Residents policy, revised (MONTH) 2007 documented, .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . 2. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Wandering and Elopement Evaluation dated 6/28/19 revealed Resident #38 was assessed as low risk for wandering and elopement. Medical record review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #38 was assessed to have a Brief Interview of Mental Status (BIMS) of 3, which indicated severe cognitive impairment. The resident was visually impaired and had delusional behaviors. He was not assessed to have wandering behaviors. Medical record review of a Nurses' Note dated 8/15/19 revealed Resident #38 was anxious and agitated and was exhibiting exit-seeking behaviors such as lingering around exit doors and trying to push the doors open. A physician's orders [REDACTED].Wanderguard r/t (related to) elopement risk . Medical record review of a Wandering and Elopement Evaluation dated 8/15/19 (the day his exit seeking behaviors began) revealed Resident #38 was reassessed as a low risk for wandering. Medical record review of the Comprehensive Care Plan revised 8/15/19 revealed Resident #38 was an elopement risk and had wandering tendencies due to impaired safety awareness. The interventions included to distract the resident from wandering by offering diversional activities, to document wandering behaviors and attempted diversional activities, and to check placement of wanderguard per protocol. The facility was unable to provide a protocol for wanderguards. A Nurses' Note dated 8/20/19 at 3:30 PM documented, .staff reported resident was observed outside. therapy (Therapy) and nursing staff obtained resident from road next to parking lot entrance. Resident was in his w/c (wheelchair), self propelling to road. resident (Resident #38) exited facility from exit door near chapel that exits to parking lot .wander guard remains in place to right ankle . Review of a Wandering and Elopement Evaluation dated 8/20/19, after Resident #38 eloped from the facility, revealed moderate risk for wandering and elopement. The National Weather Service records revealed the recorded high temperature for the facility area on 8/20/19 (the day of the elopement from the facility) was 95 degrees Fahrenheit. The facility is located near a school on a hill. The road is heavily traveled by traffic and has limited visibility. Medical record review revealed after Resident #38 exhibited exit seeking behaviors, there was no nursing documentation in the progress notes between 8/15/19 and 8/20/19 related to any type of exit seeking behaviors. Observations in the Dining Room on 8/25/19 at 10:15 AM, revealed Resident #38 was sitting in a wheelchair, wearing glasses, and had a wanderguard on his right ankle. Interview with Licensed Occupational Therapist (OT) on 8/26/19 at 11:18 AM, in the ADON Office, the OT was asked to review her written statement and sign and date it if there were no changes. The statement dated 8/20/19 read as follows, At approximately 3:30 PM I was sitting in my car in the parking lot talking with my ride .I looked out to see (Named Resident #38) self-propelling his wheelchair in the road . At this time the OT changed her statement to read, .(Named Resident #38) was seen self-propelling toward the road, not in the road . The OT wrote this statement at the bottom of her previous written statement. The OT was asked where Resident #38 was when she found him. The OT stated, Where the parking lot and road meet . The OT was asked what the weather conditions were outside at the time. The OT stated, Hot. Observation and interview with the OT on 8/26/19 at 11:45 AM, in the facility's parking lot, the OT stated, We were parked in the 3rd parking spot and there were no cars beside us so we could see where he (Resident #38) was . The OT was asked to clarify why she stated Resident #38 was in the road on her original statement. The OT stated, Because I thought he (Resident #38) was in the road when I first saw him .his wheelchair was literally sitting right here (pointed with her toe to the line where the pavement of the facility's parking lot met the pavement of the heavily traveled city street) . Observations in the East Hall on 8/26/19 at 2:36 PM, revealed Resident #38 was self-propelling in a wheelchair and had a wanderguard on his right ankle. Interview with CNA #5 on 8/26/19 at 3:01 PM, in the ADON Office, CNA #5 confirmed she was working the East Hall the day Resident #38 eloped from the facility. CNA #5 was asked if she observed the incident. CNA #5 stated, No ma'am .heard them (staff) yelling and running toward the front door .saw them (staff) bringing him (Resident #38) back from the road and a school bus had stopped. Telephone interview with Licensed Practical Nurse (LPN) #2 on 8/26/19 at 4:13 PM, LPN #2 confirmed that she was Resident #38's assigned nurse that day (8/20/19) and Resident #38 was beside her at the Nurses' Station at 3:15 PM. LPN #2 was asked if Resident #38 had tried to get out of the facility before this incident. LPN #2 stated, He (Resident #38) wanders around a lot and will push on the doors . LPN #2 was asked when Resident #38 first began exhibiting exit-seeking behaviors. LPN #2 stated, Maybe a few weeks ago. LPN #2 was asked the outcome of the facility's investigation of the incident. LPN #2 stated, We found out he had gotten out that back door (East Hall exit door). LPN #2 was asked if the door was unlocked when she checked it after Resident #38 eloped from the facility. LPN #2 stated, Yes .the Administrator was the one who first discovered it (East Hall exit door) was unlocked and he told me .I put the key in .locked it .checked it. Interview with the Administrator on 8/26/19 at 4:42 PM, in the ADON Office, the Administrator confirmed that he was in his office when Resident #38 eloped from the facility and once the resident was back in the facility, he began checking exit doors. He stated, .it had rained .and it was easy to see there were wheelchair tracks from the exit door to the left of therapy (East Hall exit door), opposite the smoking entrance. When I pushed on the door, it opened without the delayed egress. I looked up and the light was green indicating .mag (magnet) lock was unlocked . The Administrator stated, (Named LPN #2) .remembers that a coroner took a body out that door (on 8/14/19) and that's the only time she remembered it being unlocked . The Administrator was asked if the East Hall exit door could have been left unlocked for 6 days. The Administrator stated, .the likely thing that should happen, is if someone takes a key and unlocks it, they should relock it . Interview with the Maintenance Director on 8/26/19 at 5:09 PM, in the ADON Office, the Maintenance Director was asked about the incident where Resident #38 eloped from the building. The Maintenance Director stated, I was notified by (Named Administrator). He called me and asked who had keys to the door .I check the doors every week .I have all week to do the (Named maintenance documentation system) but basically, I check them every morning. The Maintenance Director was asked how he could tell the door was locked. The Maintenance Director explained the locking mechanism and stated, It makes a noise, you turn it all the way to the right to the green then back to the center and the light turns to red and that resets it. The Maintenance Director confirmed he locked the door per this procedure on 8/14/19. Per the Maintenance Director's documentation the door was checked and documented as locked on 8/14/19. There was no other documentation of a door checks on the exit doors until 8/21/19. Telephone interview with CNA #4 on 8/27/19 at 9:23 AM, CNA #4 confirmed she was working when Resident #38 eloped from the building. CNA #4 stated, I'm not sure what happened .was walking down North Hall, looked out the windows .saw a man in a wheelchair .realized who it was (Resident #38) .I saw the bus through the window and [MEDICATION NAME] kicked in .one of the therapists had already seen him (Resident #38) and was bringing him back from the road to the parking lot . Observations in the Dining Room on 8/27/19 at 11:38 AM, revealed Resident #38 slowly rolled his wheelchair backward and forward using his feet and had a wanderguard on his right ankle. Observations from facility's parking lot on 8/27/19 from 3:00 PM to 3:55 PM, revealed several school buses and a heavy flow of traffic on the road. Telephone interview with (Named School Bus Driver) on 8/28/19 at 5:02 PM, (Named School Bus Driver) was asked if she saw a person in a wheelchair beside the road close to the facility on the afternoon of 8/20/19. (Named School Bus Driver) stated, Yes Ma'am. He (Resident #38) was in the road .I stopped pretty far back and put my signs out and my light on so that nobody would pass me or my bus . Observations in the hallway by the Rehabilitation (Rehab) Department on 8/29/19 at 9:05 AM, revealed Resident #38 attempted to reach the East Hall exit door on the parking lot side of the hallway. Staff were between the door and Resident #38, and were redirecting Resident #38. Observations outside of the facility on 8/29/19 at 2:08 PM, revealed the Rehabilitation Director measured the distance in linear feet from the exit door where Resident #38 eloped to the heavily traveled street. The distance was 146 linear feet to the road. 3. Medical record review revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan revised 7/7/19 documented, (Named Resident #44) is an elopement risk/wanderer .wanders aimlessly .Interventions .Placement of wanderguard per protocol. Monitor for placement and in working order. Date Initiated: 10/18/2017 Medical record review of a Wandering and Elopement Evaluation dated 7/8/19 revealed Resident #44 was assessed as low risk for wandering and elopement. Medical record review of the quarterly MDS for Resident #44 dated 7/11/19 revealed a BIMS of 1 which indicated severe cognitive impairment. The physician's orders [REDACTED].Monitor placement and function of wanderguard two times day . Medical record review of Resident #44's (MONTH) and (MONTH) 2019 Activity of Daily Living (ADL) task list revealed there was no documentation of monitoring wanderguard equipment checks for the day shift on 7/7/19, 8/11/19, 8/12/19, or 8/25/19, and there was no documentation for either shift on 8/13/19 through 8/24/19. Observations in the Dining Room on 8/26/19 at 9:30 PM, revealed Resident #44 walking around in the Dining Room. Observations in the North hallway on 8/28/19 at 8:49 AM, revealed Resident #44 walking up and down the hallway. Interview with the DON on 8/29/19 at 12:04 PM, in the ADON Office, the DON was asked how often should the wanderguards be checked. The DON stated, Every shift .we did not realize it (the checks) had dropped off (from the electronic documentation record) until we started looking for stuff for you all on the 25th of (MONTH) .they should have done paper charting when the task was dropped off . 4. Medical record review revealed Resident #272 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Wander guard (wanderguard) in place to left ankle . Medical record review of a Wandering and Elopement Evaluation dated 8/15/19 revealed Resident #272 was assessed as low risk for wandering and elopement. Medical record review of the Baseline Care Plan dated 8/16/19 documented, .Minimize Risk of Elopement .Wander Bracelet (wanderguard) . Medical record review of Resident #272's ADL task list documented, .August 2019 .MONITORING Wandering (monitor for wandering behaviors) .Q (every) shift . There was no documentation of wander monitoring for the day shift for 8/16/19, 8/17/19, 8/19/19, 8/20/19, 8/25/19, or 8/26/19, and for the night shift for 8/23/19 and 8/25/19. Medical record review of Resident #272's ADL facility task list for (MONTH) 2019 revealed there was no documentation of monitoring wanderguard equipment checks for the day shift for 8/16/19, 8/17/19, 8/22/19, 8/23/19, 8/25/19, and 8/26/19. Observations in the North hallway on 8/26/19 at 10:00 AM, revealed Resident #272 had a wanderguard to her left ankle walking to Activities with a staff member. Interview with CNA #1 on 8/26/19 at 1:11 PM, in the ADON Office, CNA #1 was asked if she was assigned to Resident #272 for the day. CNA #1 stated, Yes. CNA #1 was asked if Resident #272 had a wanderguard. CNA #1 stated, I don't know . CNA #1 was asked who was responsible to check the wanderguards. CNA #1 stated, I don't know. I would have to find that out . CNA #1 was asked how she would know if a resident had a wanderguard. CNA #1 stated, I just see it when I am getting her dressed. It is not a structured thing. Interview with LPN #1 on 8/26/19 at 3:23 PM, at the North Hall Nurses' Station, LPN #1 was asked if the CNAs should know if a resident had a wanderguard. LPN #1 stated, Absolutely. LPN #1 was asked when should CNAs look at the kardex (CNA Plan of Care for the resident) to know how to take care of the residents. LPN #1 stated, Daily, at the beginning of the shift to see if anything has changed. LPN #1 was asked if there would be a reason for a CNA who had taken care of a resident for 5 hours not to know a resident was a wanderer with a wanderguard in place. LPN #1 stated, Absolutely not. Interview with CNA #2 on 8/26/19 at 4:52 PM, at the North Hall Nurses' Station, CNA #2 was asked if she had reported to CNA #1 that Resident #272 had a wanderguard when she arrived to work on the North Hall to take care of the resident. CNA #2 stated, I did not. Interview with the DON on 8/27/19 at 6:20 PM, in the ADON Office, the DON was asked when was the wanderguard ordered for Resident #272. The DON stated, 8/15/19. The DON was asked when the wanderguard was placed on Resident #272. The DON stated, On 8/16 (19) . The DON confirmed there was no documentation the wanderguard was placed on 8/15/19. The DON was asked if Resident #272 was exit seeking. The DON stated, Sometimes she is. The DON confirmed the wanderguard functioning tests and wanderguard checks had not been performed. The DON was asked if she expected the CNAs to review a resident's kardex to know if a resident was exit seeking and if the resident had a wanderguard in place. The DON stated, Yes. 5. Medical record review revealed Resident #422 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Nursing: Wandering & Elopement Evaluation dated 8/16/19 documented, .New Admission .Current Evaluation .Lacks safety awareness of current situation .Immediate interventions .wanderguard .Low Risk . Medical record review of a Baseline Care Plan for Resident #422 dated 8/17/19 documented, .Goal: Minimize Risk of Elopement .Interventions .Wander Bracelet (checked) . Medical record review of a Nurses' Note dated 8/20/19 documented, .Resident was standing at the front entrance and pushing on the door handle. She was very agitated and requesting to go outside as this nurse was attempting to leave for the day. Resident states she wants to 'get out of here.' Attempted to determine why she wanted to leave/go outside. She declined to answer questions stating that it was 'none of your business . Medical record review of a Nursing: Wandering & Elopement Evaluation for Resident #422 dated 8/25/19 documented, .Low Risk . Observations on 8/25/19 at 9:30 AM and 11:23 AM, revealed Resident #422 wandered the halls throughout the facility. Observations in the East hallway on 8/26/19 at 8:01 AM, revealed Resident #422 ambulated in the hallway with a staff member and held an ink pen and clipboard in her hand, Resident #38 was overheard telling staff member that she badly needs to find someone. A physician's orders [REDACTED].Wander guard (wanderguard) in place to right ankle . Interview with the DON on 8/27/19 at 6:30 PM, in the ADON Office, the DON was asked if a wanderguard was placed on Resident #422 on 8/20/19, when the resident was documented as exit-seeking. The DON stated, .I think it was on there before that but the (nursing) documentation says the 25th (8/25/19) .I honestly can't answer that question. It shouldn't have happened . The DON was asked if an elopement risk evaluation should have been completed when the resident was actively exit seeking on 8/20/19. The DON stated, Yes. Telephone interview with LPN #2 on 8/28/19 at 9:05 AM, LPN #2 was asked if she placed a wanderguard on Resident #422 after she assessed her on 8/20/19. LPN #2 confirmed Resident #422 did not have a wanderguard in place on 8/20/19 and stated, .I know I didn't place the wanderguard on the resident. Interview with the DON and the Administrator on 8/27/19 at 7:06 PM, in the ADON Office, the DON and Administrator were asked why a resident would have a wanderguard. The DON stated, .Exit seeking, wandering . The DON was asked how staff would know how to check wanderguards per protocol if the facility did not have a protocol. The DON stated, I know that the protocol was asked for and we don't have one . Interview with the Administrator on 8/28/19 at 5:25 PM, in the ADON Office, the Administrator was asked who was responsible to ensure care plan interventions, elopement evaluation forms, charting, and staff education were completed. The Administrator stated, The DON. The Administrator was asked who was responsible to ensure the residents were safe. The Administrator stated, The Administrator and the team. Every employee here . The failure of the facility to ensure a safe environment, the failure to provide adequate supervision and monitoring of residents with wandering and exit seeking behaviors resulted in Immediate Jeopardy for Resident #38, #44, #272, and #422. Resident #38 exited the facility through an unsecured exit door without staff knowledge and was found on a heavily traveled city street. The survey team verified the A[NAME] by: 1. Education was initiated with the Interdisciplinary Team (IDT) members on 8/27/19 by Administrator. All staff were re-educated regarding policies including Elopement; Safety and Supervision of Residents, and the Wanderguard Protocol on 8/27/19 by the DON, ADON, and/or designee. Education of staff will occur upon entering the facility for their scheduled shift. The survey team reviewed the in-service sign in sheets and interviews with staff on all shifts confirmed this. 2. Beginning on 8/27/19 the charge nurse will monitor Plan of Care (P[NAME]) documentation by the CNAs at the end of every shift to ensure P[NAME] documentation is completed, for ongoing compliance. Any behaviors will be documented and a P[NAME] alert will be sent to the Licensed Nursing Staff on the dashboard. Interviews with the DON, nurses, and CNAs on all shifts confirmed this. 3. Beginning on 8/28/19 the DON, ADON, and/or Designee will audit clinical alerts in (Named electronic charting for documentation) for compliance daily, in morning clinical meeting. Interviews with the DON and ADON confirmed this and the survey team reviewed the audit forms. 4. Beginning 8/27/19 if wandering or any behavior occurs during a shift, staff will follow current interventions, and place resident on 72 hour alert charting which monitors for effectiveness of interventions, followed by documentation in (Named electronic charting for documentation). Licensed Nurses will update Care Plan interventions as deemed appropriate. Interviews with the DON and Nursing staff on all shifts confirmed this. 5. Exit doors will be checked beginning 8/28/19 by the Maintenance Director and/or Housekeeping Supervisor hourly for proper operation/locking during normal shift hours Monday - Friday for two weeks, then decrease to twice daily for two weeks, then daily ongoing. After hour door checks will be completed hourly by the RN Supervisor, Charge Nurse, and/or designee. Checks will be placed on a log verifying that door checks were completed hourly. Audit log for exit doors was reviewed by the survey team. Interviews with the Maintenance Director, Housekeeping Supervisor, and Nursing staff on all shifts confirmed this. 6. Beginning 8/28/19 Daily rounds will be completed by Administration/Department Managers to include monitoring of door alarms for four weeks, then monthly. Interviews with the Administrator and Department Managers confirmed this. 7. On 8/28/19 the Kardex (CNA Care Plan) and daily tasks were reviewed and updated as necessary for wandering residents. Interviews with the Nursing and CNA staff on all shifts confirmed this. 8. Beginning 8/28/19 doors will not be unlocked without notification/consent from the Administrator. Interviews with the Administrator and staff on all shifts confirmed this. 9. Beginning 8/28/19 an Elopement Binder, which includes policies & procedures regarding Wandering Residents, is located at both Nurses' Stations. The survey team reviewed the Elopement Binder and interviews with Nursing staff on all shifts confirmed this. 10. Beginning 8/28/19 Licensed Nursing Staff will monitor wanderguards, document on the Treatment Administration Record (TAR), communicate with the DON and Social Worker regarding residents who display behaviors, and update the Kardex and Nursing Care Plan to reflect new interventions, as needed. The survey team reviewed the TARS, Kardex, and care plans, and interviews with the DON and Nursing staff on all shifts confirmed this. 11. Beginning 8/27/19 Licensed Nursing Staff will implement appropriate interventions such as 1:1 or 15 minute checks when residents listed at risk for wandering display behaviors. Interview with the DON and Nursing staff on all shifts confirmed this. 12. Beginning 8/27/19 documentation of monitoring residents at risk for wandering is a Task in the CNA P[NAME]. Interviews with the DON and CNA staff on all shifts confirmed this. Noncompliance of F-689 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.",2020-09-01
2387,ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER,445397,409 PARK AVENUE,ADAMSVILLE,TN,38310,2019-07-16,657,J,1,0,98W311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, closed medical record review, and interview the facility failed to ensure care plans were revised for 1 of 4 (Resident #1) sampled residents reviewed to include new interventions for wandering, exit seeking behaviors, and elopement after Resident #1 a cognitively impaired and vulnerable resident with vision impairment eloped from the Secure Unit. The facility's failure to update Resident #1's care plan with new interventions to address Resident #1's exit-seeking behavior resulted in Resident #1 leaving the facility and being found 0.7 miles away at a grocery store. This failure placed Resident #1 in Immediate Jeopardy. An Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-657 was cited at a scope and severity of [NAME] A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: 1. The facility's undated Care Plans-Comprehensive policy documented, .individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .develops and maintains a comprehensive care plan for each resident .Care plans are revised as changes in the resident's condition dictate. Care plans are reviewed quarterly .care plan goals and objectives are defined .goals and objectives are reviewed and/or revised .significant change in the resident's condition .when the desired outcome has not been achieved .resident has been readmitted to the facility from a hospital/rehabilitation stay .nurse supervisor uses the care plan to complete the CNA's (Certified Nursing Assistant) daily work assignment sheets .CNA's are responsible for reporting to the nurse supervisor any changes in the resident's condition and care plan goals and objectives that have not been met or expected outcomes that have not been achieved .changes in the resident's condition must be reported to the MDS (Minimum Data Set) Assessment Coordinator so that a review of the resident's assessment and care plan can be made .The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans .when the resident has been readmitted to the facility from a hospital stay . 2. The facility's undated Care Planning-Interdisciplinary Team policy documented, .development of an individualized comprehensive care plan for each resident .Prior to attending the care planning conference, each discipline will be responsible for developing a problem identification list .any area of difficulty or concern that prevents the resident from reaching his/her fullest potential. Problems must be stated .short-term goals must be resident oriented, behaviorally stated, measurable. Approach-The specific action (s) or intervention (s) that the staff will take to assist the resident in meeting/achieving the short-term goals . 3. Closed medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Closed medical record review of the MDS dated [DATE] revealed Resident #1 had a Brief Interview of Mental Status score of 7 which indicated Resident #1 was severely impaired cognitively. Closed medical record review of Resident #1's comprehensive care plan created on 3/12/19 documented, .3/12/19 .Has wandering tendencies and exit seeking behaviors at times d/t (due to) Dementia .Place resident in area where frequent observation is possible .Provide diversional activities .Redirect when wandering into other resident's rooms .Instruct visitors to inform staff when they are leaving the designated area with the resident .Implement facility protocol for locating an eloped resident .If wandering away from unit, instruct staff to stay with resident, converse and gently persuade to walk back to designated area with them . There were no new interventions implemented until 6/28/19. Closed medical record review revealed Resident #1 was admitted to the hospital from 5/21/19 to 6/6/19 due to increased confusion, aggression toward staff at facility, anxiety, and noted instability. Interview with the Administrator on 7/11/19 at 7:30 PM, in the Administrator's Office, the Administrator was asked had Resident #1 ever left the facility before. The Administrator stated, .I believe he got out of the Secure Unit but not off of the premises .didn't investigate . Interview with Licensed Practical Nurse (LPN) #1 on 7/12/19 at 1:38 PM, in the Conference Room, LPN #1 was asked about when Resident #1 had exited the Secure Unit without awareness of the staff. LPN #1 stated, .I know he got out the doors (400 hall doors) on the 100 side of the unit .it was in the evening maybe around 5-6 (5:00 PM-6:00 PM). I walked back to the nurses' station and (Named Clinical Manager #1) brought him in through the door of the Secure Unit .I know I wrote a nurse's note about him leaving the unit but it's gone .I'll go talk to (Named Clinical Manager #1) she was the nurse that brought him to the unit .she will know the date . LPN #1 returned a few moments later and stated, .I asked (Named Clinical Manager #1), she said it was (MONTH) 20th (5/20/19) . LPN #1 was asked if an incident report or an assessment was done. LPN #1 stated, .no I didn't do an incident report .just a head to toe assessment to be sure he was ok .and a nurses note which is gone . Interview with Clinical Manager #1 on 7/15/19 at 10:27 AM, in the Conference Room, Clinical Manager #1 was asked about when Resident #1 exited the Secure Unit to an unsecured area in the building. Clinical Manager #1 stated, .May 20th 2019 (5/20/19) .yes .possibly around 6 PM-7 PM (6:00 PM - 7:00 PM) .exit the Secure Unit through the 400 hall doors . Clinical Manager #1 was asked if there were any staff or visitors with the resident. Clinical Manager #1 stated, .no just him .he walked out the 400 hall doors and turned toward the 100 hall nurses station and started walking very fast toward the nurses station .I immediately escorted him back to the unit . Closed medical record review of the comprehensive care plan reviewed on 6/20/19 revealed there were no new interventions for the exit seeking behaviors that occurred on 5/20/19 when he was readmitted on [DATE]. Closed medical review of a Nurses' Note dated 6/28/19 at 6:00 PM documented, .continued exit seeking behavior noted. Resident waving out window for help, standing at door until it opens in attempt to leave and attempting to call on nurse station phone w/o (without) permission . Closed medical review of a Nurse's Note dated 6/29/19 at 6:03 AM documented, .at 2000 (8:00 PM on 6/28/19) resident was returned to hall when brought back to facility by police after elopement .resident stated 'I just followed some man out the door.' Told staff he just was going for a walk and got lost and knew he needed to find someone to take him back .checked on every 30 minutes throughout the night . Interview with MDS Coordinator #1 on 7/12/19 at 4:55 PM, in the Conference Room, MDS Coordinator #1 was asked who updated and initiated the care plans. MDS Coordinator #1 stated, .sometimes I do care planning but (Named MDS Coordinator #2) does most of it . MDS Coordinator #1 was asked if she attended the morning meetings. MDS Coordinator #1 stated, .yes .we go over the 24 hour nurse report book, go over incidents and orders that are written . MDS Coordinator #1 was then asked if Resident #1 had ever left the Secure Unit or the building. MDS Coordinator #1 stated, .I have no knowledge of him leaving the unit or the building . Interview with MDS Coordinator #2 on 7/13/19 at 9:43 AM, in the Conference Room, MDS Coordinator #2 was asked about the care plan process and who was involved. MDS Coordinator #2 stated, .we cover incident reports in the daily clinical meeting and update the care plans .the DON, the Administrator, Risk Management, (Named Clinical Manager #1) .the meetings are not held on the weekend. If it happens on the weekend it will be discussed Monday . MDS Coordinator #2 was asked if Resident #1 left the facility or the unit in (MONTH) (2019). MDS Coordinator #2 stated, .no .I don't recall that . MDS Coordinator #2 was asked if she had updated Resident #1's care plan. MDS Coordinator #2 stated, .I could have potentially updated the care plan . MDS Coordinator #2 was asked to review Resident #1's care plan and if there were any interventions related to Resident #1 exiting the Secure Unit in (MONTH) (2019). MDS Coordinator #2 stated, .No . Interview with the Administrator and the DON on 7/13/19 at 5:04 PM, in the Conference Room, they were asked what facility action was taken when Resident #1 exited the Secure Unit to an unsecured area of the building on 5/20/19. The Administrator stated, .codes changed on secure unit doors (corridor) and exit door of secure unit (to the outside) .sent him to (Named geriatric psychiatric facility) . The Administrator and DON confirmed there were no new interventions put into place after this exit seeking behavior. The facility failed to ensure that the care plan was revised to include new interventions to prevent elopement for a cognitively impaired resident with known exit seeking behaviors and a history of elopement. Refer to F600 and F689 The surveyor verified the A[NAME] by: 1. Active Exit-Seeking policy was updated on 7/14/19 to reflect definition and actions to take when residents are actively exit seeking. 100% of staff, which included all departments, will be in-serviced by the DON and/or Designee on updated policy by 7/15/19. Staff unable to attend this in-service will not be allowed to work until in-serviced. Changes included to the policy included: the definition of active exit seeking, if staff observes a resident actively exit seeking they are to stay with resident at all times, inform the Charge Nurse or Director of Nursing, utilize all of the care plan interventions currently in place, the charge nurse will complete a skilled nursing assessment to determine potential causes of behavior and will ensure the resident is on documented 1:1 immediately and complete an updated Elopement Risk Assessment and update the care plan with appropriate and new interventions. Resident will remain on 1:1 until an evaluation is completed by the Interdisciplinary Team and a determination is made the resident no longer requires the 1:1. The surveyor reviewed the in-service sign in sheets and interviewed staff on each shift. 2. Director of Nursing and/or Designee will educate all licensed and registered nurses on how to update care plans with appropriate interventions. Staff unable to attend will not be allowed to work until in-serviced. The surveyor reviewed the in-service sign in sheets and interviewed staff on each shift. 3. The DON and/or Minimum Data Set (MDS) Nurse will update care plans for residents with past exit seeking behaviors beginning 7/15/19. The surveyor reviewed the care plans. Noncompliance of F-657 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.",2020-09-01
2388,ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER,445397,409 PARK AVENUE,ADAMSVILLE,TN,38310,2019-07-16,689,J,1,0,98W311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, closed medical record review, and interview, the facility failed to ensure adequate supervision to prevent elopement for 1 of 4 (Resident #1) cognitively impaired, vulnerable, visually impaired residents who had wandering/exit seeking behaviors resulting in Immediate Jeopardy (IJ) for Resident #1. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility failed to ensure a safe environment and placed Resident #1 in Immediate Jeopardy (IJ) by failing to adequately supervise Resident #1, a cognitively impaired resident with prior wandering and exit seeking behaviors, who was missing for approximately 1 hour and 20 minutes before the staff realized he had eloped from the facility. Resident #1 was found by a customer wandering outside of a grocery store located 0.7 miles from the facility. This resulted in an IJ for Resident #1. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-689 was cited at a scope and severity of [NAME] F-689 J is Substandard Quality of Care. A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: 1. The facility's Accident-Incident-Elopement-Wandering Resident undated policy documented, .every effort will be made to prevent wandering episodes while maintaining the least restrictive environment for residents who are at risk for wandering/elopement .should a wandering/elopement episode occur, the contributing factors, as well as the interventions tried, will be documented on the resident's medical record and review by the interdisciplinary team .responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse . 2. Closed medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Closed medical record review revealed there was no elopement risk assessment completed when Resident #1 was admitted to the facility on [DATE]. Closed medical record review of the Care Plan dated 3/12/19 and revised 6/28/19 revealed Resident #1 had wandering tendencies and exit seeking behaviors due to Dementia. The interventions included if wandering away from unit, instruct staff to stay with the resident, converse and gently persuade to walk back to designated area, place resident in an area where frequent observation is possible, provide diversional activities as needed, implement facility protocol for locating an eloped resident, designate staff to account for residents whereabouts throughout the day, alert staff to wandering behaviors, and approach wandering resident in a positive, calm, and accepting manner. Closed medical record review of the quarterly Minimum data Set (MDS) with an assessment reference date (ARD) of 6/12/19 revealed Resident #1 was assessed to have a BIMS of 7, which indicated severe cognitive impairment. The resident was visually impaired, had hallucinations and other behavioral symptoms not directed toward others which occurred 1 to 3 days of the assessment period. Resident #1 had wandering behaviors which occurred 1 to 3 days of the assessment period, needed limited assistance with walking, and required no assistive devices. Closed medical record review revealed Resident #1 was admitted to the hospital from 5/21/19 to 6/6/19 due to increased confusion, aggression toward staff at the facility, anxiety, and noted anxiety. The Psychiatric Evaluation dated 5/22/19 from this hospital stay documented, .Justification for hospitalization - Inpatient Failure or treatment at a lower level of care, hallucinations, delusions, agitation, anxiety, depression, resulting in a significant loss of functioning. Emotional or behavioral conditions and complications requiring 24 hour medical and nursing care. Failure of social or occupational functioning, Inability to meet basic life and health needs . Interview with the Administrator on 7/11/19 at 7:30 PM, in the Administrator Office, the Administrator was asked if Resident #1 ever left the facility prior to 6/28/19. The Administrator stated, .I believe he got out of the Secure Unit but not off of the premises . The Administrator was asked when this occurred and what interventions were implemented to address it. The Administrator stated, .about 3 months ago .I'll have to check .didn't investigate . Interview with Licensed Practical Nurse (LPN) #1 on 7/12/19 at 1:38 PM, in the Conference Room, LPN #1 was asked when Resident #1 exited the Secure Unit without awareness of the staff. LPN #1 stated, yes .I was the nurse the day he stepped out of the unit .I know he got out the doors (400 hall doors) on the 100 side of the unit .it was in the evening maybe around 5-6 (5:00 PM-6:00 PM) because I had went to the 300 hall to give medications. I walked back to the nurses' station and (Named Clinical Manager #1) brought him in through the door of the Secure Unit .was (MONTH) 20th . LPN #1 was asked if an incident report or an assessment was done. LPN #1 stated, .no I didn't do an incident report just a head to toe assessment to be sure he was ok . Interview with Clinical Manager #1 on 7/15/19 at 10:27 AM, in the Conference Room, Clinical Manager #1 was asked when Resident #1 exited the Secure Unit to an unsecured area in the building. Clinical Manager #1 stated, .May 20th 2019 (5/20/19) .yes .possibly around 6 PM-7 PM (6:00 PM-7:00 PM) .exit the Secure Unit through the 400 hall doors . Clinical Manager #1 was asked if there were any staff or visitors with the resident. Clinical Manager #1 stated, .no just him .he walked out the 400 hall doors and turned toward the 100 hall nurses station and started walking very fast toward the nurses station I immediately escorted him back to the unit . Review of Resident #1's medical record revealed there was no documentation of the incident on 5/20/19. There were no new interventions for the exit seeking behavior when the resident returned from the hospital on [DATE]. There was no investigation of the incident to determine how the resident left the Secured Unit. Closed medical record review revealed there was no elopement risk assessment completed when Resident #1 was readmitted to the facility on [DATE] from the hospital. Closed medical record review revealed documentation that Resident #1 displayed impaired cognitive status and exit seeking behaviors: a. A Nurse's Note dated 6/6/19 at 6:48 PM documented, .repetitive confusion noted with place. Periods of anxiety . b. Review of an Admission/Readmission Note dated 6/6/19 revealed Resident #1 had Chronic Repetitive Disruptive Behavior that could potentially cause harm to himself or other, Chronic Wandering Behavior and Hallucinations. c. A Nurse's Note dated 6/9/19 at 7:28 PM documented, .resident pulled fire alarm in dining room . d. A Nurse's Note dated 6/10/19 at 4:13 PM documented, .continues to ask where his (he is) at and who comes to see him . e. Review of a Long Term Care Observation nurses' note dated 6/14/19 revealed Resident #1 was anxious, agitated, had chronic repetitive behavior, and wandering that included wandering at night and hallucinations. Resident #1's current level of mental status was documented as severe impairment that affected all areas of judgment. f. Review of a Long Term Care Observation nurses' note dated 6/21/19 revealed Resident #1 had chronic repetitive behavior, short term memory loss, and was currently disorientated and confused. g. A Nurse's Note dated 6/28/19 at 6:00 PM documented, .continued exit seeking behavior noted. Resident waving out window for help, standing at door until it opens in attempt to leave, and attempting to call on nurses' station phone w/o (without) permission . h. A Nurse's Note dated 6/29/19 at 6:03 AM documented, .at 2000 (8:00 PM on 6/28/19) resident was returned to hall when brought back to facility by police after elopement .resident stated 'I just followed some man out the door.' Told staff he just was going for a walk and got lost and knew he needed to find someone to take him back .checked on every 30 minutes throughout the night . i. A Nurse's Note dated 6/29/19 documented, .start of shift (7:00 AM 6/29/19), resident watched one on one . Based on the National Weather Service records, the recorded high temperature for the facility area on 6/28/19 (the day of the elopement from the facility) was 86 degrees Fahrenheit. The facility is located near an abandoned factory, a public park, and a community center with public parking. Closed medical record review revealed Resident #1 was transferred to the psychiatric hospital on [DATE], after this elopement episode. Closed medical record review of the (Named Hospital) ADMISSION NURSING assessment dated [DATE] documented, .Reason for admission .per facility pt. (patient) having danger issues and has been combative and tries to elope .Has the patient been violent to others in the past 6 months? (Yes checked) . Behaviors .Other (checked) exit seeking .Potential for elopement (checked) . The History and Physical from this hospital stay dated 6/30/19 documented, .anger, agitated threatens to shoot people high elopement risk . 3. Interview with LPN #2 on 7/12/19 at 8:52 AM, in the Conference Room, LPN #2 was asked if Resident #1 had exited the building on 6/28/19. LPN #2 stated, .I work the 400 hall day shift .I worked day shift 7 AM-7 PM (7:00 AM-7:00 PM) .when he formulates a plan, he will execute it if he wants to get out .standing by the door, when someone was going out the door, he would try to talk to them, and try to go out behind them .he had left here and went to another facility but they couldn't handle his exit seeking, he got out of that facility while he was there .I talked to him the night he eloped about 6:20 PM .that was the last time I saw him that night .changed shift and went home . Interview with Certified nursing Assistant (CNA) #1 on 7/12/19 at 9:40 AM, in the Conference Room, CNA #1 stated, .(Resident #1) always watching the door, seemed to be more focused on who was coming in and out of door .that day in particular (6/28/19) he was waving at me out the window .I saw him about 6:40 PM leaned against the corner of the 400 hall near the exit door (to outside) . Interview with Activity Assistant #1 on 7/12/19 at 9:55 AM in the Conference Room, Activity Assistant #1 stated .(Resident #1) always exit seeking .seemed more agitated that day (6/28/19) . Interview with the police officer on 7/12/19 at 1:05 PM, at the (Named City) Police Department, the police officer was asked about the incident on 6/28/19. The police officer stated, .there is not a police report .just the 911 dispatch information .according to it (dispatch log) the call came in at 19:11 (7:11 PM) suspicious person .the person was confused and doesn't know where he is .sitting on bench out front .the officer arrived at 7:15 PM at the grocery store. I arrived at 19:26 (7:26 PM) .he was confused and seemed scared .I asked his name and where he was from .he told me his name and that he was from (Named city) .I asked some more questions about his family and I recognized his daughter's name. We have a mutual friend so I got on (Named social media website) to find the more information, contacted a friend and got in touch with his daughter .I took him back to the facility around 8:00 PM .(staff) didn't know a resident was missing from the nursing home . Interview with MDS Coordinator #2 on 7/13/19 at 9:43 AM, in the Conference Room, MDS Coordinator #2 was asked if Resident #1 left the facility or the unit in (MONTH) of 2019. MDS Coordinator #2 stated, .no .don't recall that . MDS Coordinator #2 was asked if she had updated Resident #1's care plan. MDS Coordinator #2 stated, .I could have potentially updated the care plan . MDS Coordinator #2 was asked to review Resident #1's care plan and if there were new interventions related to the resident exiting the Secure Unit in (MONTH) of 2019. MDS Coordinator #2 stated, .no .it was reviewed 6/20/19 . Telephone interview with the grocery store employee on 7/13/19 at 2:00 PM, the employee was asked what happened on 6/28/19. The employee stated, .it was later in the day .a regular customer came in the store and said there was a gentleman wandering around outside at the front of the store. The customer said you might want to call 911, so I did. We asked him his name and he told us, but we didn't know anyone to call. The police came and the officers asked who his children were .the officer got in touch with someone that knew the man's daughter the police put him in vehicle and left . Interview with the Administrator and the DON on 7/13/19 at 5:04 PM, in the Conference Room, they were asked what facility action was taken when Resident #1 exited the Secure Unit to an unsecured area of the building on 5/20/19. The Administrator stated, .codes changed on secure unit doors (corridor) and exit door of secure unit (to the outside) .sent him to (Named geriatric psychiatric facility) . The Administrator and DON confirmed there were no new interventions put in place after the exit seeking behavior on 5/20/19. The surveyor verified the A[NAME] by: 1. Door Code was immediately reset by the Maintenance Director on 6/28/19. 2. Signage was posted on the back exit door on the unit not to utilize door except in an emergency. Signage was posted on all other exit and corridor doors reminding visitors to be aware of others potentially exiting with them on 6/28/19. The signage was viewed by the surveyor on 7/16/19. 3. Maintenance Director checked all the windows on the Secure Unit to ensure that [MEDICATION NAME] were in place that limit the windows opening more than 4 inches on 6/28/19. This was confirmed by the surveyor through observations and interview on 7/16/19. 4. Head counts of all residents on the Secure Unit will be conducted by Licensed Nurses hourly on the Head Count Form. This was initiated on 7/15/19. The surveyor reviewed the Head Count Form and interviewed staff on each shift. 5. Active Exit-Seeking policy was updated on 7/14/19 to reflect definition and actions to take when residents are actively exit seeking. 100% of staff, which included all departments, will be in-serviced by the DON and/or Designee on updated policy by 7/15/19. Staff unable to attend this in-service will not be allowed to work until in-serviced. Changes included to the policy included: the definition of active exit seeking, if staff observes a resident actively exit seeking they are to stay with resident at all times, inform the Charge Nurse or Director of Nursing, utilize all of the care plan interventions currently in place, the charge nurse will complete a skilled nursing assessment to determine potential causes of behavior and will ensure the resident is on documented 1:1 immediately and complete an updated Elopement Risk Assessment and update the care plan with appropriate and new interventions. Resident will remain on 1:1 until an evaluation is completed by the Interdisciplinary Team and a determination is made the resident no longer requires the 1:1. The surveyor reviewed the in-service sign in sheets and interviewed staff on each shift. 6. Director of Nursing and/or Designee will educate all licensed and registered nurses on the Elopement Risk Assessment, the Nursing Summary and how to update care plans with appropriate interventions. Staff unable to attend will not be allowed to work until in-serviced. The surveyor reviewed the in-service sign in sheets and interviewed staff on each shift. 7. The DON and designee re-assessed all residents in the building to determine any residents with exit seeking behaviors on 6/28/19 and 6/29/19. Results were no new residents identified as an elopement risk or added to the list. The assessments were reviewed by the surveyor. 8. Housekeeping Director or Designee will audit doors daily beginning 7/15/19 to ensure signage is still in place for two weeks, then weekly for two months and/or substantial compliance is achieved. The surveyor reviewed the audit forms. 9. Maintenance Director or Designee began elopement drills on each shift beginning 6/28/19 then weekly for four weeks then one shift weekly for two months and/or when substantial compliance is achieved. The surveyor reviewed the audit forms. 10. Beginning 6/28/19 the DON, Staff Development Coordinator or Designee began to conduct audits of resident head counts at shift change for two weeks, then three times weekly for four weeks, then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 11. Beginning 6/28/19 Maintenance Director or Designee checked all windows in resident rooms and will continue on a monthly basis to ensure that [MEDICATION NAME] are in place to limit opening to 4-6 inches on an ongoing basis. This began on 6/28/19. 12. Social Services Director or Designee will audit elopement books beginning 7/15/19 to ensure they are updated based on new and updated elopement risk assessments weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 13. Employee Relations Director or Designee will audit new hires beginning 7/15/19 to ensure they received elopement procedure training weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 14. Beginning 7/15/19 the DON and/or Designee will audit five elopement risk assessments weekly for four weeks then monthly for two months to ensure any exit seeking behaviors are care planned appropriately. The surveyor reviewed the audit forms. 15. The DON and/or Minimum Data Set (MDS) Nurse will update care plans for residents with past exit seeking behaviors beginning 7/15/19. The surveyor reviewed the care plans. 16. On 7/15/19 results of the audits will be discussed at the Quality Assurance Performance Improvement Committee weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. Noncompliance of F-689 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.",2020-09-01
2110,LAUDERDALE COMMUNITY LIVING CENTER,445354,215 LACKEY LANE,RIPLEY,TN,38063,2017-05-05,226,K,1,0,QMFO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, employee file review, medical record review, and interview, the facility failed to identify abuse, investigate all allegations of abuse and mistreatment, report allegations of abuse, investigate injuries of unknown origin, investigate a resident death for possible entrapment, and provide a safe environment free of retaliation for 5 of 13 (Resident #s 16, 45, 55 and 57 and 61) sampled residents in the stage 2 review. The facility failed to ensure all residents were free of abuse, neglect and mistreatment by the failure to implement policies and procedures placed all residents in a SERIOUS and IMMEDIATE THREAT to their health and safety resulting in IMMEDIATE JEOPARDY (IJ) to Resident #s 16, 45, 57 and 61 and psychological harm to Resident #55, as evidenced by the tearful, emotional responses during an interview. Immediate Jeopardy is a situation is which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Director of Nursing and Region One Nurse Consultant #1 were informed of the Immediate Jeopardy on [DATE] at 1:09 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F226-K, which is Substandard Quality of Care. An extended survey was completed on [DATE]. The Immediate Jeopardy was effective [DATE]. The findings included: 1. Review of the facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Policy documented, .The facility has developed and implemented written policies and procedures designed to prohibit and prevent mistreatment, neglect, exploitation, and abuse of residents .The prohibition plan includes the following components .5. Investigation of allegations .6. Protection of the resident during investigations .7. Reporting and responding .The facility will report alleged violations, conduct investigations of alleged violations, report the results to proper authorities, and take necessary corrective actions . The facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Staff training policy documented, .how and when to report allegations without fear of reprisal .The facility management staff will receive training needed to provide good leadership, encourage teamwork, and promote a pleasant, safe environment . The facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Prevention policy documented, .Staff supervision for inappropriate behaviors during interaction with or care of residents .The facility will continue to make the work environment a pleasant and safe one for all employees so they may provide a pleasant and safe environment for the residents. Staff will be supervised to identify behaviors such as derogatory language: rough handling; ignoring residents while giving care .The facility administrator and or the Director of Nursing should review risk management reports at each administrative meeting to identify possible situations of abuse. This may include but is not limited to incident reports, including injuries of unknown origin and grievance reports . The facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan INVESTIGATION policy documented, .All injuries or bruises that are suspicious in any way or injuries of unknown origin must be investigated .The administrator and/or the Director of Nursing is responsible for initial reporting, investigation of alleged violations, and reporting of result to the proper authorities. Review of the Dignity and Respect Policy documented, .It is the policy of this facility to treat each resident with respect .the staff shall display respect for residents when speaking with, caring for, or talking about them . 2. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the nurse's note dated [DATE] at 9:00 PM revealed LPN #7 was called to the resident's room. The LPN documented, .entered the room, the resident's head was turned toward the headboard with the left side of her face pressed against the side rail. Her body was off the bed, her bottom was on the floor and her legs were stretched out in front of her. The right arm and shoulder were on the bed pointing towards the headboard The LPN documented the resident was without vital signs and expired. The following interviews were conducted via telephone and in the facility concerning the resident being found lifeless with her head between the side rail and mattress: On [DATE] at 8:01 AM Confidential Interviewee (CI) #7 stated they heard about the incident on [DATE]. CI #7 stated she told the DON this is a reportable incident. CI #7 stated the DON replied it was not a State reportable incident. CI #7 stated after reading the nurse's note, they felt like it was a reportable. On [DATE] at 5:32 PM CI #8 stated Resident #16 fell out of the bed and got hung in the side rails, with her legs on the floor and her neck caught between the side rails. Resident #16 had a pressure alarm on the bed that did not alarm. CI #8 began to cry and said she had never seen Resident #16 attempt to get out of the bed. CI #8 stated she told the Administrator and DON the resident's head was caught in the side rails. CI #8 stated she wrote a statement of what she had observed and gave it to the DON. The resident was not breathing or moving. CI #8 stated .her head was facing the wall, her face was to the railing and was caught up . CI #8 stated Resident #16 had an air overlay on the mattress. On [DATE] at 8:55 PM CI #12 stated the resident 's right arm and head were pinned in the side rail, and her feet were almost at the wall. Her bottom was not touching the ground. CI #12 stated the resident's jaw seemed to be in the rail and was turned looked unusual. On [DATE] at 8:00 AM CI #10 stated when she walked in the room Resident #16 was sitting in the floor by the bed and her head was turned toward the headboard so that made the left side of her face up against the side rail. The resident did not have a pulse and was not breathing. CI #10 stated she notified the doctor that the resident was found on the floor and had passed. Resident #16's face was turned to the right toward the headboard, her legs were stretched out in front of her and were under the geri chair. The resident had a discolored area on her jaw. On [DATE] at 10:01 AM the DON was informed the survey team had asked for all facility investigations of any incident. The DON was asked if an accidental or unusual death had occurred in the facility, the DON stated, No. The DON stated she was in the facility the night of Resident #16's death. The DON stated it looked like Resident #16 had slid out of the bed after she expired, That's what we assumed . The DON stated this incident was not reported to the State. When the DON was asked if an investigation was done, she stated, There was nothing formal. I just asked them what happened . The DON stated she wrote the witnesses statements and the witnesses signed the statements. The DON was asked if there should have been an investigation. The DON stated, By investigation, do you mean getting the data, analyzing and doing to a conclusion? . I made the wrong decision . The facility failed to thoroughly investigate the resident's death. The circumstances of the resident's death was not reported to the Medical Director, the police, Adult Protective Services, the Medical Examiner, or the State Survey Agency. The witness statements were discarded and were re-written by the DON. The facility's failure to investigate and report all incidents of accidental deaths placed all residents in a SERIOUS and IMMEDIATE threat to their health, safety and well-being, resulting in IMMEDIATE JEOPARDY. 3. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], Anxiety Disorder, Kyphosis (outward curvature of the spine), Major [MEDICAL CONDITION], Contracture of the Knee and Hip, Dementia with Behavioral Disturbances. Interview with CI #4 on [DATE] at 9:53 AM, in the conference room, CI #4 stated, .I told the staff you can't jerk her legs because they will break her legs with her being so little . CI #4 stated that CNA #1 came into the room and got ready to lay the resident down and just threw her down. CI #4 stated .She (CNA #1) got so mad and threw the chair around so fast . CI #4 stated the Social Worker wanted to split up the resident and her roommate, to move the resident to another room to separate the group. Interview with CI #1 on [DATE] at 1:45 PM, in the Conference Room, CI #1 requested that CNA #1 not provide further care for Resident #45. CI #1 was asked if CNA #1 was rough handling her or talking to her. CI #1 stated, Both .this is about the 4th incident that I have had with her (CNA #1) .on [DATE] (the resident) had a scratch on her leg . CI #1 was asked if CNA #1 provided care for the resident after the request to not provide care. CI #1 stated, Yes .She said she didn't have time to tell CNA #1 yet that day .my fear is that they know I am in here talking to y'all. I have found (CNA #1) openly hostile for a while. (CNA #1) carries a lot of power and she can be vindictive . Interview with CI #3 on [DATE] at 5:55 PM, in the Conference Room, CI #3 was asked about concerns she had with Resident #45's care. CI #3 stated, the names of CNA #5 and CNA #9 do a good job. CI #3 stated, .The other ones (CNAs) don't do good at all . and are rough with the resident when providing care such as turning, dressing and undressing the resident. CI #3 stated Resident #45 sustained .a big scratch on her leg . while being cared for by CNA #1. CI #3 stated Resident #45 hollers Oh! Oh! when the staff come in rough and pushing her over.You can hear the bed go boom, boom .(loud noise). Interview with CNA #2 on [DATE] at 7:32 AM, in the conference room, when CNA #2 was asked how many people are necessary to get Resident #45 out of the bed, CNA #2 stated, Sometimes . 2. CNA #2 stated she did not use a lift to assist in getting Resident #45 out of the bed. CNA #2 stated it didn't seem to hurt Resident #45 when she is gotten up, CNA #2 stated, . she doesn't complain. CNA #2 stated Resident #45 was not really able to talk, she just . she says a few words. She says something sometimes. I don't know if she understands what I am saying. CNA #2 was unaware of any staff who was not to provide care to Resident #45. CNA #2 stated she was told not to go into Resident #57's room for some reason, but didn't know why she was unable to go into the room. Interview with CNA #1 on [DATE] at 1:04 PM, in the Conference Room, CNA #1 stated the DON told me not to take care of Resident #45 anymore to keep the chaos down. When CNA #1 was asked how she moved Resident #45 to the bed, CNA #1 stated, if you set her up in the chair, put your arms under her arms and bring her around to the bed, she will be sitting down on the bed. CNA #1 stated the geri chair has a arm rail on it, but it is not in the way. CNA #1 stated, . If you sit her up, you just turn her and put her on the bed. She is not heavy . She weighs maybe 96 (pounds) . When CNA #1 was asked if she had made changes to the CNA assignments during the past month, she stated changes were made because 2 families complained about CNA #7 being slow. She stated Resident #57's son would turn the call light on, and CNA #7 would go and turn it off and say she was in the middle of something and she would be back, but didn't return. CNA #1 stated this happened 3 times. She stated there was no formal complaint. CNA #1 was asked if this complaint was documented on the grievance log, and CNA #1 stated, .I don't know where it goes from there. Interview with CI #5 on [DATE] at 2:05 PM, in the Conference Room, when CI #5 was asked about the care in the facility, CI #5 stated, . Some of my little residents .can look at you and tell something is going on . they moved me off B hall, I cried .It seems like I am the only one they move .If they (DON, Social Worker and CNA #1) are in that circle, they (DON, Social Worker and CNA #1) will pick on you .If I say something, they will make my job more hard. I can deal with the residents, but you are dealing with the nurse or that nurse it is hard .You can't win. Like talking to y'all, I may get in trouble. When CI #5 was asked if she had heard anyone talking harshly to the residents, CI #5 stated, I'll get in trouble . When CI #5 was asked about Resident #45's scratch on her leg, CNA #2 stated, .CNA #1 does it (transfers Resident #45) by herself, but I always need somebody with me . Interview with CI #5 on [DATE] at 2:08 PM, in the Conference Room, when CI #5 was asked if she had worries about repercussions for talking to the surveyors the previous day, CI #5 stated, .Still worried . (about) Getting fired. CI #5 further stated a lot of other staff want to talk but they are scared. CI #5 stated she had talked with a State lady from APS with the SW present in the room, and the SW told CI #5 .answer the questions and don't tell her any more . Telephone interview with CI #1 on [DATE] at 3:42 PM, when CI #1 was asked who she talked to about her concerns regarding Resident #45, CI #1 stated she had talked to the SW. CI #1 said she reported CNA #1 was rough with Resident #45. CI #1 stated she reported the rough treatment to the DON. CI #1 stated this is why she did not want CNA #1 back in the room. When CI #1 was asked exactly what the rough treatment was, CI #1 stated jerking the resident's clothes to get them off, jerking the resident's head and moving her body parts (rough) and jerking the resident around to undress her. After CI #1 complained and told the DON she did not want CNA #1 in Resident #45's room, CNA #1 was assigned to Resident #45. CI #1 stated CNA #1 came in the room yesterday and looked at Resident #61, turned around and walked out. CI #1 stated CNA #1 just proved she could walk into the room if she wanted to. When CI #1 was asked to clarify exactly what she told the DON, CI #1 stated, I told her (CNA #1) was very rough with (Resident #45). Her attitude was very short with her (Resident #45) and this was not the first time she was uncooperative (with Resident #45) . CI #1 stated she had heard CNA #1 saying, I don't have time for that. or That's not my job. CI #1 stated if she had a concern and complained to the DON or Administrator, she did not feel the concern would be addressed. CI #1 stated she felt like there would be repercussions for talking with the survey team. CI #1 stated, .They (DON, Social Worker and CNA #1) play mind games .all the time . CI #1 stated there has been three occasions since Christmas. Resident #45 had a large scratch on her face, she fell out of the bed, and then a skin tear on her leg, but no one knows how these happened. CI #1 stated, .It is very frustrating that she keeps having accidents and no one knows anything about it . Interview with CI #2 on [DATE] at 4:35 PM, in the Conference Room, when CI #2 was asked if he worried about repercussions from CNA #1, CI #4 stated, Yes she is very bold. (Named SW) is another . She is bold . Interview with CNA #1 on [DATE] at 5:40 PM, in the Conference Room, CNA #1 was asked if the Administrator talked to her about any allegations. CNA #1 stated he talked to her about not going back into 2 other residents' rooms. CNA #1 stated that was because the family didn't want her back in there. Interview with the Administrator on [DATE] at 7:30 PM, in the Conference Room, the Administrator was asked for an incident report and investigation for a scratch to Resident #45's face that occurred some time after Christmas. The Administrator stated, There were no incidents on a scratch on Resident #45's face since Christmas. The facility failed to provide documentation of an investigation of an injury of unknown origin. Telephone interview with Medical Doctor (MD) #1 on [DATE] at 5:20 PM, MD #1 stated he comes to (named facility) every 2 months. When MD #1 was asked if he expected skin tears to be investigated to determine why they occurred, MD #1 stated, Yes and no . He stated it should be figured out why the skin tear happened. He stated, Their skin is frail. I think the nursing staff should watch how they move them .If it is frequent the nursing staff should be looked at about how they are handling the patient. MD #1 stated he thought the nursing staff investigated why a Resident has a skin tear, especially if there was a recurrent trend. He stated, .They should think why is this happening .I think they should look into it if there is a trend. MD #1 stated, Falls are the same way. Falls can happen from time to time but if they are happening often .every time a fall happens they should see how the fall happened. Did it happen about a staff management issue or did the fall (just) happen . MD #1 stated Resident #45 couldn't fall out of the bed because she doesn't move. MD #1 was informed that Resident #45 did actually have a fall recently. MD #1 was asked if he had been made aware of that. MD #1 stated, I don't remember being called about a fall on (name of Resident #45). Interview with CI #16 on [DATE] at 10:54 AM in the DON office, CI #16 was asked if Resident #45 had more incidents since the surveyors were in the facility, and CI #16 stated on [DATE] a bruise was discovered on her left forearm and an abrasion on left shin, as well as an abrasion on right forearm, and a skin tear to the left thigh on [DATE]. The facility's failure to investigate all allegations of abuse neglect, neglect, mistreatment and incidents of unknown origin and protect the residents during the investigation placed the Resident in a SERIOUS and IMMEDIATE threat to their health and safety, resulting in IMMEDIATE JEOPARDY. 4. Medical record review revealed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #55 was cognitively intact, experienced feelings of depression and hopelessness and had no behaviors coded. Interview with Resident #55 on [DATE] at 4:42 PM, in the resident's room, when the resident was asked if she could tell the surveyor about a time when she was mistreated or someone spoke harshly to her while in the facility, Resident #55 stated, .I've been treated okay since y'all came .it's just the ones before y'all came they used to hurt my feelings and make me cry and say hateful things to me . (the) DON (Director of Nursing) .said is there any way you can call your boyfriend, I need to talk to him. I called and said the DON wants to speak to you. She said, Hi, (Named Boyfriend), I just want to make sure we're on the same page, (Named Resident 55) she's getting too big and you need to stop bringing her pizza . Resident #55 stated since the survey team arrived, she has not seen the people here, so whatever y'all are doing, you're doing a good job . The resident became visibly upset, tearful, and agitated during the interview and apologized for becoming so upset. Interview with CI #5 on [DATE] at 9:04 AM, when CI #5 was asked if Resident #55 had ever expressed to her that staff had hurt her feelings and made her cry, CI #5 stated, Sometimes when I go in the room .she's crying and I ask her to talk to me. She says .her feelings have been hurt and I say tell me (Named Resident 55) but she won't . CI #5 was asked if she had reported that to anyone. CI#5 summarized that she had heard it discussed in shift report and when staff went in the room they could tell the resident was upset. CI #5 stated, .Since I've been working with her I've seen her crying several times . Interview with CI #16 on [DATE] at 2:59 PM, in the DON office, CI #16 was asked what her expectations were when a resident is frequently tearful. CI #16 stated, I would expect that they would address and identify what is causing her to be tearful, notify Social Services, notify the doctor, but first and foremost find out why they're tearful. There was no documentation the facility assessed Resident #55 for reasons that caused her to cry and be tearful. There were no interventions to assist the resident with coping skills for verbal abuse. The failure to prevent verbal abuse and provide timely interventions resulted in Psychological Harm to Resident #55 when she was belittled and treated rudely by the DON. 5. Medical record review revealed Resident #57 was initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] revealed Resident #57 had a Brief Interview for Mental Status (BIMS) of 4 indicating the resident had severe cognitive impairment. The annual MDS dated [DATE] revealed Resident #57 resident had severe cognitive impairment. The care plan revised on [DATE] documented, Focus .COMMUNICATION problem r/t (related to) [MEDICAL CONDITIONS].Invention Allow adequate time to respond .Do not rush .Resident is able to answer simple yes and no questions. Does well when given word/answer options . Interview with Social Worker (SW) on [DATE] at 10:33 AM, in the Conference Room, the SW stated any complaint she knew about would be added to the complaint/grievance log. Review of Grievance/Complaint Investigation Report revealed there were no grievances reported in the month of (MONTH) (YEAR). Review of Grievance/Complaint Investigation Report revealed there were no grievances reported in the month of (MONTH) (YEAR) regarding Resident #57. A telephone interview with CI #15 on [DATE] at 2:11 PM, CI #15 stated there had been a problem with staff back in (MONTH) or December. Cl #15 stated, She (CNA #2) talks ugly to the residents. CI #15 has heard Resident #57 say no, no, no she's mean (CNA #2) . CI #15 stated when she asked the DON not to have CNA #2 to go in Resident #57's room nothing was changed. A telephone interview with CI #17 on [DATE] at 2:45 PM, CI #17 was asked have you had concerns with the staff being rough with Resident #57. CI #17 stated (MONTH) 8th or 15th (YEAR) was the last time she heard CNA #2 handling Resident #57 roughly . CI #17 stated right after Memorial Day (YEAR) she called Corporate office, the lady on the phone asked why didn't I take the complaint to the nurse and I said the care is about the nurse and she said oh . Interview with the Administrator on [DATE] at 10:00 AM, in the Administrator's office, the Administrator stated stated he talked to CNA #2 the other day about someone she couldn't take care of in (MONTH) or October. The Administrator stated, I believe . (it was Resident #57) . The Administrator verified there should there have been an investigation of why CNA #2 can't take care of Resident #57. When the Administrator was asked if there are allegations staff are handling resident's rough, should that have been investigated. The Administrator stated, Yes, because the term rough needs to be identified what they mean by rough . The facility's failure to protect residents and investigate all allegations of mistreatment placed all residents in a SERIOUS and IMMEDIATE threat to their health and safety, resulting in IMMEDIATE JEOPARDY. 6. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with CI #4 on [DATE] at 9:53 AM, in the conference room, CI #4 was asked about the care Resident #61 received. CI #4 stated there are 3 CNA's (CNA #1, #2 and #7) that don't care about the residents. CI #4 stated CNA #1 moved Resident #61 and tore her arm. She stated CNA #1 couldn't help but tear the skin, the way she was turning her. CI #4 stated CNA #1 gets mad to have to turn Resident #61. CI #4 states CNA #1 says 'I get so sick of turning this woman' CI #4 states CNA #1, #2 and #7 come in mad and they go out mad. CI #4 states she has seen Resident #61 so many times when her head hit the rails, she would have to put a pillow between the rails and her head. CI #4 stated Resident #61's head has to be high and it slides off of the pillow, it is going to the rail if you don't have a pillow there to stop it, because she slumps over. CI #4 stated, I called Adult Protection Services. Interview with CNA #1 on [DATE] at 1:00 PM, in the conference room, when CNA #1 was asked about the skin tear on Resident #61's arm while in her care, CNA #1 stated, I noticed blood on right arm. It was dried blood, so it was old. I told the nurse, I may have bumped it. I didn't know I did . Interview with the Social Worker (SW) on [DATE] at 10:33 AM, in the Conference Room, when the SW brought in the grievance and complaint log, the SW stated there was no grievances for the month of October, (MONTH) or December. The SW stated there was 5 complaint/grievances for January, 1 for February, 1 for March, and 4 for April. The SW stated all complaint/grievances were placed on the complaint log if she is aware of them. The facility failed to provide documentation of facility investigations for the complaint/grievances in the log for January, February, March, and (MONTH) (YEAR). Interview with the DON on [DATE] at 4:43 PM, in the DON's office, the DON stated the facility investigated each complaint/grievance on the log. Interview with CI #2 on [DATE] at 4:35 PM, in the conference room, when CI #2 was asked if she had filed complaints/grievances with the DON, CI #2 stated she had been to her ,[DATE] times and showed her things, like the feeding pump not plugged up and off. When they get her up they hang it on the pole. CI #2 stated the thing that scares me the most is that it is not 1 or 2 (staff) it is the majority of them. She stated, It is a no win situation. CI #2 stated she was fearful of repercussions against Resident #61 for any complaint/grievance reported. CI #2 stated she has found Resident #61's head in the rail, the bed flat, not tilted at all (Resident #61 is a tube feeder), the mucus in her throat. CI #2 stated she is afraid she is going to choke to death. CI #2 stated the nurses don't suction her unless she goes to get them. She states she gets tired of fighting them (staff). CI #2 stated, I have found (named Resident #61) flat down so many times .[DATE] resident lying flat .CNA #7 had her left arm so far behind her it looked like she didn't have one. I knew she was in pain her face was red . CI #2 stated she worried about repercussions from CNA #1. She stated CNA #1 is . bold, (as in intimidating) . CI #2 stated she also worried about repercussions from the Social Worker because, .she is bold . Review of complaint/grievance logs for January, February, (MONTH) and (MONTH) (YEAR) revealed 3 grievances filed for poor care to Resident #61 which included lying flat in bed while tube feeding infusing and oxygen tubing on the floor. The facility failed to provide documentation the complaint/grievances were investigated. The facility failed to protect the residents from staff that were accused of alleged abuse by the failure to suspend the staff during an investigation of the allegation. The facility failed to perform reference checks on staff before they were hired. The facility failed to do thorough investigations of injuries of unknown origin. 7. Interview with the Administrator on [DATE] at 11:00 AM, in the conference room, the Administrator was asked how he ensured there were no repercussions to residents or families when grievances were made, he stated, The staff is in-serviced on our grievance policy and they are informed there should be no direct or indirect (complaints) against them . The Administrator was informed the survey team was informed 3 employees had been named in allegations of handling residents rough, being verbally abusive and they were not allowed to go into certain resident's rooms. The Administrator stated if a family requests a particular staff not be allowed in a certain room, then .We try to honor the request. The Administrator stated if a family had an issue with a staff member being unprofessional, he would talk with the family and record it on the log. The Administrator stated an injury of unknown origin should be investigated. He stated an Incident-Accident report should be completed and include where the injury is and what caused it. The Administrator stated he was not aware of any staff the facility has mandated not to go into a particular resident's room. The Administrator was informed that CNA #1, CNA #2, and CNA #7 were the staff that were alleged to be handling some residents roughly, being verbally abusive, and they were not allowed to go into certain resident rooms because of those allegations. When the Administrator was asked if he had any complaints against CNA #1, the Administrator stated, Last week the only thing I heard of her, there was a sitter that was with Resident #45 and there was a discussion back and forth with the sitter .The family will walk up to me in passing. Mom's sitter and CNA #1 had a discussion. The Administrator did not know how it was resolved. He stated, She just let me know there was a discussion . The Administrator was informed the majority of interviewees told the survey team they feared repercussions for talking to us. The Administrator was informed, the interviewees were saying there were already being repercussions. The person doing the staffing, CNA #1 is the one who is being accused of repercussions. Observations in the facility on [DATE] and [DATE], during the 6:00 AM-2:00 PM shift, revealed CNA #1 and CNA #2 were caring for residents, and on [DATE] CNA #1 was caring for residents, after the Administrator was informed by the State Surveyors of alleged abuse and/or neglect by these staff. Review of the CNA assignment sheets for [DATE] revealed CNA #1 and CNA #2 had resident assignments that day. 8. Interview with Social Worker (SW) on [DATE] at 10:33 AM, in the Conference Room, the SW brought in the Grievance and Complaint log. The SW confirmed five complaints/grievances for the month of January, one complaint/grievances for the month of February, one complaint/grievances for the month of (MONTH) and four complaint/grievances for the month of April. The SW was asked what type of complaint you would put on the complaint log. The SW stated the complaints/grievances were concerns with call lights, food issues and staff members. The SW stated any complaint she knew about would be added to the complaint/grievance log. Refer to F225",2020-09-01
1360,HARTSVILLE CONVALESCENT CENTER,445256,649 MCMURRY BLVD,HARTSVILLE,TN,37074,2019-09-19,835,K,1,0,2T6811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, employee record review, medical record review, observation and interview, the Administration failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each residents. The facility Administrator's failure to thoroughly investigate falls, failure to implement a fall intervention of monitoring the functionality of alarms, the facility's utilization of unsupervised noncertified Nurse Aides (a noncertified Nurse Aide (NA) is an employee performing direct resident care without completing the certification and competency evaluation) providing direct resident care, the failure to ensure staff had an accurate job description, reference verification, competency, and abuse registry verification and the failure to ensure staffing was providing the required assistance to residents and were supervised placed 2 residents (#1 and #2) of 9 residents reviewed with falls 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 failed to ensure staff reported an allegation of abuse to administration for investigation and failed to prevent Abuse for 1 (#5) of 13 residents reviewed. The facility's noncompliance resulted in a fall for Resident #1, the fall resulted in a laceration to the head requiring 10 sutures. The facility's noncompliance resulted in a fall for Resident #2 due to 3 different facility staff leaving Resident #2 unattended in the bathroom on 3 separate occasions. The fall resulted in a [MEDICAL CONDITION]. A partial-extended survey was conducted on 9/10/19 - 9/19/19. The Administrator and facility owner were notified of the Immediate Jeopardy on 9/18/19 at 5:10 PM in the conference room. The Immediate Jeopardy was effective from 6/3/19 through 9/19/19. F689, F728, and F835 was cited at a scope and severity of K. The facility's noncompliance resulted in psychosocial Harm to Resident #5. F600 was cited as a scope and severity of [NAME] An acceptable Allegation of Compliance (A[NAME]) which removed the immediacy of the jeopardy was received on 9/19/19 at 5:10 PM and the corrective actions were validated onsite through observation, interviews and document review. Noncompliance for F689, F728, and F835 continues at a scope and severity of [NAME] to monitor the effectiveness of the corrective actions. Substandard Quality of Care was cited at F689. The findings include: The facility did not have job descriptions for the Administrator, hired on 7/1/19, and the Director of Nursing (DON), hired on 1/2/18. 1. Review of the undated facility policy, Abuse, Neglect, Misappropriation of Property & (and) Exploitation, revealed .Definitions: Abuse - the willful infliction of injury .intimidation, pain or mental anguish .Each Resident .has the right to be free from mistreatment .Identification: identify events, such as suspicious bruising .occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation .It is the responsibility of the staff .to prohibit and prevent any Resident from Abuse . Reporting Abuse .If ABUSE is suspected, of any type, employees are required to immediately notify the charge nurse on their unit where the ABUSE is suspected to have occurred. The charge nurse, whatever shift, is then to notify the social worker or the director of nursing immediately, who will then notify the administrator . The facility failed to identify and prevent abuse for 1 resident. The facility staff failed to implement the facility abuse protocol to inform the administration of an allegation of abuse. Interview with the Social Worker, who was also the Abuse Coordinator, on 8/13/19 at 3:25 PM in the Social Worker's office, confirmed the facility staff failed to report the allegation of abuse immediately to the DON or the Social Worker per facility policy. Interview with the DON on 8/13/19 at 4:18 PM in the conference room revealed the facility did not substantiate the incident as abuse because the resident .said she was okay . Refer to F600 and F607. 2. The facility failed to implement the staff monitoring of any resident with an alarm for the proper placement and functionality of the alarm in order to prevent a fall. Resident #1 fell resulting in a laceration requiring 10 sutures. The facility failed to provide the extensive assistance and supervision, by 3 staff members on 3 separate occasions, to Resident #2 which resulted in a fall and a fracture. The facility failed to thoroughly investigate falls. The facility failed to ensure staff was competent to perform the duties required and failed to supervise staff. The facility utilization of unsupervised noncertified Nurse Aides providing direct resident care. Interview with the Administrator, DON, and ADON on 8/13/19 at 1:50 PM in the conference room confirmed the facility failed to monitor the alarm functionality, failed to interview staff and witnesses, failed to have specific information regarding the fall, and failed to determine the root cause of the fall, resulting in a non-thorough investigation. Interview with the DON and ADON on 9/11/19 at 4:30 PM in the conference room confirmed at times the facility did not obtain orders for the alarms. Interview with the DON and ADON on 9/12/19 at 2:05 PM in the conference room confirmed the facility had unsupervised noncertified NAs assigned to residents. Further interview confirmed 3 staff members (RN #1, LPN #1 and NA #1) had left a resident unattended in the bathroom at 3 separate times; therefore the facility failed to provide the supervision of staff and the required assistance to the resident. Interview with the DON and ADON on 9/12/19 at 2:55 PM in the conference room confirmed the facility failed to ensure alarms were turned on in order to alert the staff. Refer to F656 and F689. 3. Review of the undated facility Nurse Aide job description/Job position found in the employee files revealed .Major duties and responsibilities .Assist residents with dental and mouth care .assist with feeding of the residents .Perform after meal care .bathe residents as assigned in accordance with our established nursing care procedures .dress residents .comb and brush hair .Qualifications .must obtain State certification within 120 days of being employed . Review of employee files revealed the facility hired and utilized noncertified Nurse Aides (a noncertified Nurse Aide (NA) is an employee performing direct resident care without completing the certification and competency evaluation) and provided them a job description specifying the provision of direct resident care; and did not specify the need for supervision. Further review revealed the facility failed to verify the competencies for 11 (#1, #2, #3, #4, #6, #7, #8, #9, #10, #11, and #12); failed to obtain the abuse registry verification for 4 (#1, #2, #8, #9); and failed to verify references for 8 (#1, #2, #3, #7, #8, #9, #10, #12) of 11 employee records reviewed. Interview with the Administrator and the Director of Nursing (DON) on 8/7/19 at 9:03 AM in the conference room when asked what duties the facility expected the NAs to perform, the DON revealed, .my intent was to do more than just stand around but to provide assistance .They were supposed to be supervised . When asked if the NAs had been reviewed for competencies the DON revealed she .would need to check . When the DON was asked when 1 to 2 NAs were scheduled on a unit with a nurse did she expect the NAs to perform direct care and the DON would not respond. Interview with the DON on 8/13/19 at 4:18 PM in the conference room confirmed the NA's did not have competency verification. Interview with the Administrator, DON, ADON, and the Business Office Manager on 8/14/19 at 5:05 PM in the conference room, when asked why the job descriptions in the NA files included direct patient care responsibilities, the DON, ADON, and the Administrator did not respond. Interview with the Administrator, Director of Nursing, Assistant Director of Nursing, and the Business Office Manager on 8/15/19 at 4:00 PM in the conference room, when asked if the employees were required to have abuse registry verification and reference verification prior to having resident contact, the Administrator confirmed all staff were to have abuse and reference verification before any patient contact. Refer to F728. Validation of the Allegation of Compliance (A[NAME]) to remove the Immediate Jeopardy was completed on 9/19/19 through review of the facility documentation, observations, and interviews. Surveyor verified the A[NAME] by: 1. The facility had eliminated 3 of the 4 remaining noncertified Nurse Aides by 9/12/19. The one remaining noncertified Nurse Aide, NA #7, was removed from the nursing department to the activities department until the NA successfully completed the certification program and test. The facility/governing body implemented a new policy to not hire nurse aides effective 9/19/19. The facility revised policies addressing noncertified nurse aides and adequate staffing. The surveyor reviewed the facility policy, Hiring of Non-certified Nursing Aides. The review confirmed the policy was effective on 9/19/19 and the facility would not hire nor schedule any noncertified nurse aides. The surveyor reviewed the facility policy, Sufficient Staffing. The review confirmed the policy was effective on 9/19/19. Further review confirmed the Administrator and the ADON/Scheduler were to review to ensure adequate staff were scheduled twice weekly. The Administrator would utilize a spreadsheet to determine staffing per unit. The surveyor reviewed the weekly staffing report dated 9/19/19 - 9/22/19. The review confirmed the Administrator and Assistant Director of Nursing/Scheduler had reviewed the staffing on 9/17/19. The surveyor reviewed the 9/2019 nursing schedule. The review confirmed the 1 remaining noncertified nurse aide (NA #7) had not been scheduled in the nursing department since 9/1/19 and was scheduled in activities on Saturdays. Telephone interview with NA #7 on 9/11/19 at 9:57 AM confirmed the NA had no resident contact since 9/1/19 and was changed to the activities department until the certification test was successfully completed. The surveyor interviewed the Administrator, on 9/19/19 at 4:18 PM, who confirmed on 9/17/19 the Administrator and the Assistant Director of Nursing had checked the staffing for 9/19/19 through 9/22/19. Further interview confirmed the staffing was discussed at every morning meeting and reviewed for sufficiency and coverage. The staffing was based on the acuity of the residents. Further interview revealed if there were any staff shortages identified in the staffing report, current staff would be given the opportunity to provide coverage and/or the licensed staff in administration would cover the shortage. Further interview confirmed 3 noncertified nurse aides were no longer employed by the facility and the remaining NA would work in the activities department until the NA successfully completed the certification course and passed the test. Further interview confirmed all other staff were certified nurse aides or licensed nurses and no noncertified nurse aides would be hired. 2. The Ad Hoc QAPI Committee met on 9/19/19, including the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Director of Rehabilitation, to initiate new accident procedures: the Charge Nurse to report accident to the DON (ADON, MDS Coordinator or Administrator when DON not available) to ensure the fall the revised Fall Investigation packet was initiated and an intervention was put into place. The facility utilized the current Falls Risk policy. The surveyor reviewed the revised fall investigation packet. The falls investigation packet confirmed a Falls Management Program policy was implemented 7/29/19, a revised fall investigation form, a revised Incident/Accident report, a revised witness statement, and a revised neuro check form. The surveyor review of the Falls Risk policy confirmed the Charge Nurse would initiate the investigation packet, initiate an intervention and verbally notify the DON/designee immediately. The surveyor interviewed 2 LPNs, 3 CNAs and 2 dietary staff on duty on 9/19/19. The interviews confirmed the staff was knowledgeable of the reporting of falls and the duties of the charge nurse and the initiation of the intervention. Further interview with the licensed nurses confirmed the facility had in-serviced on the new fall packet, the new fall investigation forms, and the immediate notification of the DON. The surveyor review of the in-service post test addressing falls confirmed the facility had initiated the in-service training. 3. The Ad Hoc QAPI Committee met on 9/19/19, including the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Director of Rehabilitation, to initiate new accident procedures: the Attending Physician/Nurse Practitioner will be immediately notified of the fall, regardless of severity of the injury, and the intervention. The surveyor reviewed the revised fall investigation packet. The review confirmed the falls investigation packet included a Falls Management Program policy implemented 7/29/19 and the Charge Nurse would immediately notify the physician/nurse practitioner regardless of the severity of the injury. The surveyor review of the in-service post test addressing falls confirmed the facility had initiated the in-service training. The surveyor telephone interview with the Medical Director on 9/16/19 at 1:33 PM confirmed the Medical Director/Nurse Practitioner were to be notified of falls regardless of the severity of the injury. The surveyor interviewed all nursing staff on duty on 9/19/19. The interviews confirmed the staff was knowledgeable of the reporting of falls, duties of the charge nurse and the immediate notification of the physician/nurse practitioner regardless of the injury severity. 4. The Ad Hoc QAPI Committee met on 9/19/19, including the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Director of Rehabilitation, to initiate new accident procedures: the Falls Committee would investigate fall incidents the following business day to determine the root cause and develop appropriate intervention, in the event the fall occurred on Friday after business hours through beginning of business Monday, the DON/designee would determine the root cause and immediate intervention. The surveyor review of the 9/2019 Incident/Accident Analysis Log confirmed the facility had no falls after 9/17/19. Interview with the DON on 9/19/19 at 3:00 PM and review of the 3 falls on and prior to 9/17/19 confirmed the facility Falls Committee had met timely to determine the root cause and intervention. 5. The Ad Hoc QAPI Committee met on 9/19/19, including the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Director of Rehabilitation, to initiate new accident procedures: the adaptation and the utilization of the revised Post Fall Investigation by the Falls Management Committee. The surveyor review of the revised fall investigation packet confirmed a revised Post Fall Investigation form. The surveyor interviewed all nursing staff on 9/19/19. The interviews confirmed the staff was knowledgeable of the revised Post Fall Investigation form. The surveyor interview of the members of the Falls Management Committee, DON, ADON, MDS Coordinator, on 9/19/19 at 3:00 PM confirmed the committee met the business day after the fall to review the fall information and complete the revised Post Fall Investigation form. The committee would meet to determine the root cause and appropriate intervention. 6. The Ad Hoc QAPI Committee met on 9/19/19, including the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Director of Rehabilitation, to initiate new accident procedures: the discontinuation of the alarms and initiation of intervention; updating of the comprehensive and CNA care plan regarding alarm and intervention. The surveyor observed the Falls Management Committee/Interdisciplinary Team meeting on 9/19/19 to discuss the ordered discontinuation of the alarms and the determination of the new intervention. The surveyor observation of the residents on 9/19/19 confirmed the ordered removal of alarms had been completed and the new intervention was in place, and all alarms were removed from the supply storage areas to ensure inaccessibility. The surveyor review of the medical records, of all residents identified with an alarm, confirmed a physician order [REDACTED]. 7. The Ad Hoc QAPI Committee met on 9/19/19, including the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Director of Rehabilitation, to initiate new accident procedures: direct care staff education initiated 9/18/19 on the 11:00 PM-7:00 AM shift and ongoing, education of staff not on duty to be completed before scheduled shift, and education of new hired staff during orientation. The surveyor review of the in-service training records confirmed staff, of all departments, were receiving education on reporting of falls, duties of the charge nurse, the fall investigation packet contents, interventions and the updating of the comprehensive and CNA care plans. Further review confirmed the staff scheduled on 9/18/19 on the 11:00 PM - 7:00 AM had been in-serviced on the revised falls protocols. The surveyor interviews with all nursing and dietary staff on duty 9/19/19 confirmed the staff was knowledgeable of the reporting of falls, duties of the charge nurse, the revised fall investigation packet contents, interventions and care plan. The surveyor interview with the Administrator, on 9/19/19 at 4:18 PM in the conference room, confirmed any new hired staff member would be educated on the revised fall protocol upon orientation and staff not on duty would receive in-service training before the scheduled shift. Noncompliance for F835 continues at a scope and severity of [NAME] to monitor the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.",2020-09-01
4684,THE PALACE HEALTH CARE AND REHABILITATION CENTER,445329,309 MAIN ST,RED BOILING SPRINGS,TN,37150,2016-08-18,225,D,1,1,PN1C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, employee written statements, medical record review and interview, the facility failed to implement the abuse prevention policy and report the incident to the state survey agency within 5 working days of the incident for 1 of 3 (Resident #74) sampled residents of the 54 residents included in the stage 2 review. The findings included: The facility's Resident Abuse policy documented, .to be afforded basic human rights, including the right to be free from abuse, neglect mistreatment .Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations . Medical record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician ordered documented .1/21/16 ADMIT TO (NAMED HOSPICE) . The Situation, Background, Assessment and Recommendations (SBAR) Communication Form dated 8/5/16 documented, .observed purple bruising to L(left) forearm .bruising noted to L forearm after shower .Resident noted to have resisted care .currently on [MEDICATION NAME] . Review of a Written Statement dated 8/5/16 of Certified Nursing Assistant (CNA) #1 documented, .was in showers .heard water running (sign for and) someone talking. I peeked behind the curtain and saw the (Named Company Employee) giving (named room number) a shower. She was jerking her (Resident #74) (sign for and) manhandling her to dress (sign for and) put the sling under her . Review of a Written Statement dated 8/5/16 of CNA #2 documented, .(Named Company Employee) had finished bathing (named Resident #74). She was jerking her arms to dress and put the sling under her . Review of a Written Statement dated 8/5/16 of CNA #3 documented, .I gave (named Resident) a shower. I transferred her using the lift on to a shower bed .didn't notice any bruising until after the shower . Review of a Written Statement dated 8/5/16 the Director of Nursing (DON) documented, .(Named CNA #2) came to my office and stated that she had observed the (Named Company Employee CNA (CNA #3) being 'rough' with (named Resident #74) while giving her a shower . Observations in Resident #74's room on 8/15/16 at 3:57 PM, revealed Resident lying in low bed, talking to her baby doll, had 3 small purple bruised areas on left forearm. Interview with the Administrator 8/18/16 on 12:42 PM, in the Administrator's office, the Administrator was asked if she should have reported the possible abuse concerning Resident #74 to the state. The Administrator stated, .hindsight is twenty twenty . The Administrator was asked if the facility should follow their abuse policy. The Administrator stated, Yes .",2019-08-01
2391,ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER,445397,409 PARK AVENUE,ADAMSVILLE,TN,38310,2019-08-30,609,D,1,0,BV6Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, facility investigation review, medical record review, and interview the facility failed to report an allegation of resident to resident abuse for 2 of 3 (Resident #1 and #2) sampled residents reviewed. The findings include: The facility's ABUSE PREVENTION POLICY & PR[NAME]EDURE policy documented, .It is the policy of this facility to take all steps reasonable and necessary to protect the residents from harm at all times, including protection from physical and verbal abuse from other residents .Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions .An example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach .The investigation protocol must be implemented and a report given to the appropriate agencies as specified by law and regulations . Medical record review revealed Resident #1 was admitted to the secure Dementia unit at the facility on 9/18/18 with [DIAGNOSES REDACTED]. Review of the quarterly assessment dated [DATE] revealed Resident #1 had a cognitive status score of 8 of 15, indicating moderate impairment and had wandering behaviors. Observations in Resident #1's room on 8/30/19 at 10:10 AM, revealed the resident was ambulatory in her room without assistance, was well groomed and appropriately dressed, had clear speech, and was alert and oriented to person and place. Interview with Resident #1 her room on 8/30/19 at 10:10 AM, when asked if another resident at the facility had hit her, Resident #1 stated, No. Not even the men . Closed medical record review revealed Resident #2 was admitted to the secure Dementia unit in the facility on 7/16/19 with [DIAGNOSES REDACTED]. Review of the 30-day assessment dated [DATE] revealed Resident #2 had a cognitive status score of 0 of 15, indicating severe impairment, had difficulty focusing attention, displayed physical and verbal behavioral symptoms directed toward others, rejected care and wandered. The facility's SUMMARY OF INCIDENT AND INVESTIGATION dated 8/13/19 documented, .CNA (Certified Nursing Assistant) notified nurse on 8/13/19 at approximately 6:30 am that she saw (Named Resident #2) hit (Named Resident #1) on the left forearm 3 times .(Named Resident #2) has a BIM (Brief Interview for Mental Status) of 0 and does not have the ability of mental reasoning to understand what is right or wrong nor does he have the capacity to willfully act in such a manner .After complete investigation, this occurrence was unsubstantiated as abuse. It is determined that (Named Resident #2) did not act deliberately or willfully and that facility staff intervened immediately and appropriately . Review of the facility's investigation revealed Resident #2 was removed from the area immediately and placed on 1:1 observation. The Administrator/Abuse Coordinator was notified of the incident and skin assessment for Resident #1 revealed no bruising and no complaint of pain. Each of the residents' families were notified, the physician was notified and orders were received to transfer Resident #2 to a Psychiatric facility for evaluation and treatment. Telephone interview with CNA #1 on 8/30/19 at 11:55 AM, CNA #1 was asked if she had witnessed Resident #2 hit Resident #1 on 8/13/19. CNA #1 revealed she had heard Resident #1 say a few curse words and saw Resident #2 hit Resident #1 on the left forearm with his fist 3 times. Resident #2 was removed immediately and Resident #1 was assessed and had no complaint of pain or bruising noted. Interview with the Administrator on 8/30/19 at 1:30 PM, in the Administrator Office, the Administrator was asked why the altercation between Resident #1 and Resident #2 on 8/13/19 had not been reported to the State Agency as an abuse allegation. The Administrator confirmed the allegation was not reported to the State Agency and stated she did not report tbecause she determined abuse had not occurred.",2020-09-01
1995,GRACELAND REHABILITATION AND NURSING CARE CENTER,445331,1250 FARROW ROAD,MEMPHIS,TN,38116,2020-02-10,610,J,1,0,U67J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, facility investigation review, medical record review, and interview, the facility failed to ensure a thorough investigation was completed for 1 of 4 sampled residents (Resident #1) reviewed with wandering/exit-seeking behaviors, which resulted in Immediate Jeopardy (IJ) when Resident #1 exited the facility through a window and then a hole in the facility's fence, crossed a major 7 lane highway, and walked to a neighborhood 1.3 miles from the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-610 on 2/5/2020 at 2:45 PM, in the Conference Room. The facility was cited F-610 at a scope and severity of J, which is Substandard Quality of Care. A partial extended survey was conducted on 2/7/2020 through 2/9/2020. The Immediate Jeopardy was effective from 11/1/2019 through 2/9/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 2/7/2020 at 3:00 PM. The Removal Plan was validated onsite by the surveyors on 2/9/2020 - 2/10/2020 through review of assessments, policies related to exit-seeking behavior, inservice training records, observations, and interviews. The findings include: Review of the facility's policy titled, Abuse Investigation and Reporting, revised 7/2017, showed, .neglect .thoroughly investigated by facility management .witness reports will be obtained in writing . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the Nurses' Notes showed that Resident #1 exited the facility through a door on the 700 Hall on 11/1/2019 and 11/14/2019 and was redirected back into the facility by staff. During an interview conducted on 2/4/2020 at 10:50 AM, the Administrator confirmed Resident #1 had exited the facility twice in November 2019 and that these incidents were not investigated to determine possible causes of the exit-seeking behaviors. She stated that she did not think these needed to be investigated because staff observed the resident exiting through the 700 Hall door and returned the resident to the building. Review of the facility's investigation showed that the facility's video camera footage was viewed by the Administrator and DON to determine how Resident #1 exited the building. The camera footage showed that on 1/16/2020 at 1:48 PM, Resident #1 got up from her wheelchair and walked into a resident room. At 1:50 PM, Resident #1 was seen exiting a window in room [ROOM NUMBER] and walking towards the back of the building. The surveyor viewed this video camera footage. Review of the Social Services Note dated 1/16/2020, showed that Resident #1 was returned to the facility by a police officer (after being found 1.3 miles from the facility). Resident #1 had no memory of the incident when she was questioned by Social Services. Review of the facility investigation showed there were no statements written by the staff who were responsible for Resident #1's care on 1/16/2020. During an interview on 2/3/2020 at 1:30 PM, the DON stated, .yes, this is the complete investigation of the elopement .did I need statements from staff for the investigation? . During an interview on 2/7/2020 at 4:00 PM, the Administrator confirmed there were no staff or witness statements and the investigation for the incident on 1/16/2020 was not thorough and complete. The Administrator confirmed that staff should have known Resident #1 was gone. The facility failed to ensure a thorough and complete investigation was conducted when Resident #1, a cognitively impaired resident with known wandering and exit-seeking behaviors, exited the facility and was found 1.3 miles from the facility. The facility failed to ensure Resident #1's elopement attempts were investigated and failed to ensure witness statements were obtained related to Resident #1's location in the facility and the last time staff had observed the resident in the facility, which resulted in IJ for Resident #1. Refer to F-600, F-656, F-657, and F-689. The surveyors verified the Removal Plan by: 1. Written statements have been requested and obtained from staff regarding incident with Resident #1, including location prior to exiting the facility. The surveyors interviewed the Corporate Operations Officer, Administrator, DON and direct care staff on all shifts. 2. Statements will be obtained from staff dating back 3 days prior to any incident that occurs. The surveyors interviewed the Chief Operations Officer, Administrator, DON and direct care staff on all shifts. 3. The facility developed an Elopement/exit-seeking procedure and initiated inservice/education to all employees as follows: All nursing staff, Certified Nursing Assistants, Social Services, Dietary, Physical Therapy, Business office, Respiratory Therapy, Admissions, Marketing, Activities, Minimum Data Set, Administration, and contracted Housekeeping services. No staff will be able to work until inservice is completed. Inservices will be ongoing to include new hires. The surveyors reviewed inservice records and interviewed staff on all shifts. 4. When any resident opens exit doors, statements will be obtained from all staff involved in redirecting resident from exit doors. If the elopement/exit seeking behaviors continue, the elopement/exit-seeking procedure protocols will be reinstated. The surveyors reviewed procedures and protocols and interviewed staff on all shifts. 5. All residents who are exit-seeking will be interviewed to attempt to determine reasons for exit-seeking behaviors to address the residents' needs at the time. The surveyors interviewed administrative staff and staff on all shifts. 6. Inservice and education was initiated on 2/5/2020 with all licensed staff regarding the elopement assessment tool. All staff will be educated on the proper protocol to complete a thorough investigation. Protocol forms implemented were: -30-minute Elopement/Exit-Seeking Form -Elopement Risk Rounds -High Risk Elopement Location Sign In/Out Sheet -CNA Shift Change Communication Form for Elopement/Exit Seeking/Wanderers -Elopement/Exit-Seeking Report -Elopement/Exit-Seeking Notification Checklist -Elopement/Exit-Seeking Checklist -Elopement/Exit-Seeking Investigation Information -Elopement/Exit-Seeking Investigation Interview Sheet -Elopement Risk Evaluation The surveyors reviewed inservice records and interviewed staff on all shifts. Noncompliance of F-610 continues at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.",2020-09-01
2386,ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER,445397,409 PARK AVENUE,ADAMSVILLE,TN,38310,2019-07-16,600,J,1,0,98W311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, facility investigation review, medical record review, and interview, the facility failed to prevent neglect for 1 of 4 (Resident #1) sampled residents reviewed with wandering/exit seeking behaviors which resulted in Immediate jeopardy (IJ) when Resident #1 exited the facility, crossed 2 side streets, and walked to a local grocery store, 0.7 miles from the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility neglected to ensure a safe environment for Resident #1 which placed Resident #1 in Immediate Jeopardy (IJ), The facility neglected to adequately supervise Resident #1, a cognitively impaired resident with known wandering and exit seeking behaviors. Resident #1 had a history of [REDACTED]. The resident exited the facility on 6/28/19 and was located 0.7 miles from the facility at a local grocery store. The facility had no knowledge the resident was missing until the resident was returned to the facility by the police. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-600 was cited at a scope and severity of [NAME] F-600 J is Substandard Quality of Care. A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: Review of the facility's Abuse Prevention Policy & Procedure revised 1/23/17 documented, .the right to be free from .neglect .Neglect: The failure to fulfill a care-taking obligation to provide goods or services necessary to avoid physical harm, mental anguish or mental illness . Closed medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] from a Geriatric Psychiatric Unit with [DIAGNOSES REDACTED]. Resident #1 resided on the Secure Unit in the facility. Closed medical record review of an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/8/19 revealed Resident #1 was assessed with [REDACTED]. The MDS documented Resident #1 had disorganized thinking, inattention, delusions, verbal behaviors, physical behavior symptoms 1-3 days during the assessment period, impaired vision, and wore corrective lens. These behaviors placed the resident at significant risk for physical injury or illness. The resident was unsteady when ambulating. There were no Nursing Risk Assessments completed after the resident was admitted on [DATE] and readmitted on [DATE] to alert staff that Resident #1 was an elopement risk. Closed medical record review of the quarterly MDS with an ARD of 6/12/19 revealed Resident #1 was assessed to have a BIMS score of 7 which indicated the resident was severely impaired for decision making, had hallucinations, other behavioral symptoms, and the wandering behavior occurred 1 to 3 days. The resident did not require any assistive devices and needed limited assistance with walking. Closed medical record review of Resident #1's comprehensive care plan dated 3/12/19 and reviewed 6/20/19 revealed Resident #1 had wandering tendencies and exit seeking behaviors due to Dementia. Interventions to address this behavior included placing the resident in an area where frequent observation was possible, to implement facility protocol for locating an eloped resident, designate staff to account for resident's location throughout the day, and alert staff to the wandering behaviors. Interview with the Administrator on 7/11/19 at 7:30 PM in the Administrator's Office, the Administrator was asked if Resident #1 had exited the facility unattended prior to 6/28/19 and the Administrator stated, .I believe he got out .but not off of the premises .didn't investigate . Interview with Licensed Practical Nurse (LPN) #1 on 7/12/19 at 1:38 PM in the Conference Room, LPN#1 confirmed Resident #1 had exited the Secure Unit without staff being aware on 5/20/19. Review of a nurses' note dated 6/28/19 at 6:00 PM documented .continued exit-seeking behavior noted. Resident waving out window for help, standing at door until it opens in attempt to leave, and attempting to call on nurses' station phone w/o (without) permission. Will monitor behaviors . Review of the Resident Incident Report provided by the facility dated 6/28/19 revealed Resident #1 was confused and disoriented. The (named grocery store) employee notified the police department at 7:11 PM that the resident was in the store parking lot. The police returned the resident to the facility at 8:00 PM. Review of a nurses' note dated 6/29/19 at 6:03 AM documented, .at 2000 (8:00 PM on 6/28/19) resident was returned to hall when brought back to facility by police after elopement .stated 'I just followed some man out' . Interview with the Administrator on 7/11/19 at 3:50 PM in the 100 Hall, the Administrator stated, .I was here that day (6/28/19) .I was leaving to go home .I walked outside and saw 2 police officers standing outside talking. I waved at them and went to my car. It was between 7 (7:00 PM) and 8 (8:00 PM) that night .I called into the facility and they said the police had just brought (Resident #1) back to the facility from (named grocery store) .the only thing we can figure out is he walked out of the exit door on secure unit with a family member .we are unable to determine which route he took to the grocery store .I treated this like a jeopardy .my first question was how did they (staff) not know he was gone . Interview with the DON on 7/11/19 at 5:40 PM in the Conference Room, the DON was asked about Resident #1. The DON stated, .wandering .saw him at the door .around shift change stand by the door (on 6/28/19) . Interviews on 7/12/19 throughout the day with LPN #2, CNA #1, CNA #2, and Activity Assistant #1, all confirmed that on 6/28/19 Resident #1 exhibited exit seeking behavior, seemed more focused on exiting the facility, and seemed more agitated. Telephone interview with LPN #3 on 7/12/19 at 5:03 PM, LPN #3 revealed Resident #1 was .very aggressive at times .watches the doors .push on doors .watch people coming in and out through the doors .hadn't been back long from geri (geriatric)-psych (psychiatric) . LPN #3 was asked about the evening of 6/28/19 when he exited the facility. LPN #3 stated, .he wasn't in the lobby when I came on shift. He sometimes goes to bed after supper so I thought he was in bed .day shift had reported he was exit seeking that day .I had started med (medication) pass .around 8:00 PM. The 100 hall nurse (LPN # 4) brought Resident #1 in through the door (of the Secure Unit). The police had just returned him to the facility. His daughter was with him .he (Resident #1) stated, 'I went for a walk and had to find someone to bring me back' . LPN # 3 further stated .He was very, very determined .very sneaky .watching us go in and out of door . Interview with the Administrator and the DON on 7/13/19 at 5:04 PM in the Conference Room, the DON was asked how sending Resident #1 to a geri-psych facility addressed his exit seeking behavior and the DON stated, .adjusting his medications adding or decreasing and giving us other interventions that might help . The DON was asked if the staff should have been aware if a resident was missing from the facility for over an hour. The DON stated, .he wasn't gone that long . The Administrator was asked if the nurse responsible for the care of Resident #1 the evening of 6/28/19 was unaware the resident was missing from the facility prior to the police returning the resident to the facility at 8:00 PM. The Administrator stated, .yes that's true . The Administrator was asked if the employee at (Named grocery store) had not called 911 what could have happened to Resident #1. The Administrator stated, .I don't know .don't want to think about it . Interview with the Administrator, Regional Consultant for Clinical Services, and DON on 7/14/19 at 12:08 PM in the Conference Room, the Regional Consultant for Clinical Services stated, .the care plan was reviewed and updated .medications were changed .he was sent to geri-psych hospital. That is an intervention on his care plan and the activity was updated on 6/20/19 I don't think this meets criteria for an IJ . Interview with LPN #4 on 7/14/19 at 6:15 PM in the Conference Room, LPN #4 was asked about the night Resident #1 exited the facility and was located at a local grocery store, LPN #4 stated, .it was around 8:00 PM. The police walked down the 100 hall with Resident #1 and I assisted Resident #1 back to the Secure Unit . LPN #4 was asked if she was aware a resident was missing from the facility, LPN #4 stated, .no . Interview with the Regional Consultant for Clinical Services on 7/15/19 at 5:05 PM in the Conference Room, the Regional Consultant for Clinical Services was asked if the occurrence when Resident #1 exited the Secure Unit on 5/20/19 was documented on the 24 hour nurse report, the Regional Consultant for Clinical Services stated, .he did not actually leave so we did not consider that an incident .it's documented highly exit seeking behaviors noted . Interview with the DON on 7/16/19 at 5:23 PM in the Conference Room, the DON was asked if a resident should leave the Secure Unit unattended. The DON stated, .no The DON was asked if the staff should be unaware a resident was missing from the facility until the police returned the resident to the facility. The DON stated, .no . The facility's failure to supervise Resident #1, failure to respond to Resident #1's exit seeking behavior, and failure to know where Resident #1 was for 1 hour and 20 minutes resulted in neglect when Resident #1 eloped from the facility on 6/28/19 with a recorded high temperature of 86 degrees, crossed 2 side streets, and walked 0.7 miles to a local grocery store which was located 247 feet from a major 4 lane highway. Refer to F 689 The surveyor verified the A[NAME] by: 1. Head counts of all residents on the Secure Unit will be conducted by Licensed Nurses hourly on the Head Count Form. This was initiated on 7/15/19. The surveyor reviewed the Head Count Form and interviewed staff on each shift. 2. Active Exit-Seeking policy was updated on 7/14/19 to reflect definition and actions to take when residents are actively exit seeking. 100% of staff, which included all departments, will be in-serviced by the DON and/or Designee on updated policy by 7/15/19. Staff unable to attend this in-service will not be allowed to work until in-serviced. Changes included to the policy included: the definition of active exit seeking, if staff observes a resident actively exit seeking they are to stay with resident at all times, inform the Charge Nurse or Director of Nursing, utilize all of the care plan interventions currently in place, the charge nurse will complete a skilled nursing assessment to determine potential causes of behavior and will ensure the resident is on documented 1:1 immediately and complete an updated Elopement Risk Assessment and update the care plan with appropriate and new interventions. Resident will remain on 1:1 until an evaluation is completed by the Interdisciplinary Team and a determination is made the resident no longer requires the 1:1. The surveyor reviewed the in-service sign in sheets and interviewed staff on each shift. 3. Director of Nursing and/or Designee will educate all licensed and registered nurses on the Elopement Risk Assessment, the Nursing Summary. Staff unable to attend will not be allowed to work until in-serviced. The surveyor reviewed the in-service sign in sheets and interviewed staff on each shift. 4. Maintenance Director or Designee began elopement drills on each shift beginning 6/28/19 then weekly for four weeks then one shift weekly for two months and/or when substantial compliance is achieved. The surveyor reviewed the audits. 5. Beginning 6/28/19 the DON, Staff Development Coordinator or Designee began to conduct audits of resident head counts at shift change for two weeks, then three times weekly for four weeks, then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audits. 6. Social Services Director or Designee will audit elopement books beginning 7/15/19 to ensure they are updated based on new and updated elopement risk assessments weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 7. Employee Relations Director or Designee will audit new hires beginning 7/15/19 to ensure they received elopement procedure training weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 8. Beginning 7/15/19 the DON and/or Designee will audit five elopement risk assessments weekly for four weeks then monthly for two months to ensure any exit seeking behaviors are care planned appropriately. The surveyor reviewed the audit forms. Noncompliance of F-600 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction.",2020-09-01
1998,GRACELAND REHABILITATION AND NURSING CARE CENTER,445331,1250 FARROW ROAD,MEMPHIS,TN,38116,2020-02-10,689,J,1,0,U67J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, facility investigation review, medical record review, observation, and interview, the facility failed to ensure a safe environment for 1 of 4 sampled residents (Resident #1) reviewed with exit-seeking behaviors. Resident #1 was a cognitively impaired, vulnerable resident with a history of wandering/exit seeking behaviors who eloped from the facility, which resulted in Immediate Jeopardy (IJ). Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility failed to ensure a safe environment and failed to supervise Resident #1, who was missing for approximately 2 hours and 45 minutes after she was last seen by facility staff. Resident #1 was picked up by a police officer approximately 1.3 miles from the facility. The officer had responded to a 911 call concerning a suspicious female knocking on the doors of houses in the area. Resident #1 crossed State Route 175 (Shelby Drive), a heavily traveled 7 lane highway. This resulted in an IJ for Resident #1. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-689 on 2/5/2020 at 2:45 PM, in the Conference Room. The facility was cited F-689 at a scope and severity of J, which is Substandard Quality of Care A partial extended survey was conducted on 2/7/2020 through 2/9/2020. The Immediate Jeopardy was effective from 11/1/2019 through 2/9/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 2/7/2020 at 3:00 PM. The Removal Plan was validated onsite by the surveyors on 2/9/2020-2/10/2020 through review of policies related to active exit-seeking behavior, assessments, inservice training records, observations, and interviews. The findings include: Review of the facility's policy titled, Wandering, Unsafe Resident, revised 4/30/2019, showed, .strive to prevent unsafe wandering .identify residents who are at risk for harm because of unsafe wandering (including elopement) .staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering .a missing resident is considered a facility-wide emergency . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the Elopement Risk Evaluation dated 7/25/2019 showed Resident #1 was at risk for elopement. Review of the Comprehensive Care Plan dated 8/6/2019, showed that the plan of care did not include interventions for Resident #1's assessed elopement risk. Review of the quarterly Minimum Data Set ((MDS) dated [DATE], showed Resident #1 was assessed with [REDACTED]. Resident #1 required supervision and 1 person assistance with all activities of daily living, which included ambulation and locomotion on the unit in a wheelchair. Review of the Nurses' Notes dated 11/1/2019 at 1:30 PM, showed, .Door alarm heard sounding at the end of 700 Hall (Resident #1) pushing the emergency exit door open and exiting the building. Two staff aides noted running behind (Resident #1) . Review the Care Plan dated 8/6/2019 showed the plan of care was not revised for Resident #1's assessed elopement risk until this elopement attempt on 11/1/2019. Review of the Care Plan revised 11/1/2019, showed the resident was .at risk for elopement r/t (related to) poor safety awareness .will remain safely on facility property until safe discharge is possible .Interventions .assess skin under/near wander guard placement for irritation, breakdown and proper fit. Check wander guard placement every shift. Encourage participation and interactions that decreases anxiety and exit seeking . Review of the Nurses' Notes dated 11/14/2019, showed, .screaming and yelling loudly in the hallway .packed all of her belongings stating that she wanted to leave the facility. Resident held the exit door on the 700 hall until it opened and exited door .brought back into the facility by housekeeping aide and CNA (Certified Nursing Assistant) 600 hall .send resident to (Named) psychiatric hospital . Review of the Care Plan revised 11/1/2019, showed there were no new interventions added to the Care Plan after the elopement attempt on 11/14/2019. Review of the Psychiatric Follow Up Note dated 1/3/2020, showed Resident #1 was seen for worsening symptoms of anxiety, restlessness, and hyperactive behaviors. Resident #1 was anxious, delusional, flighty thoughts, and redirection was not effective. Resident #1 was identified to be clinically unstable, high acuity, and severe behavioral problems. Review of the facility's investigation dated 1/16/2020, showed that the facility's video camera footage was viewed by the Administrator and DON to determine how Resident #1 exited the building. The camera footage showed that on 1/16/2020 at 1:48 PM, Resident #1 got up from her wheelchair and walked into a resident room. At 1:50 PM, Resident #1 was seen exiting a window in room [ROOM NUMBER] and walking towards the back of the building. The surveyor viewed this video camera footage. Review of the Social Services Note dated 1/16/2020, showed, .Resident (Resident #1) exit (exited) the building, upon return she was question (questioned) by social services .she don't (doesn't) recall her were (where) bouts (abouts) when asked did she leave the facility she stated no .when ask (asked) was she with a police officer she said I don't know what you talking about with a puzzle (puzzled) look on her face. Resident returned safely no complain (complaint) of pain or injury .According to the officer they received a called (call) resident was picked up she stated she lives at an address given to cop, resident was taken to address provide (provided) a male guy was there and he informed the officer that she lives in a nursing facility were (where) she returned . Observation in the Activity Room on 2/3/2020 at 10:00 AM, showed Resident #1 was seated in a wheelchair listening to music. A wanderguard was noted to her left ankle. Observation in the resident's room on 2/5/2020 at 8:04 AM, showed Resident #1 was up walking in her room. Observation in the 800 Hall on 2/6/2020 at 4:03 PM, showed Resident #1 was seated in a wheelchair using her feet to move her wheelchair briskly down the hall toward the Nurses' Station. Observation in the Dining Room on 2/8/2020 at 12:40 PM, showed Resident #1 was eating lunch, and self-propelled herself in the wheelchair. During an interview conducted on 2/3/2020 at 3:00 PM, CNA #1, who was assigned to care for Resident #1 on 1/16/2020, stated, .I saw her at approximately 1:30 (PM) .did not see her when we changed shifts .I thought she was still in activities . During an interview on 2/3/2020 at 3:12 PM, the police officer stated, .not a police report because there was no crime committed .the 911 call came in at approximately 3:00 PM, the report was of a suspicious person, a female knocking on doors in the (Named Apartment Complex) .when I arrived I asked her (Resident #1) where she lived and she gave me an address on (Named Street) so I took her to the address .the gentleman living there knew her and said she resided at (Named Nursing Home) so I took her back to the nursing home .it was approximately 4:15 PM when I arrived at the facility . During an interview conducted on 2/4/2020 at 9:00 AM, the DON stated, .I didn't know (Resident #1 had eloped) until the officer brought her back . During an interview conducted on 2/4/2020 at 10:50 AM, the Administrator stated, .I didn't know until the police brought her back . The Administrator confirmed Resident #1 had exited the facility twice in November 2019 and that these incidents were not investigated to determine the possible causes of the exit seeking behaviors. She stated she did not think these needed to be investigated because staff observed the resident exiting through the 700 Hall door and returned the resident to the building. During an interview conducted on 2/4/2020 at 2:20 PM, Licensed Practical Nurse (LPN) #1, who was the nurse coming on shift at 3:00 PM on 1/16/2020, stated, .I came on shift .I didn't see her (Resident #1) so I asked day shift nurse where she was, she (day shift nurse) said she (Resident #1) was in activities. I walked by the activity room but didn't see her . LPN #1 was asked when she knew that Resident #1 had eloped from the building. LPN #1 stated, .when I got back to the floor .around 4 (4:00 PM) .she was sitting at the Nurses' Station in wheelchair .since she has come back from (Named Psychiatric Hospital) she's had increased exit seeking behaviors . During an interview conducted on 2/4/2020 at 2:35 PM, Registered Nurse (RN) #1, who was the Unit Manager for the D (800) Hall on 1/16/2020, stated, .I didn't know (Resident #1 had eloped) until the police brought her back . Refer to F-600, F-610, F-656, and F-657. The surveyors verified the Removal Plan by: 1. Resident #1's window was secured with screw in window locks on each side of the window on 1/16/2020. All residents' windows have been checked and secured with screw in window locks. The surveyors viewed the window locks. 2. The opening in the fence has been secured with wood fencing. The surveyors viewed the fence secured with wood fencing. 3. Maintenance Director/Designee will perform weekly audits ongoing to ensure safety and security of windows and fence. Audits will be reported to Quality Assurance Performance Improvement Committee. The surveyors reviewed the audit tools and interviewed the Maintenance Director. 4. If a resident is found attempting to exit-seek/elope, resident will be redirected and interviewed to obtain reasons for exit-seeking/elopement to address residents' needs at that time. Statements from all staff caring for the resident will be obtained for the previous 72 hours. An elopement assessment will be updated and appropriate interventions care planned at that time. Protocol forms implemented were: -30-minute Elopement/Exit-Seeking Form -Elopement Risk Rounds -High Risk Elopement Location Sign In/Out Sheet -CNA Shift Change Communication Form for Elopement/Exit Seeking/Wanderers -Elopement/Exit-Seeking Report -Elopement/Exit-Seeking Notification Checklist -Elopement/Exit-Seeking Checklist -Elopement/Exit-Seeking Investigation Information -Elopement/Exit-Seeking Investigation Interview Sheet -Elopement Risk Evaluation Inservice/Education has begun on all new implemented procedures and will continue until all current employees have been educated. Employees will not work until they have been in-serviced. Inservice/Education will also be ongoing to include, but not limited to all new employees. The surveyors viewed the new protocols and forms, and interviewed staff on all shifts. 6. The Director of Nursing, Assistant Director of Nursing, or Designee will ensure compliance with daily audits on protocols for exit seeking/eloping residents and report to Quality Performance Improvement Committee. The surveyors reviewed the audit tools and interviewed the DON. Noncompliance of F-689 continues at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.",2020-09-01
1994,GRACELAND REHABILITATION AND NURSING CARE CENTER,445331,1250 FARROW ROAD,MEMPHIS,TN,38116,2020-02-10,600,J,1,0,U67J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, facility investigation review, medical record review, observation, and interview, the facility failed to prevent neglect for 1 of 4 sampled residents (Resident #1) reviewed with wandering/exit-seeking behaviors, which resulted in Immediate Jeopardy (IJ) for Resident #1. The facility neglected to ensure a safe environment and neglected to adequately supervise Resident #1, a cognitively impaired resident with known wandering and exit-seeking behaviors. Resident #1 had exited the facility on 11/1/2019 and 11/14/2019. Resident #1 exited the facility on 1/16/2020 through a window and then a hole in the facility's fence, crossed a major 7 lane highway, and walked to a neighborhood 1.3 miles from the facility. The facility did not know Resident #1 was missing until a police officer returned the resident to the building 2 hours and 45 minutes after she was last seen by facility staff. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-600 on 2/5/2020 at 2:45 PM, in the Conference Room. The facility was cited F-600 at a scope and severity of J, which is Substandard Quality of Care. A partial extended survey was conducted on 2/7/2020 through 2/9/2020. The Immediate jeopardy was effective from 11/1/2019 through 2/9/2020. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 2/7/2020 at 3:00 PM. The Removal Plan was validated onsite by the surveyors on 2/9/2020 - 2/10/2020 through review of assessments, policies related to exit-seeking behavior, inservice training records, observations, and interviews. The findings include: Review of the facility's policy titled, Abuse and Neglect-Clinical Protocol, revised 3/2018, showed, .Neglect .failure of the facility, its employees .to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress .physician and staff will help identify risk factors for abuse within the facility .issues related to staff knowledge and skill: performance that might affect resident care .identify situations that might constitute or could be construed as neglect . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the Elopement Risk Evaluation dated 7/25/2019, showed Resident #1 was at risk for elopement. Review of the quarterly Minimum Data Set ((MDS) dated [DATE], showed Resident #1 was assessed with [REDACTED]. Resident #1 required staff supervision and 1 person physical assistance for all activities of daily living (ADLs), including ambulation and locomotion in a wheelchair. Review of the Care Plan revised 11/1/2019, showed Resident #1 was .at risk for elopement r/t (related to) poor safety awareness .will remain safely on facility property until safe discharge is possible .Interventions .assess skin under/near wander guard placement for irritation, breakdown and proper fit. Check wander guard placement every shift. Encourage participation and interactions that decreases anxiety and exit seeking Review of the Nurses' Notes dated 11/1/2019 and 11/14/2019, showed that Resident #1 held the exit door on the 700 Hall until it opened and exited the building. Resident #1 was redirected back into the building each time by staff. Review of the facility's investigation dated 1/16/2020 showed that the facility's video camera footage was viewed by the Administrator and DON to determine how Resident #1 exited the building. The camera footage showed that on 1/16/2020 at 1:48 PM, Resident #1 got up from her wheelchair and walked into a resident room. At 1:50 PM, Resident #1 was seen exiting a window in room [ROOM NUMBER] and walking towards the back of the building. The surveyor viewed this video camera footage. Review of the Social Services Note dated 1/16/2020, showed that Resident #1 was returned to the facility by a police officer responding to a call. Resident #1 had no memory of the incident when she was questioned by Social Services. Observation in the Activity Room on 2/3/2020 at 10:00 AM, showed Resident #1 was seated in a wheelchair listening to music. A wanderguard was noted to her left ankle. Observation in the resident's room on 2/5/2020 at 8:04 AM, showed Resident #1 was up walking in her room. Observation in the 800 Hall on 2/6/2020 at 4:03 PM, showed Resident #1 was seated in a wheelchair using her feet to move her wheelchair briskly down the hall toward the Nurses' Station. Observation in the Dining Room on 2/8/2020 at 12:40 PM, showed Resident #1 was eating lunch, and self-propelled herself in the wheelchair. During a telephone interview on 2/3/2020 at 3:12 PM, the police officer stated, .not a police report because there was no crime committed .the 911 call came in at approximately 3:00 PM. The report was of a suspicious person, a female, knocking on doors near the (Named Apartment Complex) .when I arrived I asked her (Resident #1) where she lived and she gave me an address on (Named Street) so I took her to the address .The gentleman living there knew her and said she resided at (Named Nursing Home) so I took her back to the nursing home .It was approximately 4:15 PM when I arrived at the facility . During an interview on 2/3/2020 at 3:00 PM, Certified Nursing Assistant (CNA) #1, who was assigned to care for Resident #1 on 1/16/2020 for the 7:00 AM to 3:00 PM shift, stated, .I saw her at approximately 1:30 (PM) .did not see her when we changed shifts .I thought she was still in activities . During an interview on 2/4/2020 at 9:00 AM, the DON stated that the facility staff was unaware Resident #1 was missing until the police brought her back. During an interview on 2/4/2020 at 10:50 AM, the Administrator stated, .I saw a police car in the parking lot .they called and asked about a resident .we went out to the car and she (Resident #1) was in the backseat of the police car .that's when I knew she had exited the facility . The Administrator confirmed Resident #1 had exited the facility twice in November 2019 and that these incidents were not investigated to determine possible causes of the exit seeking behaviors. She stated that the incidents were not investigated because staff observed the resident exiting through the 700 Hall door and returned the resident to the building. During an interview on 2/4/2020 at 2:20 PM, Licensed Practical Nurse (LPN) #1, who was the nurse coming on shift at 3:00 PM on 1/16/2020, stated, .I didn't see her (Resident #1) so I asked day shift nurse where she was .I walked by the activity room but didn't see her . LPN #1 was asked when she knew Resident #1 had eloped from the building. LPN #1 stated, .When I got back to the floor .around 4 (PM) .she was sitting at the nurse's station in a wheelchair .since she has come back from (Named Psychiatric hospital on [DATE]) she's had increased exit-seeking behaviors . During an interview on 2/7/2020 at 4:00 PM, the Administrator confirmed that staff should have known Resident #1 was gone. The facility's failure to provide supervision for Resident #1, a cognitively impaired resident with known wandering and exit-seeking behaviors, and failure to identify that Resident #1 was missing from the facility for approximately 2 hours and 45 minutes on 1/16/2020 resulted in substantiated resident neglect. Resident #1 was found by a police officer, 1.3 miles away from the facility, after a 911 call was made regarding a suspicious female knocking on doors of houses in the area. The facility failed to ensure a resident was free from staff neglect which resulted in Immediate Jeopardy for Resident #1. Refer to F-610, F-656, F-657, and F-689. The surveyors verified the Removal Plan by: 1. Nursing staff involved on 1/16/2020 with incomplete rounds had been disciplined up to and including termination. The surveyors reviewed personnel records and disciplinary forms. 2. A new elopement assessment was completed on Resident #1 on 2/5/2020 at 7:40 PM. The surveyors reviewed the assessment. 3. To meet and maintain compliance, elopement assessments for all at-risk residents for elopement were updated on 2/5/2020 with documentation of new information if applicable. The surveyors reviewed the updated elopement assessments. 4. Facility inserviced CNA staff on proper rounding frequency on residents. Additional inservice was provided on CNA shift change Communication Form for Elopement/Exit-Seeking/Wanderers. On 2/5/2020, a new 30-minute elopement/exit-seeking form was established for charge nurses with 30 minute checks for active exit-seeking residents for a period of daily for 2 weeks, weekly for 4 months, and ongoing until other adjustments are made in order to prevent exit-seeking/elopement. No staff will be able to work until inservice is completed. The surveyors reviewed inservice records, observed 30 min elopement/exit-seeking form being utilized on all 3 shifts, and interviewed staff on all 3 shifts. 5. An inservice on walking rounds at the change of shift with nursing staff was initiated on 2/5/2020. No nursing staff will be able to work until inservice is completed to include new hires. The surveyors reviewed inservice records, observed all shifts conducting walking rounds, and interviewed staff on all shifts. 6. Elopement assessments will be reviewed in daily clinical meetings for accuracy. The surveyors interviewed management staff and reviewed inservices related to elopement assessments in daily clinical meetings. 7. The use of the elopement assessment tool inserviced and educated to all nurses on 2/5/2020. The surveyors reviewed the elopement assessment tool and interviewed nurses on all shifts. 8. Inservice and education was initiated on 2/5/2020 with all licensed staff regarding the elopement assessment tool. No licensed nurse will be allowed to work until inservice is completed to include new hires. The surveyors reviewed inservice records and interviewed licensed staff on all shifts. 9. A new elopement risk rounds document has been adopted and will be utilized by unit managers and house supervisors on a daily basis ongoing. The document will identify residents' name, date, time, room number, location and a signature of responsible employee which will safeguard measures to ensure staff supervision of residents assessed to be at risk for elopement and known exit-seeking behaviors. The Director of Nursing, Assistant Director of Nursing, or a designee will conduct daily audits to ensure compliance and report findings to the Quality Assurance Performance Improvement Committee. The surveyors reviewed audit tools and interviewed the Director of Nursing, Assistant Director of Nursing, and the Unit Managers. 10. A sign-in sheet has been added to the existing elopement book on each unit to show time and location of a resident when taken to another location within the facility. The surveyors reviewed the elopement books, observed sign in/out sheets being used, and interviewed staff on all shifts. 11. The facility conducted elopement drills on 1/20/2019, 2/5/2020, and 2/6/2020 as a measure to ensure staff are familiar with their roles in the event of an elopement. The surveyors reviewed documentation and interviewed staff on all shifts. Noncompliance of F-600 continues at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.",2020-09-01
3246,THE HIGHLANDS OF DYERSBURG HEALTH & REHAB,445497,350 EAST TICKLE STREET,DYERSBURG,TN,38024,2019-07-22,610,J,1,0,T41H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, facility investigation review, review of a hall camera monitoring system recording, hospital record review, open and closed medical record review, observation, and interview, the facility failed to thoroughly investigate a suspicion of resident sexual abuse for 1 of 7 (Resident #2) sampled residents reviewed after Resident #2 was observed ambulating in the hall with a disheveled appearance from Resident #1's room. Resident #1 had repeated sexually inappropriate behaviors (physical, gestures and comments), and also resided on the Secure Unit. The facility's failure to thoroughly investigate a suspicion of resident sexual abuse placed the 11 vulnerable cognitively impaired female residents residing in the Secure Unit at risk for sexual abuse, which resulted in Immediate Jeopardy. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 7/20/19 at 6:20 PM in the Conference Room. F610 was cited at a scope and severity of [NAME] The facility was cited F610J which is Substandard Quality of Care. A partial-extended survey was conducted from 7/20/19 through 7/22/19. The Immediate Jeopardy was effective 7/9/19 through 7/22/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on 7/22/19 at 10:25 AM, and corrective actions were validated onsite by the surveyors on 7/22/19. The findings include: 1. Review of the facility's Abuse Prohibition policy and procedure dated (MONTH) (YEAR) documented, Residents have the right to be free from abuse, corporal punishment, and involuntary seclusion .The facility must have evidence that all violations, including allegations, are thoroughly investigated .All center staff will be advised that they must ensure the following protocols are followed: .No one may disturb the scene where the alleged abuse took place .The resident may not be cleansed, until authorization from authorities is received .A complete body audit will be conducted by nursing staff, which will note specifically: signs of trauma, bruising, bodily fluids, torn clothing or linens .Once the scene has been cleared by officials (police or other investigative parties) the clothing and linens must be bagged and kept in a secure location .The alleged victim must be sent out immediately for a rape kit to be completed at the hospital .Investigation guidelines include: Resident(s) and responsible party interviews, as applicable .Physical examination .Staff interviews and written statements, as applicable .Methods to support the individual and detect and prevent further victimization . 2. Closed medical record review revealed Resident #2 was admitted to the facility 10/19/15 with [DIAGNOSES REDACTED]. Closed medical record of the annual MDS assessment dated [DATE] revealed unclear speech, a cognitive score of 3, which indicated severe cognitive impairment, continuous inattention, physical symptoms directed toward others, daily rejection of care, daily wandering. Resident #2 required limited assistance of staff for transfer and ambulation, extensive assistance for dressing and eating, and was dependent on staff for toileting, personal hygiene and bathing, and was always incontinent of bowel and bladder. Closed medical review of the comprehensive care plan for Resident #2 initiated on 4/26/19 revealed a history of wandering and impaired safety awareness. 3. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Medical record review of psychiatric hospital records revealed the resident was admitted from 12/27/18-1/16/19 to the psychiatric hospital. The psychiatric hospital History and Physical dated 12/28/18 documented, .This patient was displaying inappropriate sexual behavior. He was asking residents and staff for sex. Per records, he touched a CNA (Certified Nursing Assistant) inappropriately between her legs. He was also asking other people to come and get in the bed with him. He is here for behavior and medication management . Medical record review of the psychiatric hospital Discharge Summary dated 1/16/19 revealed [MEDICATION NAME] (an antidepressant) was started and increased during his stay and appeared, .to be effective with decreasing sexual urges and inappropriate behavior . [MEDICATION NAME] (A medication which counteracts the effect of testosterone in males) was also ordered. Medical record review of Resident #1's initial care plan dated 1/17/19, which was initiated on his return to the facility from an inpatient psychiatric hospital, revealed the resident had a behavior concern of inappropriate sexual behavior. The care plan was updated on 7/9/19 to reflect the resident's move to a room closer to the nurse's station and 7/10/19 for visual checks every 15 minutes for location. Medical record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a cognitive score of 3, which indicated severe cognitive impairment, and required limited assistance of staff for all activities of daily living (ADL). Medical record review of the nursing progress notes for Resident #1 dated 7/3/19, 7/9/19, 7/10/19, 7/17/19, and 7/20/19 revealed the resident continued to have sexually inappropriate behaviors. Interview with Certified Nursing Assistant (CNA) #2 on 7/19/19 at 1:30 PM in the Conference Room and LPN #1 on 7/19/19 at 1:45 PM in the Conference Room confirmed Resident #1's history and ongoing sexually inappropriate behaviors and confirmed Resident #2's history of continually wandering on the unit. 4. Review of the hall monitoring camera recording dated 7/9/19 from 6:03 PM through 6:23 PM revealed the following: Resident #2 had been casually and appropriately dressed wandering on the unit, sat at the nurses station next to Resident #1, stood and began wandering down the hall and was followed by Resident #1. Resident #1 and Resident #2 were observed to enter Resident #1's room at the end of the hall at 6:06 PM together, Resident #1 was walking on Resident #2's left side and had his right arm around Resident #2's lower back and hand at the right side of her waist. Resident #1 guided Resident #2 into his room. At 6:20 PM Resident #2 exited the room alone, shut the door, and wandered into a room across the hall. After Resident #2 came out of Resident #1's room, one of her legs was bare and she appeared to be inappropriately dressed. The resident was observed by the Registered Nurse (RN) Supervisor and CNA #2 in the hall. The resident was assessed by the RN Supervisor who reported her observations to the DON. 5. Interview with the RN Supervisor on 7/18/19 at 12:15 PM, in the Conference Room, the RN Supervisor confirmed her written statement of her observations on 7/9/19. The RN Supervisor revealed both of Resident #2's legs were in one pant leg, her pants were inside out and her brief was missing. The RN Supervisor confirmed she had notified the DON, who came to the unit and examined the resident. After the RN Supervisor had written her statement, she had asked the DON if she should document her observations on an incident report or make any contacts and was told, .not at this point Interview with CNA #2 on 7/18/19 at 12:15 PM, in the Conference Room, CNA #2 confirmed her written statement of her observations on 7/9/19. CNA #2 revealed both of Resident #2's legs were in one pant leg, her pants were inside out and her brief was missing. Interview with the DON on 7/18/19 at 2:50 PM, in the Conference Room, the DON stated she checked Resident #2's brief in the trash can, and she only noticed fresh urine in the brief. Interview with the Nurse Practitioner on 7/18/19 at 4:15 PM, in the Conference Room, the Nurse Practitioner was asked if she was notified when this incident occurred. The Nurse Practitioner stated, .She (nurse) called me .told her (nurse) to call DON and Administrator and follow their policy and procedures . Interview with the Administrator and DON on 7/19/19 at 12:45 PM in the Conference Room, when asked about staff reporting their observations on 7/9/19, the DON revealed she had been notified 7/9/19, had examined Resident #2, had concluded there was no evidence of sexual abuse, had notified the Administrator of her findings and they had not investigated the incident further. The suspicion of sexual abuse occurred on 7/9/19, and Resident #2 was not sent to the hospital for a rape kit until 7/12/19, when the family insisted the resident be transferred to the hospital. Interview with the Administrator/Abuse Coordinator on 7/20/19 at 3:30 PM, in the Conference Room, the Administrator was asked if she agreed with the DON that the allegation of sexual abuse reported by staff on 7/9/19 did not need to be further investigated. The Administrator stated, Yes. The facility's failure to thoroughly investigate a suspicion of sexual abuse placed the 11 cognitively impaired female residents residing on the Secure Unit at risk of potential sexual abuse which resulted in Immediate Jeopardy. Refer to F 600. The surveyors verified the A[NAME] by: All staff were in-serviced by the facility Administrator and DON beginning on 7/17/19 with competency testing, on the importance of Identifying, Reporting and Completing a thorough investigation of sexual abuse to include: Identifying the Abuse Coordinator, Identifying all types of abuse: Physical, Verbal, Mental, Sexual, Misappropriation of funds, Neglect, Involuntary Seclusion, and Corporal Punishment, Ensure that all alleged violations involving abuse, neglect, and exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property, are reported immediately, but no later than 2 hours after the unknown allegation is made, if the event that caused the allegation involves abuse or results in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and other officials (including the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Facility abuse policy and Federal/State regulation and guidelines for abuse were reviewed with all staff. Upon hire all new employees will be in-serviced on the facility abuse policy as well as Federal/State regulations and employees will be in-serviced at least annually. Any employee not working will be in-serviced prior to returning to work. The surveyors reviewed in-service sign in sheets and interviewed staff on each shift. Noncompliance of F610 continues at a scope and severity level of D for monitoring of the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.",2020-09-01
2537,MILLINGTON HEALTHCARE CENTER,445425,5081 EASLEY AVENUE,MILLINGTON,TN,38053,2019-01-27,656,J,1,0,Q97T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, hospital medical record review, medical record review, observation and interview, the facility failed to ensure care plan interventions were implemented for 2 of 7 (Resident #1 and #2) sampled residents reviewed for accidents. The facility failed to implement the intervention to supervise Resident #1, who was assessed with [REDACTED]. This resulted in actual harm and Immediate Jeopardy when Resident #1 was not supervised by facility staff during transport to an outside appointment and fell sustaining lacerations and a fractured nose. The facility failed to implement the safe mechanical lift (assistive transfer device) transfer intervention utilizing 2 staff members to transfer Resident #2. Resident #2 was assessed with [REDACTED]. This resulted in actual harm and Immediate Jeopardy when Resident #2 was transferred via mechanical lift by 1 staff member and was found with a discoloration on the cheek on 11/7/18. On 12/12/18 Resident #2 developed bruising and swelling of the face and sustained a fractured mandible (jaw). Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 1/27/19 at 9:00 AM in the conference room. The facility was cited an Immediate Jeopardy at F656-[NAME] The Immediate Jeopardy is ongoing. An extended survey was conducted on 1/26/19 and 1/27/19. The findings include: 1. Review of the facility Care Plan policy revised on 12/12/17 documented, .Each resident will have a plan of care to identify problems, needs, and strengths that will identify how the facility staff will provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 2. Medical record review for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed a score of 10 out of 15 which indicated the resident had moderately impaired cognition. A Fall Risk assessment dated [DATE] and 12/19/18 revealed a score of 14 and was .at high risk for potential falls. Resident #1's Care Plan initiated on 11/19/18 documented, The resident has an ADL (activity of daily living) Self Care Performance Deficit .Interventions .The resident requires staff participation with transfers. A Care Plan initiated on 11/28/18 documented The resident has impaired cognitive function r/t (related to) dementia . Interventions .supervise . Resident #1's Care Plan initiated on 11/28/18 documented The resident has impaired cognitive function r/t (related to) dementia .Interventions .supervise . Resident' #1's Nurses note by the DON dated 12/19/18 at 2:45 PM documented, .Patient with dental apt (appointment) today .Patient noted to have left the front door for dentist apt with (Named Transport Company) transport x1 (1 transport employee). A few mins (minutes) later entered the facility with (Named Transport Company) transport .Patient was sitting up in WC (wheelchair) with blood noted on face .911 called for transport . Interview with the DON on 1/15/19 at 1:00 PM in the conference room, the DON was asked if anyone accompanied Resident #1 to the dental appointment and the DON stated, No staff accompanied (Named Resident #1) . The DON was asked the cognitive status of Resident #1 and stated, .his cognition does come and go .he didn't remember anything after the fall .he has had previous falls . The DON was asked what was expected during transportation if a resident was cognitively impaired and stated, If a resident is cognitively impaired then either a family member or a CNA (certified nursing assistant) goes with them . Interview with Transportation Employee #1 on 1/16/19 at 1:00 PM via telephone, Transportation Employee #1 was asked if anyone accompanied him and Transportation Employee #1 stated, .I went to the desk .I was told his daughter was going to meet us at the doctor's clinic . Interview with Resident #1 on 1/16/19 at 1:40 PM in his room, Resident #1 was asked to describe the events on the day he fell in the parking lot and stated, .1 transport guy came to (my) room .(I) got in wheelchair .the transport guy took me out the front doors and down the ramp, at the bottom he stopped but I didn't, I slid out (of the wheelchair) in the driveway and landed on my knees, hands and hit my face .He took me out forward and took me down that ramp forward . Observations during this interview revealed Resident #1 had a healed scar area across the bridge of his nose and healed scars on both knees. The facility failed to ensure the care plan intervention of supervision was implemented for Resident #1, a cognitively impaired resident with a history of falls and mobility deficits resulting in actual harm and Immediate Jeopardy when Resident #1 was transported out of the building unaccompanied, unsupervised by facility staff, and not assessed to travel independently. Resident #1 was taken from the facility to the transport van by a transport company employee. The resident fell and sustained lacerations and a fractured nose. 3. Review of the facility Lift Management Program policy dated (MONTH) (YEAR) documented, .Our Lift Management Program is designed to meet the following goals: .To protect .residents from injury .Each co-worker is expected to support this program 100% (percent) .This procedure is always done with 2 people . 4. Medical record review for Resident #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. An Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 was assessed with [REDACTED]. Resident #2's Care Plan initiated on 4/4/18 revealed, The resident has an ADL (activities of daily living) Self Care Performance (deficit) .r/t (related to) stroke .dementia .[MEDICAL CONDITION] .Interventions .Hoyer (mechanical) lift with assist of 2 for transfers . An incident report dated 11/7/18 at 1:30 AM revealed Resident #2 was found with a discoloration on her left cheek. An Incident Report dated 12/12/18 at 10:06 AM documented, .Witnesses Statement 12/12/18 Phone interview with (named Certified Nursing Assistant (CNA) #1) states she believes she did not have adequate assist with Hoyer (mechanical) lift. She said it was possible the lift arm tapped (named Resident #2) cheek . Review of Resident #2's hospital medical record revealed a History and Physical (H&P) dated 12/15/18 that documented, .She (Resident #2) presented from a nursing home with worsening altered mental status and facial bruising .Significant bruising on the left side of her jaw .CT maxillofacial: Subtle (high energy trauma) nondisplaced [MEDICAL CONDITION] body of the right mandible (jaw) . Interview with CNA #1 on 12/28/18 at 12:57 PM via telephone, CNA #1 was asked how she transferred Resident #2 and she stated, .I get her up in the morning, 1 person .since I've been there, I've always transferred by myself . Interview with the DON on 1/15/19 at 1:00 PM in the conference room, the DON was asked what she expected staff to do during lift transfers and she stated, .2 people are to transfer with lifts. The facility failed to ensure staff implemented the care plan interventions, appropriately and safely transferred Resident #2 via mechanical lift which resulted in actual harm and Immediate Jeopardy when Resident #2 was found with a discoloration on her left cheek 11/7/18 and on 12/12/18 developed significant facial bruising, swelling, deterioration of swallowing status and was found with a fractured right mandible (jaw) after 1 staff member independently transferred the resident by mechanical lift.",2020-09-01
2909,HENDERSON HEALTH AND REHABILITATION CENTER,445471,412 JUANITA DRIVE,HENDERSON,TN,38340,2019-03-25,684,D,1,0,CQU611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, hospital record review, medical record review, observation and interview, the facility failed to follow physician's orders for treatment for 1 of 3 (Resident #1) residents reviewed for wound care and treatment. The findings include: The facility's Wound Care Management policy documented, .Each resident is evaluated by the interdisciplinary team to determine .the presence of wounds .to ensure appropriate measures are in place to .aid in healing to extent possible . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital record dated 3/6/19 revealed Resident #1 had been diagnosed with [REDACTED]. Review of the discharge progress note dated 3/6/19 revealed an order for [REDACTED]. BID (two times a day) . Physician orders dated 3/6/19 documented, .Apply mupirocin ointment daily to left foot and leave open to air . Review of the electronic treatment administration record (eTAR) and electronic Medication Administration Record [REDACTED]. The facility was unable to provide documentation the mupirocin treatment had been administered as ordered. Observation in Resident #1's room on 3/22/19 at 10:15 AM revealed Resident #1 lying in bed with the left foot uncovered and open to air. Telephone interview with the Nurse Practitioner (NP) on 3/22/19 at 2:50 PM, the NP was informed the facility was unable to provide documentation the mupirocin ointment had been applied as ordered on [DATE]. The NP stated the mupirocin had been ordered for a reason and should have been applied to the nail bed as ordered. Interview with the Director of Nursing (DON) in the DON office on 3/22/19 at 2:55 PM, the DON was asked if Resident #1 should have received the topical application of antibiotic ointment to her left great toe and the DON stated, Oh yes .",2020-09-01
3245,THE HIGHLANDS OF DYERSBURG HEALTH & REHAB,445497,350 EAST TICKLE STREET,DYERSBURG,TN,38024,2019-07-22,600,J,1,0,T41H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, hospital record review, review of a hall camera monitoring system recording, review of a facility investigation, open and closed medical record review, observation and interview, the facility failed to protect 1 of 7 (Resident #2) sampled residents reviewed from sexual abuse placing the 11 cognitively impaired female residents residing on a Secure Unit at risk for potential sexual abuse/neglect when Resident #2 was observed exiting a male resident's (Resident #1) room, and was not thoroughly assessed for possible sexual abuse resulting in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). Resident #1 was known to have repeated sexually inappropriate behaviors (physical, gestures and comments) who also resided on the Secure Unit. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 7/20/19 at 6:20 PM in the Conference Room. F600 was cited at a scope and severity of [NAME] The facility was cited F600-J which is Substandard Quality of Care. A partial-extended survey was conducted from 7/20/19 through 7/22/19. the Immediate Jeopardy was effective 7/9/19 through 7/22/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on 7/22/19 at 10:25 AM and corrective actions were validated onsite by the surveyors on 7/22/19. The findings include: 1. Review of the facility's Abuse Prohibition policy and procedure dated (MONTH) (YEAR) documented, Residents have the right to be free from abuse, corporal punishment, and involuntary seclusion .The facility must have evidence that all violations, including allegations, are thoroughly investigated .All center staff will be advised that they must ensure the following protocols are followed: .No one may disturb the scene where the alleged abuse took place .The resident may not be cleansed, until authorization from authorities is received .A complete body audit will be conducted by nursing staff, which will note specifically: signs of trauma, bruising, bodily fluids, torn clothing or linens .Once the scene has been cleared by officials (police or other investigative parties) the clothing and linens must be bagged and kept in a secure location .The alleged victim must be sent out immediately for a rape kit to be completed at the hospital .Investigation guidelines include: Resident(s) and responsible party interviews, as applicable .Physical examination .Staff interviews and written statements, as applicable .Methods to support the individual and detect and prevent further victimization . 2. Closed medical record review revealed Resident #2 was admitted to the facility 10/19/15 with [DIAGNOSES REDACTED]. Closed medical record review of the comprehensive care plan initiated on 4/26/19 revealed a history of wandering and impaired safety awareness. Closed medical record review of the annual MDS assessment dated [DATE] revealed unclear speech, a cognitive score of 3 which indicated severe cognitive impairment, continuous inattention, physical symptoms directed toward others, daily rejection of care, and daily wandering. Resident #2 required limited assistance of staff for transfer and ambulation, extensive assistance for dressing and eating, was dependent on staff for toileting, personal hygiene and bathing, and was always incontinent of bowel and bladder. 3. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's psychiatric hospital record revealed the resident was admitted on [DATE]. The History and Physical dated 12/28/18 documented, .This patient was displaying inappropriate sexual behavior. He was asking residents and staff for sex. Per records, he touched a Certified Nursing Assistant (CNA) inappropriately between her legs. He was also asking other people to come and get in the bed with him. He is here for behavior and medication management . The psychiatric hospital Discharge Summary for Resident #1 dated 1/16/19 documented [MEDICATION NAME] (an antidepressant) was started and increased during his stay and appeared, .to be effective with decreasing sexual urges and inappropriate behavior . [MEDICATION NAME] (A medication which counteracts the effect of testosterone in males) was also started. Medical record review of Resident #1's initial care plan dated 1/17/19, on his return to the facility from an inpatient psychiatric hospital, revealed the resident had a behavior concern of inappropriate sexual behavior. Medical record review of a Baseline Care Plan dated 1/17/19 documented, .Behaviors concerns: Negative sexual behavior .Interventions administer meds (medications) as ordered. Monitor for inappropriate behaviors. Monitor for elopement. Other Conditions: Inappropriate behavior. talk sexually or grab staff or resident inappropriately. Monitor and redirect before they happen. Intervention: medication ([MEDICATION NAME]) 15 min checks . The care plan was updated on 7/9/19 to reflect the resident's move to a room closer to the nurse's station and 7/10/19 for visual checks every 15 minutes for location. Medical record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Resident #1 required limited assistance of staff for all activities of daily living (ADL). The nursing progress notes for Resident #1 documented the following: a. 7/3/19 at 3:25 AM - .CNA entering resident's bathroom to answer emergency light where resident was sitting on toilet when he attempted to grab cna's arm stating 'be my baby.' after (After) discovering resident did not need assistance and pulled emergency light string by accident CNA exited resident's room and notified this nurse of incident. resident (Resident) was educated that he could not grab staff resident did not express understanding . b. 7/9/19 at 10:12 PM - .Resident has made several advancements towards staff and has attempted to put arm around staff. Resident is redirected without success . c. 7/10/19 at 2:27 AM - .resident noted to be looking into random rooms, staff called him out of a female room when he started to step into door way. Resident backed out and returned to his room . d. 7/17/19 at 4:04 PM - .Resident exhibiting sexually inappropriate behavior. Staff reports resident repeatedly asking them to get into bed with him . e. 7/20/19 at 6:29 PM - .Resident exhibiting sexually inappropriate behavior - Staff reports resident attempting to pat them on the behind as they pass by . Observations of Resident #1 on initial tour and focused observations on 7/17/19 at 3:15 PM, 7/18/19 at 10:00 AM, 7/19/19 at 4:40 PM, 7/20/19 at 3:02 PM and 5:30 PM, 7/21/19 at 12:05 PM and 1:25 PM and 7/22/19 at 11:35 AM and 5:45 PM, revealed the resident had clear speech, was alert and oriented to person, and transferred and ambulated without assistance. Interview with CNA #2 on 7/19/19 at 1:30 PM in the Conference Room, when asked about Resident #1's and Resident #2's behavior symptoms, the CNA revealed Resident #1 had both verbal and physical inappropriate sexual behaviors and would try to get his arms around staff or grab their bottoms. When asked about behaviors toward other residents, CNA #2 revealed having seen the resident take female residents' hands and try to take them into his room. CNA #2 confirmed Resident #2 wandered in the halls and in and out of other residents' rooms. Interview with Licensed Practical Nurse (LPN) #1 on 7/19/19 at 1:45 PM in the Conference Room, when asked about Resident #1's and Resident #2's behavior symptoms, LPN #1 confirmed Resident #1 displayed inappropriate sexual behaviors and revealed the resident would catch the hands of ambulating female residents and try to take them to his room. LPN #1 revealed Resident #2 wandered on the unit and did go in and out of residents' rooms. 4. Review of the hall monitoring camera recording dated 7/9/19 revealed the following: a. 6:03 PM - Resident #2 wandered up the hall and sat down in a chair beside Resident #1 at the nurse's station. Resident #2 was appropriately dressed in lounging pants and a top. b. 6:05 PM - Resident #2 got up and wandered back down the hall. Resident #1 got up and joined her. Together they were observed walking toward the end of the hall. Resident #1 was walking on Resident #2's left side with his right arm around her low back and right hand on her waist. c. 6:06 PM - Resident #1 opened the door to his room at the end of the hall, Resident #1 guided Resident #2 into the room, both residents entered the room and the door closed. d. 6:20 PM - Resident #2 exited the room and closed the door. One of her legs was bare and her pants appeared to be inappropriately dressed. She wandered into a room across the hall. e. 6:21 PM - Resident #2 exited the room across the hall and was approached by the Registered Nurse (RN) Supervisor who spoke with her then immediately went into Resident #1's room, exited quickly and returned to Resident #2. CNA #1 joined them in the hall. f. 6:23 PM - The RN Supervisor entered Resident #1's room and CNA #1 walked with Resident #2 toward her room up the hall. Interview with the DON on 7/19/19 at 12:45 PM in the Conference Room, when asked about the facility's cameras and viewing terminal, the DON revealed the cameras recorded only in the facility's common areas. The camera footage could be viewed in the Administrator's office. Footage was reviewed on an as needed basis. The DON also revealed she had reviewed the footage documented above prior to leaving the facility the evening of 7/9/19. Review of a statement dated 7/9/19 written by CNA #1 revealed she had observed Resident #2 walk out of a resident's room with her pants inside out. CNA #1 asked Resident #2 if she was ok and Resident #2 said yes. The CNA also asked the resident if Resident #1 had touched her and Resident #2 said Yes. Everywhere. Interview with CNA #1 on 7/18/19 at 12:15 PM in the Conference Room, when asked about what occurred on the Secure Unit with Resident #1 and #2 on 7/9/19, the CNA confirmed her written statement and revealed Resident #2's pants had been inside out and 2 of her legs were in one pant leg. When she and the RN Supervisor had taken Resident #2 to her room and examined her, the resident's brief was missing. After the RN Supervisor examined the resident, the RN Supervisor left to get the DON. Review of a statement dated 7/9/19 written by the RN Supervisor, who was working in the Secure Unit, revealed she had observed Resident #2 coming out of another resident's room. Resident #2's pants were inside out, upside down and both of her legs in one pant leg. The RN Supervisor had taken Resident #2 to her room and examined her. There were no signs of trauma, redness or bruising seen. She then went to Resident #1's room and found Resident #2's brief in his trash can. She contacted the Nurse Practitioner (NP) on call, the DON, wrote a statement and went home. Interview with the RN Supervisor on 7/18/19 at 12:45 PM in the Conference Room, when asked about what had occurred on the Secure Unit with Resident #1 and #2 on 7/9/19, the RN Supervisor confirmed her written statement and revealed the NP had instructed her to follow the facility's policy and procedures. The RN Supervisor revealed the DON was present in the facility at the time and came to the unit and examined Resident #2. The RN Supervisor confirmed she had asked the DON if she needed to document her observations in an incident report or make any further notifications and was told .not at this point . Review of a statement dated 7/10/19 written by the DON revealed, on 7/9/19 at approximately 6:45 PM, she had been notified by staff members of their observations of Resident #1 and #2. The DON documented Resident #1 .has a history of exhibiting sexually inappropriate behaviors. Both residents have a BIMS (Brief Interview for Mental Status) on their most recent MDS of 3 (indicating severe cognitive impairment). Due to this, DON and staff conducted a full investigation to ensure the (there) was no allegation of abuse that should be reported . She had asked Resident #2 if Resident #1 had touched or hurt her and the resident had answered no. The DON performed a head to toe assessment of Resident #2 and found no unexplained marks on her body or redness, irritation or secretions and documented, .There was no indication per assessment that anything inappropriate had occurred . The DON then interviewed Resident #1 in his room and when asked, he reported Resident #2 had walked down to his room and then left and denied touching her in any way. The DON had noted the brief in Resident #1's trash can and documented Resident #1 .is continent, and the brief belonged to the female resident (Resident #2) .Resident sheets were clean except for a small stain . The DON then instructed staff to put both residents on 15 minute checks and left the unit to review camera footage. After reviewing the above documented camera footage, the DON returned to the unit and instructed staff to continue the 15 minute checks until the morning of 7/10/19 at which time Resident #1 would be moved .to an available room in view of nurse's station and commons area . Interview with the DON on 7/18/19 at 2:50 PM, in the Conference Room, the DON stated she checked Resident #2's brief in the trash can, and she only noticed fresh urine in the brief. The DON was then asked if she had done an examination of his genital area. The DON confirmed she had not. Interview with the Nurse Practitioner on 7/18/19 at 4:15 PM, in the Conference Room, the Nurse Practitioner was asked if she was notified when this incident occurred. The Nurse Practitioner stated, .She (nurse) called me .told her (nurse) to call DON and Administrator and follow their policy and procedures . Interview with the DON on 7/19/19 at 12:45 PM, the DON was asked why the investigation of an allegation or suspicion of sexual abuse was not continued for the incident on 7/9/19. The DON stated, .There was nothing to insinuate he (Resident #1) had done anything to her . The DON was asked why she had examined Resident #2 and the DON stated, .To ensure nothing had happened . The DON was then asked what would constitute an investigation, the DON stated, .If I had found anything - a mark, redness, or secretions . When asked if she had done a head to toe assessment on Resident #1, the DON stated, .I looked him over also. There was nothing visible . Interview with the Administrator (the Abuse Coordinator) on 7/19/19 at 12:45 PM in the Conference Room, when asked why the facility did not continue investigating and report a suspicion of abuse, the Administrator stated, .If we were to investigate every time she (Resident #2) went in and out of a male resident's room, there would be several investigations a day . 5. Review of the facility's investigation revealed the following: Review of a statement written by the DON dated 7/13/19 revealed on 7/12/19 at 8:52 PM, the DON had received a call from the facility informing the family of Resident #2 wanted to speak to the Administrator. She offered to speak with the family and did so over the phone. The family member wanted information about an abuse allegation involving Resident #2. The DON documented, .DON explained that we assessed the resident and investigated the situation as a precaution and that we found nothing to imply anything inappropriate had occurred .had we found anything to imply she had been abused, we would have immediately reported it to the state and police and she would have been notified . The written statement was verified by the DON on 7/20/19 at 3:25 PM. Review of a statement dated 7/13/19 revealed the Administrator received a voice mail from a nurse at the facility at approximately 8:50 PM on 7/12/19 informing her the family of Resident #2 were at the facility and wanted to speak with her. The Administrator returned to the facility. The Administrator documented, .they (family) felt like they should have been called, they were told that they were not called because there was nothing to call them about. (Resident #2) frequently wanders in and out of other residents rooms and stays in those room for minutes at a time, I told the family that if they would like for the facility to start calling them every time (Resident #2) wanders in another residents room that we could do that for them so that they would be aware .The family also demanded that (Resident #1) be sent out of the facility immediately, family was told that there was no reason to send him out because there was no proof that anything had happened .(Resident #2) was sent out to the (Named Hospital) on 7/12/19 per family request .(Resident #2) returned to the facility on [DATE] . The statement was verified by the Administrator on 7/20/19 at 3:30 PM. Review of a statement dated 7/16/19 written by the DON revealed Resident #2 returned to the facility on [DATE] and .was placed on the West hall of the building due to family refusing for (Resident #2) to go back to the secure unit . The statement also revealed on 7/15/19 the family of the resident requested referral be sent to a different long term care facility. The statement was verified by the DON on 7/20/19. Resident #2 was transferred to a different facility on 7/17/19. The facility's failure to protect the 11 cognitively impaired vulnerable female residents on the Secure Unit resulted in I[NAME] The surveyors verified the A[NAME] by: 1. Resident #1 was placed on 1:1 supervision on 7/20/19 and will remain until discharged to a psychiatric hospital for further evaluation. The surveyors observed Resident #1 was on 1:1 supervision on the Secure Unit on 7/21/19 and 7/22/19. The surveyors interviewed staff and confirmed Resident #1 was on 1:1 supervision until discharged for evaluation. 2. All residents on the Secure Unit have been assessed and no other cases of sexual abuse were found. Assessments were done by the DON with assistance of the nursing staff for possible physical indicators of sexual abuse that would require investigation by the facility and survey team which included but is not limited to: bruises around the breast, genital areas, or inner thighs, signs and symptoms of unexplained [MEDICAL CONDITION] or genital infections, unexplained vaginal or anal bleeding, and/or torn stained or bloody underclothing. All residents on the Secure Unit are non-interviewable; however, they did not show sudden or unexplained changes in behavior, there was no fear or avoidance of a person or place, of being left alone, of the dark, nightmares, and/or disturbed sleep. The surveyors reviewed the skin assessments provided on the residents residing in the Secure Unit. The surveyors interviewed the Regional Administrator who confirmed body audits and observations of residents on the Secure Unit were completed for indicators of sexual abuse and none were found. The surveyors' observations of residents on the Secure Unit revealed no fear or avoidance of person or place. 3. All facility personnel were in-serviced by the facility Administrator and DON beginning on 7/17/19 and are ongoing with competency testing, on the importance of Identifying, Reporting and Completing a thorough investigation of sexual abuse to include: Identifying the Abuse Coordinator, Identifying all types of abuse: Physical, Verbal, Mental, Sexual, Misappropriation of funds, Neglect, Involuntary Seclusion, and Corporal Punishment, Ensure that all alleged violations involving abuse, neglect, and exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property, are reported immediately, but no later than 2 hours after the unknown allegation is made, if the event that caused the allegation involves abuse or results in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and other officials (including the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Facility abuse policy and Federal/State regulation and guidelines for abuse were reviewed with all staff. Upon hire all new employees will be in-serviced on the facility abuse policy as well as Federal/State regulations and employees will be in-serviced at least annually. Any employee not working will be in-serviced prior to returning to work. The surveyors reviewed in-service sign in sheets and interviewed staff on each shift. Noncompliance of F600 continues at a scope and severity level of D for monitoring of the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.",2020-09-01
2000,GRACELAND REHABILITATION AND NURSING CARE CENTER,445331,1250 FARROW ROAD,MEMPHIS,TN,38116,2020-02-10,867,J,1,0,U67J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, job description review, medical record review, facility investigation review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program recognized concerns related to potential staff neglect, the completion of a thorough investigation of an incident of elopement, resident assessment and care planning related to exit-seeking/wandering behaviors, and failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently in order to provide a safe environment for residents. Failure of the QAPI Committee to ensure systems and processes were in place, and systems were consistently followed by staff and Administration, and the failure to address quality concerns placed 1 of 4 sampled residents (Resident #1) in Immediate Jeopardy when the resident, a cognitively impaired resident with known wandering and exit-seeking behaviors, was missing approximately 2 hours and 45 minutes after she was last seen by facility staff. Resident #1 was picked up by a police officer 1.3 miles from the facility. The officer had responded to a 911 call concerning a suspicious female knocking on the doors of houses in the area. Resident #1 had crossed State Route 175 (Shelby Drive), a heavily traveled 7 lane highway. This resulted in Immediate Jeopardy for Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death to a resident. The Administrator and Director of Nursing (DON) were notified of the IJ for F-865 on 2/9/2020 at 11:38 AM, in the Conference Room. The facility was cited F-600, F-610, F-656, F-657, F-689, F-835, and F-867 at a scope and severity of J. F-600, F-610, and F-689 are Substandard Quality of Care. A partial extended survey was conducted 2/7/2020 through 2/9/2020. The Immediate Jeopardy was effective from 11/1/2019 through 2/9/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 2/10/2020 at 12:30 PM. The Removal Plan was validated onsite by the surveyors on 2/10/2020 through review of newly developed policies, procedures and auditing forms, inservice training records, assessment and Care Plan review, and interviews. The findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement Program's Statements and Guiding Principles, dated 11/21/2019, showed, .Addressing Care and Services: The QAPI program will aim for safety and high quality with all clinical interventions and service delivery while emphasizing autonomy, choice, and quality of daily life for residents and family by ensuring our data collection tools and monitoring systems are in place and are consistent for proactive analysis, system failure analysis, and corrective action .The scope of the QAPI program encompasses all types and segments of care and services that impact clinical care, quality of life, resident choice and care transitions. These include, but are not limited to, customer service, care management, patient safety . Review of the facility's undated job description titled Administrator, showed, .Committee Functions .Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice . Review of the facility's undated job description titled, Director of Nursing Services, showed, .Administrative Functions .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies . Review of the facility's investigation dated 1/16/2020, showed that the facility's video camera footage was viewed by the Administrator and DON to determine how Resident #1 exited the building. The camera footage showed that on 1/16/2020 at 1:48 PM, Resident #1 got up from her wheelchair and walked into a resident room. At 1:50 PM, Resident #1 was seen exiting a window in room [ROOM NUMBER] and walking towards the back of the building. The surveyor viewed this video camera footage. During an interview on 2/7/2020 at 4:00 PM, the Administrator stated that herself, the DON, Medical Director, and all department managers attend the monthly QAPI meetings. An ad hoc (a meeting to obtain information as the need arises) QAPI meeting would be held if necessary. During an interview with the Administrator and the DON on 2/7/2020 at 6:20 PM, the Administrator confirmed an ad hoc QAPI meeting should be called for anything that may cause harm or has caused harm. When asked for clarification, the DON gave the example of elopement. The Administrator then stated that the facility was waiting until the State Survey Agency completed an investigation of the facility reported allegation of neglect related to Resident #1's elopement before calling the ad hoc meeting. The Administrator also confirmed that the facility's QAPI Committee should have met as soon as possible after the elopement. The facility's QAPI Committee failed to identify, investigate, analyze, implement, and evaluate possible regulatory compliance concerns related to Resident #1's elopement from the facility to ensure the safety of residents with wandering and/or exit-seeking behaviors. Refer to F-600, F-610, F-656, F-657, and F-689. The surveyors validated the Removal Plan by: 1. Ad hoc QAPI Committee meetings will be held to identify, investigate, analyze, implement, and evaluate corrective actions or performance improvement activities in addition to the monthly QAPI meetings to assure that all policies, procedures, and directions are followed for each elopement/exit-seeking/active wandering residents, are in compliance, and are maintained. The surveyors interviewed Administration. 2. An ad hoc QAPI meeting was to be conducted to discuss all elopement, exit-seeking/wandering residents on 2/10/2020 to identify potential opportunities for improvement and corrective actions. The surveyors interviewed management staff related to QAPI committee guidelines for meeting. 3. Management of systemic method of checks and balances as follows: a. The Chief Operating Officer (COO) will be immediately made aware of alleged abuses and incidents, and will be updated with all pertinent documentation. b. The DON/Assistant Director of Nursing (ADON) will ensure all steps of the elopement/exit seeking policy and procedures are being adhered to. c. The Administrator/Designee will have meetings with the DON/ADON to measure compliance of the elopement/exit-seeking policy and procedures. Meeting to take place Monday - Friday. In the event of a weekend occurrence, the Administrator/Designee and DON/ADON will be in constant communication. d. The QAPI Committee will meet weekly for 4 weeks and monthly ongoing to oversee that all elopement/exit-seeking measures are executed appropriately and to ensure the continued safety of all residents. e. As an additional method of inservice, education and resource, the facility's contracted corporate compliance company will be consulted monthly, and as needed, to ensure proper elopement/exit-seeking methods are identified, met, and maintained. f. All elopement/exit-seeking residents will be reported to the monthly QAPI Committee. g. If any resident is reported to be exit-seeking or has eloped, the facility will have a QAPI meeting without delay to discuss all policies, procedures, and directions for each resident. The surveyors reviewed audit tools, and interviewed the Administrator, DON, ADON and the COO related to how information will be gathered for QAPI meetings. 4. An Abuse and Compliance Committee was initiated on 2/9/2020 to oversee that all policies, procedures, practices, and investigations are executed effectively. The Abuse and Compliance Committee members will meet weekly for 4 weeks and monthly ongoing and will include but not limited to the following: Administrator, DON/ADON/Designee, COO, Medical Director, facility/Staff Liaison, Minimum Data Set (MDS) Director, and Social Services Director (SSD). The committee will serve as a compliance/oversight team to ensure that all elopement and exit-seeking procedures that were implemented are 100 percent in compliance and maintained. A Resident Occurrence Form was developed for Alleged Abuse and will be utilized to identify, measure, and ensure that all interventions related to previous and current occurrences are aligned with facility's goals related to resident safety. Findings will be reported to the QAPI Committee. The surveyors reviewed the resident occurrence form and interviewed the Administrator, DON, ADON, and COO. 5. Administration will ensure that each resident will have a plan of care and will be updated with individualized interventions to help modify the behavior for exit-seeking, eloping and wandering residents. The Care Plan will be updated with any new occurrences and staff will be informed of the interventions put in place. The surveyors reviewed updated care plans and interviewed staff on all shifts regarding their responsibilities for care plan interventions. 6. Administration will ensure that the SSD or Designee updates and maintains a current listing and binder of all exit-seeking, elopement and wandering residents located throughout the facility. The systemic actions will look comprehensively across all involved systems to prevent future events and promote sustained improvement. The surveyors reviewed current binder for at risk residents and interviewed staff on all shifts related to the elopement, wandering/exit-seeking book. Noncompliance at F-867 continues at a scope and severity of D for the monitoring and effectiveness of corrective actions. The facility is required to submit a Plan of Correction.",2020-09-01
2114,LAUDERDALE COMMUNITY LIVING CENTER,445354,215 LACKEY LANE,RIPLEY,TN,38063,2017-05-05,323,J,1,0,QMFO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, manufacturer's guidelines review, medical record review, observations and interview the facility failed to follow facility policies, manufacturer's guidelines and resident care plans for fall interventions, side rail use, and mechanical lift use for 2 of 5 (Residents #16, and 45) sampled residents reviewed for accidents of the 34 included in the stage 2 review. The failure of the facility to ensure Resident #16, a vulnerable resident, was assessed, care planned, and had a physician order for [REDACTED].#16 was found between the siderail and the mattress without a pulse or respirations. Immediate Jeopardy is a situation is which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing and Region One Nurse Consultant #1 were informed of the Immediate Jeopardy on [DATE] at 1:09 PM in the Conference Room. The facility was cited Immediate Jeopardy at F323-J, which is Substandard Quality of Care. An extended survey was completed on [DATE]. The Immediate Jeopardy was effective [DATE] and is ongoing The findings included: 1. The facility's Bed Rail Guideline Policy documented, .It is the policy of this center to limit the use of bed rails and similar device unless the benefit outweighs the risk. No rails of any type will be applied to a bed without prior assessment as to the appropriateness of the use and the device selected. This policy applies to the use of any type of rail attached to the bed .Maintain the placement of specialized support surfaces (low air loss or alternating pressure mattresses) within the bed frame .A physician order will be obtained, a care plan implemented, and side rails will be checked for functionality and placement .Care plan interventions are implemented when bed rails are utilized and reviewed at least quarterly and prn . The manufacturers guidelines for the Panacea Air Overlay, used by the facility, revealed, .Failure to comply with all directions and warnings may result in injury or death .Due to the alternating pressure feature .some devices and products may not be appropriate for the use with this device. Do not use pressure pad alarm or alert systems in conjunction with the overlay .This device is not designed to replace good care giving practices, including, but not limited to .Adequate care plans and training for staff personnel for entrapment and fall prevent . The facility's Fall Risk Management policy documented.Interventions will be implemented as needed to help manage the potential for falls and assist in minimizing the risk. Interventions will be re-evaluated for effectiveness .Potential risk factors should be identified, evaluated and addressed as needed. The facility's Mechanical Lift Evaluation policy documented, In order to facilitate a safe lifting environment for staff and resident. Mechanical lifts are to be utilized for lifting and transferring residents whenever possible. 2. Medical record review revealed Resident #16 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] revealed Resident #16 was severely cognitively impaired for daily decision making, and had no falls since admission. a. The Progress Notes dated [DATE] documented, .Called to resident's room .resident in floor beside bed .scratch to left side of face .No other apparent injuries noted .Neuro checks involved . The care plan initiated [DATE] documented, Focus .resident has had an ACTUAL FALL [DATE] - fall from bed - scratch to cheek .Intervention .Neuro-checks as per policy upon hospital return .Date Initiated [DATE] . After the fall on [DATE] at 2:45 AM, neuro checks were not done at the following times: [DATE] at 9:30 PM [DATE] at 1:30 AM [DATE] at 9:30 AM [DATE] at 5:30 PM Interview with Regional Nurse Consultant (RNC) #1 on [DATE], in the Conference Room, RNC #1 was asked were you able to find the neuro checks for the every 8 hours checks on Resident #16. RNC #1 stated, We did not have the last 2 . The RNC #1 was asked should it have been done. The RNC #1 stated, Yes. b. Review of the medical record for Resident #16 revealed there was no physician order for [REDACTED]. The [DATE] 8:00 PM nurse's note by Licensed Practical Nurse (LPN) #7 was errored out with with a line through the documentation indicating it as incorrect. The documentation error referenced as incorrect documentation revealed, .Called to resident's room by CNA (certified nursing assistant) . When I entered the room, the resident's head was turned towards the headboard and her neck was between the mattress and the siderail on the right side of the bed. Her body was off the bed, her bottom on the floor with her legs stretched out in front of her. Her right arm was up on the bed close to her head .This nurse felt for a pulse, listened for breathing and heartbeat. Another nurse's note by LPN #7 for [DATE] at 9:00 PM documented, .Called to resident's room by CNA . When I entered the room, the resident's head was turned toward the headboard with the left side of her face pressed against the side rail. Her body was off the bed, her bottom was on the floor and her legs were stretched out in front of her. The right arm and shoulder were on the bed pointing towards the headboard . This nurse assessed for pulse, breathing and heartbeat. None was found. Review of the [DATE] Director of Nursing (DON) note for 8:15 PM revealed, incorrect documentation errored out with a line through the documentation indicating it as incorrect revealed, .observed resident lying in bed upon assessment no pulse, no respirations noted, time of death pronounced at 8:11 PM . Interview with Confidential Interviewee (CI) #8 on [DATE] at 5:32 PM, in the Conference Room, CI #8 was asked if she knew of any accidental deaths in this facility. CI #8 stated, Yes, (Resident #16). CI #8 was asked what happened. CI #8 stated, She (Resident #16) was in the bed and fell out of the bed and got hung in the railing. She got caught up in the railing in the bed .her legs were on the floor and the neck was caught between the railings. CI #8 was asked if she meant the side rails. CI #8 stated, Yes. She has an alarm but it didn't go off. CI #8 was asked if she meant a bed pressure alarm did not go off. CI #8 stated, Yes. CI #8 was asked how often the facility checks the alarms. CI #8 stated, It was working if you pressed real hard. When she came out of the bed it didn't make any noise. CI #8 was asked if the resident had a history of [REDACTED].#8 stated, People on the other shifts said she tried to get up but I have never seen her try to get up. CI #8 was asked if Resident #16 was breathing. CI #8 stated, No and she wasn't moving. CI #8 was asked how Resident #16 was lying. CI #8 got on the floor to try to demonstrate and stated, Her head was facing the wall, her face was to the railing and was caught up .the geri chair (reclining geriatric chair) was on the side that she was. CI #8 was asked if both the top rails were up. CI #8 stated, Yes. She was on the door side of the bed away from the (other) resident .she was between the rail and the mattress. CI #8 was asked if the resident had a special mattress. CI #8 stated, She had the bubbles, the thing on the foot of the bed. CI #8 was asked if it was an air overlay. CI #8 stated, Yes. Interview with CI #12 on [DATE] at 8:55 PM, by telephone, CI #12 was asked what she knew about the death of Resident #16. CI #12 stated, .Whenever I walked in the room .her head and arm were pinned in the side rail. Her feet were almost at the wall. Her bottom was not touching the ground. CI #12 was asked what was caught in the side rail. CI #12 stated, It seemed like more her jaw. CI #12 was asked about the position of her neck. CI #12 stated, .the way it was turned looked unusual. It was turned sideways and up. The jaw line under the mandible was up making her look toward the ceiling. The previous statements were re-read to CI #12, and she was asked if that was what she had said. CI #12 stated, Yes .the side rail had her jaw and her arm pinned up. I could not tell if her feet were touching the wall or not. It could have been her feet, she had long legs so it might have been that it wouldn't let her come down. CI #12 was asked if there were any marks on Resident #16. CI #12 stated, If I remember correctly, there was one on the jaw line. I'm not 100 per cent but I think there was. CI #12 was asked on which side of her face was the mark. CI #12 stated, On the left side of her face. Interview with CI #10 on [DATE] at 8:00 AM, in the conference room, CI #10 was asked what she knew of Resident #16's death. CI #10 stated, .When I walked in the room she was sitting in the floor by the bed and her head was turned toward the headboard so that made the left side of her face up against the side rail. CI #10 was asked if Resident #16 had fallen. CI #10 stated, She had to have rolled out of the bed. She did not walk. She sat in a geri chair. CI #10 was asked if there were any marks on Resident #16 after the incident. CI #10 stated she had a spot on her jaw .left .a little discoloration there. CI #10 was asked what type of mattress Resident #16 had. CI #10 stated, an air mattress. CI #10 was asked if Resident #16 had fallen before. CI #10 stated, Not since I've been here . CI #10 was asked if Resident #16 had a pressure alarm on her bed. CI #10 stated, She did but it did not go off. But, it was on. That was my big thing because it did not go off. CI #10 continued, It did not go off. (Named Administrator) asked when I check my alarms. I check them at my 8:00 med (medication) pass and that is what I was doing when that happened. Interview with the DON on [DATE] at 10:01 AM, in the conference room, the DON was asked if they had any accidental deaths in the facility. The DON stated, No .It looked like she (Resident #16) had slid out of the bed after she expired. The DON was asked how it was determined that she slid out of the bed after she expired. There was a long pause. The DON stated, That's what we assumed. Cause she had definitely slid out of the bed. Her body was still warm. The CNA said she was part way on the floor. She had no bruising or anything so she couldn't have been there long. The DON was asked if the resident had any marks on her. The DON stated, Yeah, she had a light red, it was pink in color, where her face had been touching the side rail. The DON pointed to her right face and stated, I'm not sure if it was right or left . Because the way she had explained her earlier that was not correct. When I looked at the bed. She had quarter side rails and she had the mattress overlay, so there was no way that was possible. Interview with Resident #16's Medical Doctor (MD) #1 on [DATE] at 5:20 PM, by telephone, MD #1 was asked if he was notified when there were events, incidents, or accidents of his residents in the facility. MD #1 stated, Yes. They said they just found her (Resident #16) dead. MD #1 was asked if he was aware of allegations that her head was caught between the side rails and mattress. MD #1 stated, Not that I know of. I was told she was found dead. If she had a heart attack, she may have struggled or that may have caused her death. MD #1 was asked if he would expect that if she was found with her head between the mattress and side rail and her bottom on the floor, that they would tell him. MD #1 stated, Oh, yeah, that kinda sounds like a choking incident or a neck injury. MD #1 was asked if the resident had a problem with her neck. MD #1 stated, She had arthritis and osteoporosis. She was thin and frail. MD #1 was asked if the kyphosis could exacerbate the possibility of severe injury to the neck. MD #1 stated, It depends on how it was caught .She was thin. She could not have pulled herself out of that position. Interview with RNC #1 on [DATE] at 10:42 AM in the conference room, RNC #1 was asked what is the difference between an air mattress and an overlay. RNC #1 stated, .The overlay goes over the current mattress. So there is a standard mattress and the overlay is zipped or secured around our mattress. Interview with the Maintenance Supervisor (MS), son of deceased Resident #16, on [DATE] at 10:42 AM in Room 118, the MS was asked if he or the nurses apply the overlays. The MS stated, I do not install them . The MS was asked if his mother ever tried to get up. The MS stated, She has in the past. She was a fall risk, but I mean not so much toward the end (recently) . The MS was asked if Resident #16 was mobile. The MS stated, Not very mobile, she had dementia and since the stroke. The MS was asked to describe her mobility. The MS stated, She had jerk motions. She had to be fed .I wouldn't have wanted to see her on the floor. Interview with CI #10 on [DATE] at 1:36 PM in Room 118, CI #10 was asked if she had been in-serviced about side rails or air overlays. CI #10 stated, No. CI #10 was asked how resident #16's head was positioned when CI #10 came into the room. CI #10 stated, It was turned up against the side rail. CI #10 was asked what was on the other side. CI #10 stated, the bed .the mattress. Her arm was up on the mattress, I am not sure if it was straight or bent, the left side of the lower jaw was on the side rail. Interview with CI #12 on [DATE] at 5:19 PM in Room 118 CI #12 was asked if she had been in-serviced about side rails in the last year. CI #12 stated, No. CI #12 was asked if she had been in-serviced about bed overlays. CI #12 stated, No, honestly I didn't even know what a bed overlay was until I came to work here . CI #12 was asked if she was present the night of Resident #16's death. CI #12 stated, Yes. CI #12 was asked what was the position of Resident #16's head. CI #12 stated, The side rail is hitting right here (pointing to lower chin) head is turned to right and up. The rail was at her jawline, if I'm not mistaken she actually had a bruise right there where the rail was touching. CI #12 was asked what had to be done to get the resident to the floor. CI #12 stated, .I guess we had to pull her a little bit to get her from the rail, had to pull her to the side and once that happened, they just eased her to the floor . Second interview with CI #8 on [DATE] at 9:28 PM in Room 118 CI #8 was asked if she had an in-service on side rails. CI #8 stated, Not that I know of. CI #8 was asked if she had an in-service on air mattresses. CI #8 stated, .I don't think so . CI #8 was asked if she had an in-service on overlays. CI #8 stated, I don't even know what that is. CI #8 was asked to describe to the best of their ability the position of Resident #16's head the night of her death. CI #8 stated, I know her head was caught in the railing. She was facing the wall . CI #8 was asked to describe moving the resident to the floor. CI #8 stated, We had to get her neck from the railing. Her neck was caught in the railing. We had to scoot the mattress back away from her neck. It was close to the railing. CI #8 was asked if her right neck was touching the mattress. CI #8 stated, I'm trying to think. One part of the mattress, but she had the bubble thing on top. Interview with CI #18 on [DATE] at 5:25 PM, by telephone, CI #18 was asked if she had been in-serviced about side rails. CI #18 stated, No ma'am. CI #18 was asked if she had been in-serviced on air mattresses. CI #18 stated, No ma'am .not at (named facility). Interview with CI #16 on [DATE] at 10:54 AM in the DON office, CI #16 was asked if Resident #16 had an order for [REDACTED].#16 stated, No, but .it is a nursing intervention. CI #16 was asked if it was necessary to have an order for [REDACTED].#16 stated, No. CI #16 was asked if side rails were on the current care plan when she died . CI #16 stated, It was not on the most up to date care plan. CI #16 was asked if there was an order for [REDACTED].#16 stated, No order for the overlay. CI #16 was asked if Resident #16 had an order for [REDACTED].#16 stated, No there is no order for the pressure alarm .or the overlay. CI #16 was asked if there were any concerns using a pressure alarm with the overlay. CI #16 stated, I guess that would depend if the pressure alarm was on the top or under the overlay .I would put it under the overlay. That is the only way I know how to answer that question. CI #16 was asked if the pressure alarm would be effective under the overlay. CI #16 stated, Yes. CI #16 was asked if there were any concerns if the pressure alarm is on top of the overlay. CI #16 stated, I would prefer for it to be under it for stability. CI #16 was asked if the pressure alarm would be effective on the top of the overlay. CI #16 stated, Yeah. Interview with CI #16 on [DATE] at 12:15 PM in Room 118, CI #16 was asked if Resident #16 was care planned for the pressure alarm. CI #16 stated, Yes ma'am .and we should have an order for [REDACTED].#16 was asked if Resident #16 should have had an order for [REDACTED].#16 stated, Yes. Interview with the Interim Administrator (RNC #1) on [DATE] at 9:50 AM, in Room 118, the Interim Administrator was asked where the policies for the facility's beds and the overlays were located. The Interim Administrator stated, We always refer to manufacturer's recommendations for policy for overlays. Interview with the Interim Administrator on [DATE] at 11:12 AM, in Room 118, the Interim Administrator was shown the manufacturer's guidelines that the MS had given the survey team for the Panacea Air Overlay and the Panacea Bed Manuals. The Interim Administrator was asked to read what the Panacea Bed Manual said on page 4, regarding air mattresses. The Interim Administrator read from the manual, .Powered air mattress surfaces may pose a risk of entrapment. Prior to use, ensure the therapeutic benefit outweigh the risk of entrapment. The Interim Administrator was asked if those were the guidelines the facility was working under. The Interim Administrator stated, for the beds? Correct, I guess. I can't say 100%. He (MS) gave it to you, so he should know. It is not my area of expertise. The Interim Administrator was asked to read the manufacturers guidelines of the air overlay on page 6, number 3 about the use of pressure alarms with overlays. The Interim Administrator read from the manual, Do not use pressure pad alarm or alert systems in conjunction with the overlay. The Interim Administrator was asked according to the Panacea overlay manual and according to the guidelines, should a pressure pad be used with an overlay. The Interim Administrator stated, No. The failure of the facility to ensure policies and manufacturers guidelines were followed and that Resident #16 was assessed, care planned, and had a physician's order for siderails, resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all residents and placed them in IMMEDIATE JEOPARDY when Resident #16 was found between the siderail and the mattress without a pulse or respirations. 3. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There were no physician orders in (MONTH) or (MONTH) (YEAR), for use of side rails. The care plan updated [DATE] documented, .Kyphosis The resident has an ADL SELF PERFORMANCE DEFICIT r/t (related to) Alzheimer's disease, Kyphosis, Bilateral lower extremity contractures .TRANSFER: The resident uses .lift with transfers. Provide with up to extensive staff assistance with this task .The resident has had an ACTUAL FALL XXX[DATE]-No injury .Fall mat to side of bed .Pressure alarm to bed .Resident moved and scooted too close to edge of bed and rolled off . a. Observations in Resident #45's room on [DATE] at 4:00 AM, revealed Resident #45 lying in the bed on her right side with eyes closed. Resident #45's head was bent forward. The upper quarter side rails were up. There was no fall mat on the floor. There was no sitter present in the room. Observations in Resident #45's room on [DATE] at 4:48 PM, revealed Resident #45 was lying in the bed with the pressure pad alarm on the side rail. The pressure pad alarm was not on. The upper quarter side rails were up. Observations in Resident #45's room on [DATE] at 6:58 PM, [DATE] at 4:13 PM and [DATE] at 9:18 revealed Resident #45 was lying in bed with the upper quarter rails up. Interview with LPN #3 on [DATE] at 4:51 PM, in Resident #45's room, LPN #3 was asked if Resident #45 had a bed alarm. LPN #3 stated, Yes ma'am. LPN #3 was asked when the alarm should be turned on. LPN #3 stated, When she is in bed. LPN #3 was asked if the light should blink green. LPN #3 stated, I'm not sure. I believe it blinks green. It is not on. LPN #3 was asked if it should have been on. LPN #3 stated, Yes ma'am and turned it on. b. Interview with CNA #1 on [DATE] at 1:04 PM in the Conference Room, CNA #1 was asked how many people it takes to put Resident #45 in the bed. CNA #1 stated, One .I set her chair up and grab her under the arms and transfer her over to the bed. CNA #1 was asked if Resident #45 stands up. CNA #1 stated, No ma'am. CNA #1 was asked how she picks her up and moves her to the bed. CNA #1 stated, She is not heavy. If you set her up in the chair and then you put your arms under her arms and bring her around to the bed and she will be sitting down on the bed. CNA #1 was asked if there is an arm rail on the chair. CNA #1 stated, It is a geri chair, so yes it does. CNA #1 was asked how she gets Resident #45 over the arm rail. CNA #1 stated, The arm rest is not in the way. If you sit her up, you just turn her and put her on the bed. She is not heavy. CNA #1 was asked if Resident #45's feet touch the floor. CNA #1 stated, No ma'am. She is not heavy. CNA #1 was asked how much Resident #45 weighs. CNA #1 stated, In her 90s, maybe 96 now. CNA #1 was asked if Resident #45 moans when she puts her in the bed. CNA #1 stated, Sometimes. CNA #1 was asked if the sitters are in the room when she puts her in the bed. CNA #1 stated, They are always in there. Interview with CNA #5 on [DATE] at 2:05 PM, in the Conference Room, CNA #5 stated, When I transfer (Resident #45), CNA #1 does it by herself, but I always need somebody with me. The sitter will help me transfer her. CI #5 was asked if she had seen CNA #1 transfer Resident #45 by herself. CI #5 stated, Naw, but I ask her and she says, 'No, I got her.' I don't ever transfer her by myself. CI #5 was asked how she knew who to use the lift to transfer. CNA #5 stated, They let us know. Resident #45 can't transfer with a lift. Sometimes the family doesn't like that. If she is in the bed, we use the draw sheet. Interview with Family Member (FM) #1 on [DATE] at 3:42 PM by telephone, FM #1 was asked if there were concerns with them using the lift to get her up. FM #1 stated, They don't use a lift getting her up. I'm not aware of it. They just pick her up and put her in the chair .1 person or 2 . Interview with the DON on [DATE] at 7:53 AM, the DON was asked how Resident #45 should be gotten up. The DON stated, She can be transferred by the staff or a mechanical lift. The DON was asked if the care plan said to use a lift, would she expect a lift to be used. The DON stated, If it is in her care plan then yes. The DON was asked if the CNAs use a lift to get her up. The DON stated, I'm not sure. Interview with MD #1 on [DATE] at 5:20 PM, by telephone, MD #1 stated, Falls can happen from time to time but if they are happening often .every time a fall happens they should see how the fall happened .Resident #45 couldn't fall out of the bed because she doesn't move. MD #1 was informed that Resident #45 did actually have a fall recently. MD #1 was asked if he had been made aware of that. MD #1 stated, I don't remember that. She didn't have any major injuries from it. I don't remember being called about a fall on (Resident #45). Interview with CI #16 on [DATE] at 12:15 PM, in Room 118, CI #16 stated, .We should have an order for [REDACTED].#16 was asked if Resident #45 should have an order for [REDACTED].#16 stated, Yes . Interview with CI #16 on [DATE] at 8:45 AM, in Resident #45's room, CI #16 was asked if Resident #45 had a fall mat in her room. CI #16 stated, No ma'am. Upon returning to the DON office, CI #16 was asked if Resident #45 was care planned for a fall mat. CI #16 stated, Yes. CI #16 was asked if there should be a fall mat in Resident #45's room. CI #16 stated, Yes.",2020-09-01
3103,AVE MARIA HOME,445490,2805 CHARLES BRYAN RD,BARTLETT,TN,38134,2018-08-27,554,D,1,0,XUOF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medial record review and interview, the facility failed to assess 1 of 1 (Resident #1) sampled residents for self-administration of medications. The findings included: Review of the Assessment for Self-Administration of Medication policy documented, .INSTRUCTIONS: Before performing this assessment, verify that there is a physician's order in the resident's chart for self-administration of the specific medication under consideration and that the resident has signed appropriate document(s) stating the desire to self-administer his/her own medication . Review of the Specific Medication Administration Procedures policy documented, .Oral Inhalation Administration .Nebulizer - Administering Medications through a Small Volume (Handheld) Nebulizer .Remain with the resident for the treatment unless the resident has been assessed and authorized to self-administer . Closed medical record review for Resident #1 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. A physician's order dated 3/24/18 documented, .[MEDICATION NAME] 2.5 mg )milligram)/0.5 ML (milliliter) sol (solution) every 4 hours PRN (as needed) via (by) nebulizer for SOB (shortness of breath)/wheezing . There was no physician's order found in the medical record for self-administration of the [MEDICATION NAME] nebulizer treatment. Telephone interview with the Director of Nursing (DON) on 8/27/18 at 2:15 PM, the DON was asked if Resident #2 had an assessment for self administration of medications in the medical record. The DON stated No. Interview with Licensed Practical Nurse (LPN) #1 on 8/21/18 at 2:45 PM, in a greenhouse, LPN #1 stated she was administering a breathing treatment to Resident #2 when she was called to another greenhouse on 6/4/18. Interview with Registered Nurse (RN) #1 on 8/21/18 at 3:05 PM, in the conference room, RN #1 was asked if it was acceptable to leave a resident while the resident is receiving a breathing treatment. RN #1 stated If our policy says no, then no. I have to refer to our policy .",2020-09-01
3735,ALLENBROOKE NURSING AND REHABILITATION CENTER,445485,3933 ALLENBROOKE COVE,MEMPHIS,TN,38118,2017-03-02,425,D,1,0,CJSQ11,"**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 ensure 1 of 13 (Resident #123) sampled residents were free of significant medication error. The Pharmacist failed to consistently follow a systemic process to ensure medications administered were ordered by the physician or nurse practitioner (NP), failed to ensure medication orders were transcribed accurately on the Medication Administration Record (MAR) and failed to ensure medications were given as ordered. The findings included: 1. Review of facility's ORDERING AND RECEIVING MEDICATIONS FROM PHARMACY . policy documented, .Medications are ordered and received from the pharmacy in a timely manner. The facility maintains accurate records of medications ordered and their receipt .Receiving Medications . 2. A licensed nurse receives medications delivered to the facility and documents delivery on the shipping manifest. Check off each medication .sign at the bottom of the page . 2. Medical record review revealed Resident #123 was admitted to facility 10/2/13. [DIAGNOSES REDACTED]. Review of Physician's Telephone Orders for Resident #123 dated 9/29/16 documented, .discontinue Acetazolamide 250 mg (milligrams), start Methazoleamide 25 mg PO (by mouth) tid (three times a day) . Review of the Medication Administration Record (MAR) for Resident #123 for 9/30/16 through 10/26/16 revealed Methazoleamide 25 mg PO tid was entered on the handwritten MAR and signed as given. The electronic MAR dated 10/27/16 through 1/29/17 documented Acetazolamide 250 mg at bedtime as given and/or not given. Resident #123 when not refusing meds was receiving Acetazolamide 250 mg at bedtime per the MARs. Review of the physician orders for (MONTH) (YEAR) through (MONTH) (YEAR) revealed there were no physician orders for Acetazolamide 250 mg to start or restart. 3. Telephone Interview with Pharmacist #1 on 1/30/17 at 4:08 PM, Pharmacist #1 was asked about the time frames Resident #123 was receiving Acetazolamide 250 mg and Methazoleamide 25 mg and the doses prescribed. Pharmacist #1 stated, .after reviewing this it appears we (pharmacy) never sent the Methazoleamide 25 mg. It appears we didn't do anything due to a glitch in our system changing from paper to electronic MAR's. Pharmacist #1 was asked if the Acetazolamide 250 mg was sent to the facility. Pharmacist #1 stated, It doesn't look like it .neither medication was sent to the facility. Interview with the DON on 1/31/17 at 4:59 PM, in the DON's office, the DON was asked if she was aware that Resident #123 was receiving a medication that was discontinued and not receiving a medication that was ordered on [DATE]. The DON stated, Not until I received the email from pharmacy this morning. The DON was asked if the staff followed physician orders if they failed to give an ordered medication, the DON stated, No. Review of the pharmacy CONSOLIDATED DELIVERY SHEETS on 1/31/17 on west hall for (MONTH) (YEAR) confirmed neither medication had been delivered to the facility through 1/30/17. The facility failed to follow facility policy and physician's orders for medication administration.",2020-03-01
5302,MAGNOLIA CREEK NURSING AND REHABILITATION,445461,1992 HWY 51 S,COVINGTON,TN,38019,2016-04-13,273,D,1,0,53WE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review and interview, the facility failed to complete an comprehensive assessment within 14 days of admission for 1 of 7 (Resident #6) sampled residents. The findings included: The facility's Assessments and Care Planning .Comprehensive policy documented, .The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS (Minimum Data Set) . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive admission MDS documented, .Assessment Reference Date . 03-25-2016 . The MDS was due to be completed by 2/26/16. Interview with Licensed Practical Nurse (LPN) #1 on 4/13/16 at 3:55 PM, in the MDS office, LPN #1 was asked about Resident #6's MDS and care plan. LPN #1 stated, No one had done an admission (MDS) on (Named Resident #6). I caught it on the 25th (3/25/16) and completed the admission assessment.",2019-04-01
5304,MAGNOLIA CREEK NURSING AND REHABILITATION,445461,1992 HWY 51 S,COVINGTON,TN,38019,2016-04-13,279,D,1,0,53WE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review and interview, the facility failed to develop a comprehensive care plan within 14 days of admission for 1 of 7 (Resident #6) sampled residents. The findings included: The facility's Care Plans - Comprehensive policy documented, .An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS (Minimum Data Set) . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive care plan revealed the care plan was not developed until 3/25/16 and 3/26/16. The comprehensive care plan was due to be completed by 3/4/16, 7 days after the comprehensive assessment was due. Interview with Licensed Practical Nurse (LPN) #1 on 4/13/16 at 3:55 PM, in the MDS office, LPN #1 was asked about Resident #6's MDS and care plan. LPN #1 stated, No one had done an admission (MDS) on (Named Resident #6). I caught it on the 25th (3/25/16) and completed the admission assessment and care plan.",2019-04-01
2598,AHC LEWIS COUNTY,445430,"119 KITTRELL ST, PO BOX 129",HOHENWALD,TN,38462,2018-02-08,610,D,1,1,WYPI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review and interview, the facility failed to ensure a thorough investigation for an allegation of neglect was completed for 1 of 3 ((Resident #21) residents reviewed for elopement. The findings included: Review of the facility's Abuse, Neglect, Exploitation policy documented, .Investigation of Alleged Abuse, Neglect and Exploitation .When suspicion of abuse, neglect or exploitation .Components of an investigation may include .Interview all witnesses separately .Include roommates, residents in adjoining rooms, staff members in the area, and visitors in the area .Obtain witness statements . Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A NURSE'S EVENT NOTE dated 11/5/17 documented, .CNA (Certified Nursing Assistant) reported to this writer that patient had a visitor but could not find patient .(a) patient informed staff that he saw missing patient walk out the front door .the patients visitor stated that patient used to reside in apartments across the field from facility .skilled nurse and CNA went to apartments .one nurse in vehicle searching .patient was found at apartments . Telephone interview with the Assistant Director of Nursing on 2/7/18 at 11:25 PM, the Assistant Director of Nursing, was asked if she knew about the elopement at the facility. The Assistant Director of Nursing stated that she was in the facility helping out that day and she noticed everyone was outside looking for a resident. She was told by Visitor #1 that the resident used to live in some apartments near the facility. The the Assistant Director of Nursing stated, I got in my car and went to the apartment complex and when I drove there I saw her .I got there the same time Visitor #1 .I asked if I could drive her back and Visitor #1 said, 'we will walk back' .just the two of them walked back . The Assistant Director of Nursing was asked if the facility had her write a statement about what happened for the investigation. The Assistant Director of Nursing stated, No .I guess I should have . Interview with the Administrator on 2/7/18 at 8:01 AM, in the Admission's office, the Administrator was asked if she had obtained a statement from Visitor #1, the one who and brought Resident #21 back to the facility. The Administrator stated, No . Interview with the Assistant Director of Nursing (ADON) on 2/7/18 at 3:48 PM, in the Admission's office, the ADON was asked if she had obtained a statement from the Assistant Director of Nursing. The ADON confirmed that she should have obtained a statement from the Assistant Director of Nursing but had not obtained one.",2020-09-01
3746,"COLLIERVILLE NURSING AND REHABILITATION, LLC",445495,490 WEST POPLAR AVENUE,COLLIERVILLE,TN,38017,2017-03-02,514,E,1,0,4B1111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review and interview, the facility failed to ensure complete and accurate documentation for 6 of 23 (Residents #21, 45, 111, 114, 126, and 172) sampled residents of the 47 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 care plan dated 8/3/16 documented, .L (left) hip Shear .10/2/16 Left Hip Healed .Approaches .need assist with repositioning to avoid skin friction/shearing . The physician's orders [REDACTED].Clean open area to L hip with wound cleanser, pat dry, and apply barrier cream .QD (every day) until healed . The NURSE'S NOTES documented, 8/13/16 .sm (small) shearing to L hip .8/14/16 .Resident observed .shearing to L hip .shearing to L hip .8/19/16 .Area to L hip healed . The WEEKLY BODY AUDIT documented, .8/13/16 .sm open area to L hip area .8/24/16 .sm area to L hip .notified Tx (treatment) nurse .keep resident off hip .8/30/16 .drsg (dressing) to L hip tx in progress sm dark discoloration to L lateral foot .9/7/16 .L hip area noted .small scab .L lateral ft (foot) dark area noted .9/13/16 .area to L hip healing, Sm dark discoloration to lateral L foot .9/20/16 .healing area to L hip, sm dark discoloration to lateral L foot .9/27/16 .no breakdown noted .10/11/16 .breakdown starting to L buttock .10/18/16 .breakdown starting to L buttock . Interview with Licensed Practical Nurse (LPN) #4 on 3/2/17 at 4:00 PM, in the Breakroom, LPN #4 was asked did you do Resident #21's weekly body audits. LPN #4 stated, Yes. LPN #4 was asked is shearing an open wound. LPN #4 stated, No . LPN #4 was asked if she had told the treatment nurse about Resident #21's wound. LPN #4 stated, .yes .small area open .like a stage 1 when I first saw it on the 13th more open . LPN #4 was asked if a wound opens up what does that mean. LPN #4 stated, .pressure . Interview with the Director of Nursing (DON) on 3/2/17 at 4:46 PM, in the Theater Room, the DON was asked is an open wound shearing. The DON stated, No . 2. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], and the significant change MDS dated [DATE], documented Resident #45 had severe cognitive impairment, no behaviors, and required assistance for all activities of daily living. The physician's orders [REDACTED].Order Status Active .Order Date .01/12/2016 .Start Date .02/01/2017 . Observations in Resident #45's room on 2/24/17 at 12:30 PM and 2/24/17 at 2:26 PM, revealed Resident #45 did not have on any TED hose. Interview with Registered Nurse (RN) RN #2 on 2/24/17 at 2:26 PM, in Resident #45's room, RN #2 was asked whether Resident #45 was wearing TED hose. RN #2 confirmed she was not. RN #2 was asked whether Resident #45 should be wearing TED hose based on her physician's orders [REDACTED].#2 stated, Let's check the care plan . RN #2 went outside Resident #45's room to the medication cart and began reviewing Resident #45's medical record. RN #2 stated, There's no mention of TED hose (on the care plan) .It was ordered 1/12/17 and started 2/1/17 .I can go find out. Interview with the DON on 2/24/17 at 2:45 PM, in the Theater Room, the DON was asked whether Resident #45 should have been wearing TED hose. The DON stated, .It was keyed in error. She doesn't have an order for [REDACTED]. The DON stated, Somebody should have brought it to me . 3. Medical record review revealed Resident #111 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician telephone order dated 1/11/17 documented, .Left Heel wound- continue c (with) Santyl ointment & (and) cover c dry dressing QD (everyday) & prn (as needed) x 14 days .Unstageable (wound) Of The Left Heel (Resolved On 1/27/17) . Review of a WEEKLY BODY AUDIT dated 1/25/17 documented, .Left Heel wound resolved . Review of a WOUND CARE SPECIALIST EVALUATION dated 1/27/17 documented, .Unstageable .Of The Left Heel (Resolved On 1/27/17) .Stage 4 Pressure Wound Of The Right Elbow . Review of a physician order [REDACTED]. Review of a care plan dated 11/18/16 and revised on 1/27/17 documented, .I have an arterial ulcer to .Right Elbow .Stage IV . Interview with the Treatment Nurse on 2/28/17 at 1:50 PM, in the Theater Room, the Treatment Nurse was asked about the care plan dated 11/18/16 and why the stage 4 pressure ulcer was on the care plan for arterial wounds. The Treatment Nurse stated, .that's not right . Review of a care plan dated 12/16/16 and revised 1/27/16 documented, .Wound: .Pressure Ulcer .1/27/16 R (right) elbow now Stg (Stage) IV . Interview with the Treatment Nurse on 2/28/17 at 2:50 PM, in the Theater Room, Treatment Nurse stated, .the only pressure wound he has is the right elbow and it is a stage 4 .the wounds on the left heel are resolved as of 1/27/17 . Interview with the DON in 2/28/17 at 3:20 PM, in the Theater Room, the DON was asked the process for reconciling orders for month end. The DON stated, .we compare the new month .and the last month . we compare last month MAR (Medication Administration Record) to the new month MAR, if there is any question we need to look back at the orders .for example if we are doing (MONTH) (orders) they should look back at all orders in (MONTH) . The DON looked at the current signed orders for (MONTH) and verified those were the (MONTH) orders. The DON stated, (treatment orders) should have been written to d/c (discontinue) treatment orders (when the wounds were resolved) . 4. The facility's ADMINISTRATION OF DRUGS policy documented, .It is the policy of this facility that residents receive their medications on a timely basis and in accordance with our established policies .Medications must be charted immediately following the administration by the person administering the drugs. The date, time administered, dosage, etcetera (etc.), must be entered in the medical record and signed by the person entering the data . Medical record review revealed Resident #114 was admitted to the facility on [DATE], and readmitted 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 moderate cognitive impairment, no behaviors, required extensive to total staff assistance for all activities of daily living, and received antibiotics 7 days. The physician's admission orders [REDACTED].[MEDICATION NAME] 1 gm (gram) IV (intravenously) Q (every) 24 (hours) x (times) 7 days . The admission orders [REDACTED].[MEDICATION NAME] 1 gm IV Q 24 (hours) x 7 days . There was no documentation that the [MEDICATION NAME] was administered on 11/25/16 or 11/27/16 as ordered. The nurses' notes dated 11/25/16 documented, .Midline to RUE (right upper extremity) for IV Vanco ([MEDICATION NAME]) . The nurses' notes dated 11/27/16 documented, .Continues on IV Vanco . Interview with the DON on 2/28/17 at 3:33 PM, in the Theater Room, the DON was asked whether Resident #114 had received the IV [MEDICATION NAME] as ordered. The DON provided the nurses' notes and stated, Yes, he did. The DON was asked whether the administration of the medication should have been documented on the MAR. The DON stated, Yes. 5. Medical records review revealed Resident #126 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #126's room on 2/27/17 at 12:22 PM, revealed catheter tubing hanging over the side of the bed, and a urinary drainage bag noted with a urometer. Interview with Licensed Practical Nurse (LPN) #1 on 2/28/17 at 5:16 PM, at the third floor nursing station, LPN #1 was asked what was the reason for Resident #126's catheter placement. LPN #1 stated, Chronic Stage III Kidney Disease. Interview with RN (RN) #1 on 12/28/17 at 5:20 PM, at the third floor nursing station, RN#1 was asked what is the reason for Resident #126 indwelling catheter. RN #1 stated, I only know it is due to her incontinence and the family said every time she goes to the hospital she gets a catheter . Interview with the DON on 2/28/17 at 6:15 PM, in the DON office, the DON was asked what is the reason for Resident #126's catheter placement. The DON stated, Not sure have to review her chart .we did not put the catheter in they put them in at the hospital. There was not a physician order [REDACTED]. 6. Medical records review revealed Resident # 172 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Initial Nursing assessment dated [DATE] at 11:30 AM, revealed under the bladder evaluation section that the resident had a foley. Review of Nurses Notes dated 2/8/17 for Resident #172 documented, .resident has a foley . Review of Nurses Notes dated 2/27/17 for Resident # 172 documented, .foley intact and in place . Observations in dining room on 2/28/17 at 12:10 PM, revealed Resident # 172 sitting in a wheelchair, with a blue privacy bag holding the urinary drainage bag hooked to the chair below the bladder. Interview with the Assistance Director of Nursing (ADON) on 3/1/17 at 8:45 AM, at the 300 hall nurses station the ADON was asked when a patient is admitted with a foley should they have a physican's order. The ADON stated, Yes. Interview with the Director of Nursing (DON) on 3/02/17 7:45 AM, in the DON's office, the DON was asked if it was acceptable when a resident is admitted to the facility to not have a doctors order for a catheter. The DON stated, No . Interview with the Minimum Data Set (MDS) Coordinator on 3/2/17 at 8:27 AM in the theater room, the MDS Coordinator stated, .Resident # 172 does not have a medical [DIAGNOSES REDACTED]. There was not a physician order [REDACTED].",2020-03-01
4173,AHC HARBOR VIEW,445428,1513 N 2ND STREET,MEMPHIS,TN,38107,2016-12-22,514,E,1,0,XY5611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review and interview, the facility failed to ensure medical records were completely and accurately documented related to Activities of Daily Living (ADLs) for 6 of 6 (Resident #1, 2, 3, 4, 5 and 7) residents and failed to provide care and treatment for constipation for 3 of 6 (Resident #1, 3, and 4) sampled residents. The facility failed to provide recommended and ordered interventions for Resident #1, resulting in pain, constipation, and transfer to the hospital emergency room requiring manual removal, which resulted in actual harm to Resident #1. The findings included: 1. The facilities Care Plans policy documented, .Care Planning is an essential part of healthcare providing a road map of sorts, to guide all who are involved with the patient's care . The facility's Job Description NURSING ASSISTANT AND ORDERLY documented, .The following job functions have been determined to be essential to the position of nursing assistant .3. Report changes in the resident's condition to the charge/staff nurses as soon as possible. Document in records . 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. a. The admission Minimum Data Set ((MDS) dated [DATE] documented Resident #1 had severe cognitive deficits, required extensive assistance with activities of daily living (ADLs), was always incontinent of bowel and bladder, and received antidepressant and antibiotic medications. The Care Plan dated 7/5/16 documented Resident #1 was at risk for constipation related to decreased mobility, with interventions to assess and document Resident #1's usual bowel movement history to include medication use, laxative use, diet, fluids, exercise, and personal remedies, and intervene with laxatives or stool softeners as ordered. The Care Plan dated 7/5/16 documented Resident #1 required extensive assistance with personal hygiene related to weakness and [MEDICAL CONDITION] with goals to have personal hygiene needs met daily. The Physician order [REDACTED]. These medications have the side effect of constipation. The Clinical Pathway (physician's standing orders) dated 7/20/16 for Constipation documented to check bowel movement record; Notify Provider of any abnormal distention. If no abdominal distention and no bowel movement in last 3 days to administer Milk of Magnesia (MOM) 30 cubic centimeters (cc) by mouth as needed or [MEDICATION NAME] tablet 1 po or 1 suppository daily as needed for constipation. Fleets enema if MOM or [MEDICATION NAME] not effective in 24 hours. Notify provider if Fleets not effective within 24 hours. The ADL Verification Worksheets were requested and provided for Resident #1. The ADL Worksheet did not document that Resident #1 had a bowel movement on 8/19/16, 8/20/16, 8/21/16, 8/22/16, 8/23/16, 8/25/16, 8/26/16, 8/27/16, 8/28/16, and 8/29/16. The facility was unable to provide documentation the bowel protocol was followed. The quarterly MDS dated [DATE] documented Resident #1 had moderate cognitive deficits, and was always incontinent of bowel and bladder. A facility Clinical Note dated 8/29/16 documented, .1200 Resident complained of abdominal pain. Resident's family called wanting (Resident #1) to be transported to ER (emergency room ) immediately. Nurse Practitioner called and gave verbal order to send resident to the hospital . A Physician's Telephone Order dated 8/29/16 documented to send the resident to the emergency room for evaluation related to complaints of abdominal pain. The Hospital Emergency Department's Physician Documentation notes dated 8/29/16 documented, .Diagnosis: [REDACTED].patient presents with abdominal pain. The course/duration of symptoms is constant. The character of symptoms is crampy. The degree at onset was moderate .The degree at present is moderate .Review of Symptoms .Gastrointestinal Symptoms: Abdominal pain, nausea, vomiting. No diarrhea .Differential Diagnosis: [REDACTED]. The Hospital Vital Signs/Pain assessment dated [DATE] documented, .Pain .Yes .Pain Intensity .5 .Primary pain location .Other: ABD (abdominal) pain/buttocks pain .Primary pain character .Aching . Primary pain onset .gradual .Primary pain pattern .Constant . The Hospital History Forms dated 8/29/16 documented the resident arrived via ambulance with the chief complaint of pain. The form documented, .Pt has history of ABD aneurysm . The 8/29/16 Hospital report documented at 2:15 PM, .Stool Character .Hard .GI symptoms .Constipation . The History Form dated 8/29/16 documented, the nurse .removed a very large, formed stool from patient's rectum . The facility failed to provide recommended and ordered interventions for Resident #1, resulting in avoidable pain, constipation, and hospitalization , which resulted in actual harm to Resident #1. b. The facility was unable to provide documentation oral care was provided on the following dates: August (YEAR): 8/18/16, 8/19/16, 8/20/16, 8/23/16, 8/27/16, and 8/31/16 September (YEAR): 9/2/16, 9/10/16, 9/12/16, 9/16/16, 9/17/16, 9/18/16, 9/19/16, 9/20/16, 9/21/16, 9/22/16, 9/23/16, 9/25/16, 9/27/16, and 9/28/16 October (YEAR): 10/1/16, 10/3/16, 10/7/16, 10/13/16, 10/15/16, 10/16/16, 10/18/16, 10/19/16, 10/20/16, 10/21/16, 10/23/16, 10/24/16, 10/28/16, 10/29/16, and 10/30/16 November (YEAR): 11/3/16, 11/4/16, 11/5/16, 11/6/16, 11/8/16, 11/9/16, 11/10/16, 11/11/16, 11/13/16, 11/15/16, 11/16/16, 11/17/16, 11/18/16, 1119/16, 11/20/16, 11/21/16, 11/22/16, 11/24/16, 11/25/16, and 11/26/16 December (YEAR): 12/3/16, 12/5/16, 12/6/16, 12/9/16, 12/10/16, 12/11/16, 12/12/16, 12/15/16, 12/17/16, 12/18/16, 12/19/16, and 12/20/16 The facility was unable to provide documentation a bath or shower was provided on the following dates: September (YEAR): 9/16/16, 9/17/16, 9/18/16, 9/19/16, 9/20/16, 9/21/16, 9/22/16, and 9/23/16 November (YEAR): 11/3/16, 11/4/16, 11/5/16, 11/6/16, 11/7/16, and 11/15/16, 11/16/16, 11/17/16, 11/18/16, 11/19/16, and 11/20/16 3. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS dated [DATE] revealed Resident #2 was cognitively intact and required extensive assistance for personal hygiene and bathing. The Care Plan dated 6/22/16 and revised on 9/6/16 documented, .Problems .Self-care deficit .Assistance required with bed mobility, transfers, toileting, bathing, hygiene, dressing, grooming . Interventions .Clean mouth, brush teeth/dentures after meals and at bedtime .Frequency 4 times Daily Starting 6/22/16 . The quarterly MDS dated [DATE], revealed Resident #2 had moderate cognitive impairment and continued to require extensive assistance for personal hygiene and bathing. The facility was unable to provide documentation a bath and oral care was provided on the following dates: August (YEAR): 8/27/16, 8/28/16, 8/29/16, 8/30/16, and 8/31/16. September (YEAR): 9/6/16, 9/7/16, 9/8/16, 9/9/16, 9/10/16, 9/11/16, 9/17/16, 9/18/16, 9/19/16, 9/20/16, 9/21/16, 9/23/16, 9/24/16, 9/25/16, 9/26/16, 9/27/16, 9/28/16, 9/29/16, and 9/30/16. October (YEAR): 10/6/16, 10/7/16, 10/8/16, 10/9/16, 10/11/16, 10/12/16, 10/13/16, 10/14/16, 10/15/16, 10/16/16, 10/17/16, 10/18/16, 10/19/16, 10/20/16, 10/21/16, 10/22/16, 10/23/16, 10/24/16, 10/25/16, 10/26/16, 10/27/16, 10/28/16, 10/29/16, 10/30/16, and 10/31/16. November (YEAR): 11/1/16, 11/2/16, 11/3/16, 11/4/16, 11/6/16, 11/7/16, 11/8/16, 11/9/16, 11/10/16, 11/11/16, 11/12/16, 11/13/16, 11/14/16, 11/15/16, 11/16/16, 11/17/16, 11/18/16, 11/19/16, 11/20/16, 11/22/16, 11/23/16 11/24/16, 11/25/16, 11/26/16, 11/27/16, 11/28/16, and 11/29/16. December (YEAR): 12/2/16, 12/3/16, 12/4/16, 12/5/16, 12/6/16, 12/7/16, 12/8/16, 12/11/16, 12/12/16, 12/13/16, 12/14/16, 12/16/16, 12/17/16, 12/18/16, and 12/19/16. 4. Medical record review revealed Resident #3 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 #3 was cognitively intact, required extensive assistance for bathing and oral care, and always incontinent of bowel. The Care Plan documented, .6/20/16 .and updated on 11/28/16 .Problem .Requires extensive to total assistance with personal hygiene related to [MEDICAL CONDITION] .Interventions .set up items for personal hygiene .will have oral hygiene .daily . The Care Plan dated 11/28/16 documented Resident #3 was always incontinent f bowel related to [DIAGNOSES REDACTED]. The ADL Verification Worksheets were requested and provided for Resident #3. The ADL Worksheet did not document that Resident #3 had a bowel movement on the following days: 8/2/16, 8/3/16, 8/4/16, 8/5/16, 8/6/16, and 8/7/16. The facility was unable to provide documentation bowel protocol was followed. The ADL Verification Worksheets were requested and provided for Resident #3. The ADL Worksheet did not document that Resident #3 had a bowel movement on the following days: 8/9/16, 8/10/16, 8/11/16, 8/12/16, and 8/13/16. The facility was unable to provide documentation the bowel protocol was followed. The ADL Verification Worksheets were requested and provided for Resident #3. The ADL Worksheet did not document that Resident #3 had a bowel movement on the following days: 10/4/16, 10/5/16, 10/6/16, 10/7/16, 10/8/16, 10/9/16, and 10/10/16. The facility was unable to provide documentation the bowel protocol was followed. The facility was unable to provide documentation baths and oral care was provided on the following dates: August (YEAR): 8/5/16, 8/6/16, 8/7/16, 8/8/16, 8/19/16, 8/20/16, and 8/2/16 September (YEAR): 9/6/16, 9/7/16, 9/8/16, 9/9/16, 9/10/16, 9/11/16, 9/16/16, 9/17/16, 9/18/16, 9/27/16, 9/28/16, 9/29/16, and 9/30/16 October (YEAR): 10/18/16, 10/19/16, 10/20/16, 10/21/16, 10/28/16, 10/29/16, 10/30/16, and 10/31/16 November (YEAR): 11/6/16, 11/7/16, 11/8/16, 11/9/16, 11/10/16, 11/11/16, 11/12/16, 11/13/16, 11/14/16, 11/15/16, 11/17/16, 11/18/16, 11/19/16, 11/24/16, 11/25/16, 11/26/16, and 11/27/16 December (YEAR): 12/5/16, 12/6/16, 12/7/16, 12/9/16, 12/10/16, 12/11/16, 12/12/16, 12/14/16, 12/15/16, 12/17/16, 12/18/16, and 12/19/16 5. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #4 was cognitively intact, required extensive assistance for personal hygiene, and occasionally incontinent of bowel. The annual MDS dated [DATE], revealed Resident #4 had moderate cognitive impairment, required extensive assistance for personal hygiene, and was occasionally incontinent of bowel. The Care Plan dated 11/29/16 documented Resident #4 was at risk for constipation related to history of constipation, with interventions to monitor and document Resident #4's bowel movements, intervene with stool softeners and laxatives and to have a bowel movement every three days. The Care Plan documented, .Problems .Requires extensive assistance with personal hygiene related to generalized weakness .Interventions .Set-up items for personal hygiene .Allow .to complete as much of the task as possible . The ADL Verification Worksheets were requested and provided for Resident #4. The ADL Worksheet did not document that Resident #4 had a bowel movement on the following days: 8/5/16, 8/6/16, 8/7/16, 8/8/16/8/9/16, and 8/10/16. The facility was unable to provide documentation the bowel protocol was followed. The ADL Verification Worksheets were requested and provided for Resident #4. The ADL Worksheet did not document that Resident #4 had a bowel movement on the following days: 8/12/16, 8/13/16, 8/14/16, 8/15/16,8/17/16, 8/18/16, 8/19/16, 8/20/16, 8/21/16, and 8/22/16. The facility was unable to provide documentation the bowel protocol was followed. The ADL Verification Worksheets were requested and provided for Resident #4. The ADL Worksheet did not document that Resident #4 had a bowel movement on the following days: 9/5/16, 9/6/16, 9/7/16, 9/8/16, 9/9/16, 9/10/16, 9/11/16, 9/12/16, 9/13/16, 9/20/16, 9/21/16, 9/22/16, 9/23/16, 9/24/16, 9/25/16, 9/26/16, 9/27/16, 9/28/16, and 9/29/16. The facility was unable to provide documentation the bowel protocol was followed. The facility was unable to provide documentation that baths and oral care were provided on the following dates: 10/6/16, 10/7/16, 10/8/16, 10/9/16, 10/10/16, 10/11/16, 10/12/16, 10/13/16, 10/14/16, 10/15/16, 10/16/16, 10/17/16, 10/18/16, 10/19/16, 10/20/16, 10/21/16, 10/22/16, 10/23/16, 10/25/16, 10/26/16, and 10/27/16. 6. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 5/18/16 documented Resident #5 required extensive assistance with personal hygiene, with the goal to have oral and personal hygiene needs met daily. The facility was unable to provide documentation oral care was provided on the following dates: August (YEAR): 8/21/16, 8/23/16, 8/27/16, 8/28/16, 8/29/16, and 8/31/16 September (YEAR): 9/1/16, 8/23/16, 8/27/16, 8/28/16, 8/29/16, and 8/31/16 October (YEAR): 10/1/16, 10/2/16, 10/7/16, 10/11/16, 10/12/16, 10/13/16, 10/18/16, 10/21/16, 10/22/16, 10/23/16, 10/24/16, 10/25/16 10/26/16, 10/27/16, and 1/28/16 November (YEAR): 11/2/16, 11/3/16, 11/8/16, 11/9/16, 11/13/16, 11/14/16, 11/15/16, 11/16/16, 11/17/16, 11/18/16, 11/19/16, 11/20/16, 11/21/16, 11/22/16, 11/23/16, 11/24/16, 11/26/16, 11/28/16, and 11/29/16 December (YEAR): 12/2/16, 12/3/16, 12/4/16, 12/5/16, 12/7/16, 12/14/16, 12/15/16, 12/18/16, and 12/19/16 The facility was unable to provide documentation a bath or shower was provided on the following dates: September (YEAR): 9/17/16, 9/18/16, 9/19/16, 9/20/16, 9/21/16, 9/23/16, 9/24/16, 9/25/16, 9/26/16, and 9/27/16 October (YEAR): 10/27/16, 10/22/16, 10/23/16, 10/24/16, 10/25/16, 10/26/16, 10/27/16 and 10/28/16 November (YEAR): 11/13/16, 11/14/16, 11/15/16, 11/16/16, 11/17/16, 11/18/16, 11/19/16, 11/20/16, 11/21/16, 11/22/16, 11/23/16, and 11/24/16 7. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] documented Resident #7 had severe cognitive deficits, required total assistance for ADLs including oral care, bathing and was always incontinent of bowel and bladder. The Care Plan dated 9/19/16 revealed Resident #7 was totally dependent for toileting. Resident #7 was extensive assist with personal hygiene with goals to have hygiene needs met daily. The quarterly MDS dated [DATE] documented a Brief Interview of Mental Status (BIMS) of 4 which indicated Resident #7 was severely impaired cognitively, was total assist for ADLs including oral care, bathing, had impairment on both sides of the upper and lower extremities, and was always incontinent of bowel and bladder. The facility was unable to provide documentation that oral care was provided on the following dates: August (YEAR): 8/2/16, 8/4/16, 8/5/16, 8/6/16, 8/7/16, 8/8/16, 8/9/16, 8/10/16, 8/11/16, 8/12/16, 8/14/16, 8/15/16, 8/17/16, 8/19/16, 8/20/16, 8/22/16, 8/24/16, 8/25/16, 8/27/16, 8/28/16, 8/29/16, 8/30/16, and 8/31/16. September (YEAR): 9/1/16, 9/2/16, 9/3/16, 9/4/16, 9/5/16, 9/7/16, 9/8/16, 9/9/16, 9/18/16, 9/20/16, 9/21/16, and 9/26/16 October (YEAR): 10/2/16, 10/10/16, 10/17/16, 10/18/16, 10/19/16, 10/21/16, 10/23/16, 10/24/16, 10/25/16, and 10/31/16 November (YEAR): 11/2/16, 11/3/16, 11/4/16, 11/6/16, 11/7/16, 11/10/16, 11/15/16, 11/16/16, 11/17/16, 11/18/16, 11/19/16, 11/22/16, 11/23/16, 11/24/16, 11/25/16, 11/27/16, and 11/28/16 December (YEAR): 12/3/16, 12/4/16, 12/5/16, 12/8/16, 12/10/16, 12/11/16, 12/14/16, 12/17/16, and 12/19/16 The facility was unable to provide documentation that a bath or shower was provided on 8/5/16, 8/6/16, 8/7/16, 8/8/16, 8/9/16, 8/10/16, 8/17/16, 8/18/16, 8/19/16, 8/20/16, 8/27/16, 8/28/16, 8/29/16, 8/30/16, and 8/31/16. The facility was unable to provide documentation that a bath or shower was provided on 9/2/16, 9/3/16, 9/4/16, and 9/5/16. 8. Interview with the Director of Nursing (DON) on 12/20/16 at 7:00 PM, in the conference room, the DON was asked how the Certified Nursing Assistants (CNAs) know what they were to do for their assigned residents. The DON stated, .the kiosk lists the resident care needs and it's updated as things change for the resident . The DON was asked what the blanks on the ADL records meant. The DON stated, The blanks mean the care wasn't given or it wasn't documented that it was given. The DON was asked if the care plans document that ADL needs are to be met daily, were the care plans followed. The DON stated, No. Interview with Certified Nursing Assistant (CNA) #2 on 12/20/16 at 2:30 PM, in the conference room was asked who was responsible for charting bowel movements. CNA #2 stated, .the CNA's .",2019-11-01
1138,PINE MEADOWS HEALTH CARE,445232,700 NUCKOLLS ROAD,BOLIVAR,TN,38008,2017-05-18,514,D,1,1,7VZO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review and interview, the facility failed to ensure the medical record was accurate and complete for documentation of skin, resident change in status, and medications for 3 of 12 (Resident #42, 87,103) sampled residents reviewed of the 32 residents included in the stage 2 review. The findings included: 1. The facility's Charting and Documentation policy documented, .3. All incidents, accidents, or changes in the resident's condition must be recorded . 2. Medical record review revealed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The ADMISSION EVALUATION DATA sheet dated 3/6/17 documented Resident #42 had a skin tear to the left forearm. The physician's orders [REDACTED].Cleanse S/T (skin tear) to Rt (Right) FA (forearm) . The Treatment Administration Record (TAR) dated 3/7/17 through 3/31/17 documented Resident #42 received a treatment to a skin tear to the right forearm. Interview with Treatment Nurse #1 on 5/17/17 at 2:23 PM, at the C/D hall nurses station, Treatment Nurse #1 was asked if Resident #42 had skin tears on his left arm as indicated on the admission sheet or on the right as indicated on the orders and TAR. Treatment Nurse #1 stated, .all his were on his right. 3. Medical record revealed Resident #87 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #87 was cognitively intact, required extensive assistance with activities of daily living, and had no functional limitations in range of motion. A Confidential QA (Quality Assurance) document - allegation of neglect of (Named Resident #87) (undated) documented, .The C.N.[NAME] (Certified Nursing Assistant) #3 who cared for the resident on 2/2/17 stated .She stated that around 5:45-6:00 [NAME]M. she made her round on the resident and noted he was not speaking as he had been earlier and was staring. She immediately got the night nurse to check him. They both went into the room and the resident was cold to touch. His blood pressure was 90/50 and he started responding by nodding his head when they asked him questions . Written statement by Registered Nurse (RN) #1 (undated) documented, .At approximately 545 AM, the CNA (Certified Nursing Assistant) call me to his room. She stated he was not talking to her. We checked his vitals. I noted his skin was cool so I replaced his blanket and sheet . Written statement by CNA #3 (undated) documented, .On Thursday [DATE]nd (YEAR) .When I went in to check on (Resident #87) around 5:45am-6:00am he was lying like he was sleeping with his eyes open and he was cold to the touch. He would not answer me. I called for the nurse. She came right away to check on him. The nurse tried to take (Resident #87) O2 (oxygen) but his fingertips were very cold. The nurse told me to take his BP and it was 90/50. The nurse and I kept talking to (Named Resident #87) to try to get a response. (Named Resident #87) did not talk but he nodded his head in response to the nurse and I . Interview with Director of Nursing (DON) on 5/16/17 at 1:10 PM, in the breakroom, the DON was asked if the physician was notified when the resident became unresponsive in the night. The DON stated, .Not to my knowledge .there was not any documentation of that incident . The DON was asked if there should have been documentation describing the earlier incident with the resident. The DON stated, .oh yes, there should have been . The DON was asked if the family was notified. The DON stated, Not to my knowledge. The DON was asked if she expected her staff to notify the physician when there is a change in status. The DON stated, Yes, the nurse should have notified the doctor. The DON was asked why the facility performed an in-service on abuse. The DON stated, .because the night nurse didn't notify the day shift nurse . The facility failed to provide documentation that Resident #87 was found unresponsive on 2/3/17 approximately 5:45 AM. 4. The facility's Medical Records policy documented, .Appropriate medical/clinical records shall be maintained for each resident .that reflect the day-to-day activities and services/treatment provided to the resident . Medical Record Review revealed Resident #103 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The BEHAVIORAL MEDICINE/PROGRESS NOTE dated 10/24/16, and 11/21/16 documented, .Current Psych Meds: [MEDICATION NAME] 15mg . The physicians orders dated 6/2/16 documented, .D/C (discontinue) [MEDICATION NAME] . Telephone Interview with the Nurse Practitioner (NP) on 5/16/17 at 4:21 PM in the Staffing Coordinator's office, the NP was asked if resident was receiving [MEDICATION NAME]. The NP stated, .I probably just missed it, I can't get my computer to open .I will call you back . The NP returned telephone call on 5/16/17 at 5:30 PM, the NP stated .Yes, I missed it .I will take it off .",2020-09-01
671,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-03-10,580,D,1,0,TO3W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review and interview, the facility failed to ensure the physician and resident representative were notified of the use of oxygen, antibiotic therapy, breathing treatments and a recent [DIAGNOSES REDACTED].#5 and #6) sampled residents. The findings include: 1. The facility's Change in a Resident's Condition or Status policy documented, .Our facility shall notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and /or status .The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: .e. A need to alter the resident's medical treatment significantly .Except in medical emergencies, notifications of a change occurring in the resident's medical/mental condition or status will be made . 2. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview with Respiratory Therapist (RT) #1 on 2/27/19 at 3:25 PM in the respiratory therapy office, RT #1 stated, .Monday he was wheezing .Nurse put O2 (oxygen) on him because he was winded .the RT (RT #2) on Sunday night had put O2 on him as precaution . During an interview with RT #2 on 2/28/19 at 11:38 AM in the conference room, RT #2 stated, .went and got a concentrator for O2 . RT #2 was asked if the physician or family was notified of the need for oxygen. RT #2 stated, I didn't. I guess not. Medical record review revealed there was no documentation the physician or the family had been notified of the changes in Resident #5's condition or the need for the use of oxygen. 3. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Telephone Orders dated 2/5/19 documented, .CXR (chest x-ray) due to congestion, cough, rales . Review of the Telephone Orders dated 2/6/19 documented, .[MEDICATION NAME] (an antibiotic used to treat a bacterial infection) 250 mg PO (by mouth) tab (tablet) BID (twice daily) for pneumonia For 7 days .[MEDICATION NAME] sulfate (a [MEDICATION NAME][MEDICATION NAME]) 0.083% (percent) 2-5-3 mg (milligram) INH (inhalation) Q (every) 8 hrs (hours) for 7 days . Review of a Progress Note dated 2/6/19 documented, .CHEST X-RAY RESULTS RECEIVED; LEFT LOWER LOBE PNEUMONIA FOUND . Medical record review revealed there was no documentation Resident #6's family/representative had been notified of the change in condition, the results of the chest x-ray,the new [DIAGNOSES REDACTED].",2020-09-01
3915,SIGNATURE HEALTHCARE OF PRIMACY,445140,6025 PRIMACY PARKWAY,MEMPHIS,TN,38119,2017-01-25,323,D,1,0,NGES11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review and interview, the facility failed to ensure the post falls investigation, assessment, neurological (neuro) checks and documentation were completed after falls for 1 of 4 (Resident #115) sampled residents reviewed for falls. The findings included: 1. The facility's Falls policy documented .3. If a fall occurs the following actions will be taken: a. Assess resident including neuro checks .b. Assess resident each shift for 72 hours .c. Neuro checks will be completed on residents that experience an unwitnessed fall .d .Pain will be evaluated every shift for 72 hours for all residents .f .Document assessment, pertinent facts .begin investigation . 2. Medical record review revealed Resident #115 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nursing assessment dated [DATE] at 12:00 PM, documented Resident #115 had a fall. Review of the Daily Skilled Nurses Notes dated 1/19/17 through 1/22/17 revealed no documentation related to falls. There were no Daily Skilled Notes for 1/22/17. Interview with Director of Nursing (DON) on 1/25/17 at 9:09 AM in the conference room, the DON was asked what documentation should be completed by the staff after a resident had a fall. The DON stated, .the nurse should assess and document on the resident every shift for 72 hours . The DON was asked to provide the post fall documentation for the fall sustained by Resident #115 on 1/19/17. The DON stated, I can't find any documentation for that time frame, it's not there. The DON was asked if the staff followed the Falls policy documentation after Resident #115's fall. The DON stated, No.",2020-01-01
5473,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2016-02-04,514,D,1,0,E7MR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review and interview, the facility failed to maintain accurate clinical medication administration records (MARs) when 7 of 10 (Nurses #1, 6, 7, 9, 10, 12 and 13) nurses failed to document on the narcotic logs. The findings included: The facility's Medication Administration General Guidelines policy documented, .Medications are administered as prescribed . 1. The individual who administers the medication dose, records the administration on the resident's MAR following the medication being given . 2. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record . Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] Tablet 10-325mg ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet by mouth every 4 hours for pain . The (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) MARs documented Resident #1 was to receive [MEDICATION NAME] 10-325 milligrams (mg) every 4 hours starting at 8:00 AM. The (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) narcotic logs contained no documentation of the medication being signed out by the nurse on the following dates: a. Nurse #1 - 12/10/15 - 12:00 PM; 12/13/15 - 4:00 PM and 8:00 PM; 12/14/15 - 12:00 PM; 12/17/15 - 1200 PM; 12/23/15 and 12/24/15 - 12:00 PM; 12/26/15 - 8:00 PM; 12/28/15 - 8:00 AM, 12:00 PM and 4:00 PM; 12/30/15 - 12:00 PM; 1/1/16 - 12:00 PM; 1/9/16 and 1/14/16 - 12:00 PM. b. Nurse #6 - 12/6/15 and 12/8/15 - 8:00 AM; 12/11/15 - 12:00 PM; 12/15/15 - 8:00 AM and 12:00 PM; 12/19/15 and 12/20/15 - 8:00 AM. c. Nurse #7 - 1/15/16 - 4:00 AM. d. Nurse #9 - 1/1/16 - 8:00 PM. e. Nurse #10 - 12/9/15 - 12:00 AM; 12/21/15 - 4:00 AM; 12/28/15 - 12:00 AM; 12/31/15 - 4:00 AM; 1/3/16 - 4:00 PM and 1/13/16. f. Nurse #12 - 11/26/15 and 11/27/15 - 12:00 AM. g. Nurse #13 - 1/20/16 - 4:00 AM. Interview with Nurse #10 on 1/30/16 at 4:45 PM, in the conference room, Nurse #10 confirmed Resident #1's MAR indicated [REDACTED]. I sign out anything I give on the narcotic log. I was just in a hurry and clicked the MAR. Interview with Nurse #1 on 1/31/16 at 10:15 AM, in the conference room, Nurse #1 confirmed Resident #1's MAR indicated [REDACTED]. Nurse #1 stated, On 12/28/15 8:00 AM, I signed it out on the MAR, but not on the narcotic book. If it is not signed out on the narcotic book then it was not given. Interview with the Director of Nursing (DON) on 1/30/16 at 3:40 PM, in the conference room, the DON was asked what do you expect on documentation of medication administration. The DON stated, I expect them to sign out the medication if given and if not given document why. The DON confirmed Resident #1's MAR indicated [REDACTED]",2019-02-01
3838,PARKWAY HEALTH AND REHABILITATION CENTER,445387,200 SOUTH PARKWAY WEST,MEMPHIS,TN,38109,2017-02-02,325,D,1,0,JVU611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review and interview, the facility failed to obtain daily weights for 3 days post admission and weekly weights for 1 of 5 (Resident #43) sample residents reviewed for nutrition. The findings included: The facility's WEIGHTS policy documented, .All residents will be weighed upon admission, then everyday for 3 days .All residents will be weighed every week for four weeks upon admission . Medical record review revealed Resident #43 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #43 had a Brief Interview for Mental Status (BIMS) score of 1 which indicated severe cognitive impairment. Weight of 148 pounds. The physician orders [REDACTED].weight pt (patient) weekly . The Weight Summary for Resident #43 documented 1 weight dated 11/15/16 of 148 Lbs (pounds). Interview with the Director of Nursing (DON) on 2/2/17 at 2:55 PM, in the DON office, the DON was asked if she expected the staff to follow the weight policy for obtaining residents weights for 3 days post admission and weekly for 4 weeks. The DON stated, I do. The DON was shown the weight summary for Resident #43 and was asked if that was acceptable. The DON stated, No it is not. I would expect weights to have been done on the 3 days after the admission, and weekly as long as he was in the building .",2020-02-01
2722,AHC DYERSBURG,445446,1900 PARR AVENUE,DYERSBURG,TN,38024,2017-10-06,280,J,1,1,DRLB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review and interview, the facility failed to revise the care plan to reflect falls for 1 of 7 (Resident #58) sampled residents reviewed for falls. The facility's failure to develop and implement an individualized plan of care that included interventions to address a vulnerable resident, who was blind in both eyes and had bilateral lower extremity amputations (surgical removal of both legs), safety for travel independently/without an escort on a wheelchair van resulted in Immediate Jeopardy (IJ) for Resident #58. Resident #58 sustained a fall during transport, resulting in a serious injury, a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) during transport on [DATE]. The resident was hospitalized as a result of the fall, declined during hospitalization , and expired in the hospital on [DATE]. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Regional Nurse Consultant (NC), and the Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 4:48 PM, in the Conference Room. The facility was cited an Immediate Jeopardy at F280-[NAME] An extended survey was completed on [DATE]. An acceptable allegation of compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on [DATE] at 6:57 PM. Corrective actions were validated onsite by the surveyors on [DATE] and [DATE]. The Immediate Jeopardy was effective [DATE]. The immediacy was removed [DATE]. The noncompliance continues at F280-D for monitoring of effectiveness of the corrective actions to ensure sustained compliance. The findings included: The facility's Fall Risk/Fall Prevention Guidelines policy dated (MONTH) 2014, documented, .Post Fall Management is an opportunity to conduct a root cause analysis (RCA) of a patients (patient's) fall, identifying specific factors that contributed to the fall. The fall determination will assist care givers in implementing interventions that are cause specific, possibly reducing future falls .Licensed Staff .Will .implement/modify the patient's current plan of care with intervention(s) associated with the cause of the fall .The Interdisciplinary Team .will .Modify the patient's plan of care as needed . The facility's Care Plan policy dated (MONTH) 2014, documented, .GENERAL INFORMATION Care planning is an essential part of healthcare providing a road map of sorts, to guide all who are involved with the patient's care. Many people view the care plan solely as nursing domain, but to be effective and comprehensive, the care planning process must involve all disciplines that are involved in the care of the patient. The care plan process must begin upon admission into the facility and be fluid and changeable representing the patient's status until patient is discharged from the facility or is deceased .COMPREHENSIVE CARE PLANS .The care plan .Must be reviewed every 90 days and as needed. As needed may mean .When there is a change in patient status . Closed medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #58 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Nursing Admission/Readmission Form dated [DATE] revealed a fall risk assessment score of 13, which indicated Resident #58 was at moderate risk (score of ,[DATE]) for falls. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], and the quarterly MDS dated [DATE], revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment, had severely impaired vision, required extensive staff assistance x (of) 2 for transfers, extensive staff assist x 1 for locomotion, walking did not occur, was not steady for surface to surface transfers, and was only able to stabilize with human assistance. No use of mobility device was documented. The care plan dated [DATE] documented, .At risk for falls R/T (related to) legally blind, poor balance d/t (due to) right BKA (below knee amputation) .(and recent) Left AKA (above knee amputation) . Review of the Clinical Notes Report dated [DATE] at 1:51 PM revealed, .resident returned from access center (an outpatient surgery center) .he stated he slid out of chair on wheelchair van .No new orders noted .Wheelchair van driver came and told this nurse that he did slide out of wheelchair . The current care plan dated [DATE] revealed no revisions to the care plan with interventions associated with the cause of the fall on [DATE] while Resident #58 was riding in the wheelchair van, or a Post Fall Management Root Cause Analysis (RCA) per facility policy. Review of the Transfer To [MEDICAL TREATMENT] Form dated [DATE] revealed Resident #58 was transported without an escort via wheelchair van to the [MEDICAL TREATMENT] clinic. There was no documentation of a re-assessment for Resident #58, a vulnerable blind and bilateral [MEDICAL CONDITION] resident, for safety risk for transport via wheel chair van without an escort to or from [MEDICAL TREATMENT] after sliding out of his chair during transport on the wheelchair van. Interview with the Director of Nursing (DON) on [DATE] at 4:50 PM, in the DON's Office, the DON was asked for the Nurse Event note for Resident #58's fall on [DATE] on the wheelchair van. The DON stated, .nurse didn't make one .It didn't happen here . The Clinical Notes Report dated [DATE] at 11:06 AM, documented, .received call from (name of [MEDICAL TREATMENT] clinic) that resident was in the process of being picked up by (name of company) transportation and w/c (wheelchair) tipped backwards (off the lift gate of the van) with resident in it; this nurse was informed that resident hit head (on concrete) during fall, but was alert and oriented at time of transport to ER (emergency room ); resident currently at ER for eval (evaluation) and tx (treatment) . Hospital #1's Emergency Department (ED) Nurse Documentation dated [DATE] documented, .Presenting complaint: Patient (Resident #58) states: .was getting in van the driver was lifting his wheelchair and (Resident #58) fell out of wheelchair backward (off the lift gate of the van) and hit his head on concrete . Hospital #1's ED Physician Documentation dated [DATE] documented, .The patient (Resident #58) sustained injury to the head, patient was at [MEDICAL TREATMENT] and they were getting him into there (their) van and there chir (their chair) flipped (fell off the lift gate of the van) and hit .head (on concrete) .Differential Diagnoses: [REDACTED].Per Radiologist's finding(s): 1. Fairly extensive bilateral temporal Subarachnoid Hemorrhage, greater on the right .Disposition: [DATE] 13:52 Transfer ordered to (Name of Hospital #2 for higher level of care). [DIAGNOSES REDACTED]. Review of Hospital #2's physician progress notes [REDACTED]. The facility failed to ensure safe conditions were provided for transport, failed to assess a resident for ability to safely participate in transport, and failed to provide a plan of care for safe transport to and return from [MEDICAL TREATMENT] treatments for Resident #58; a resident who was blind in both eyes, and a bilateral lower extremity [MEDICAL CONDITION] (surgical removal of both legs). The failure of the facility to conduct a RCA and develop and implement a plan of care for transportation safety resulted in an IJ for Resident #58 when the resident sustained [REDACTED]. The resident was hospitalized as a result of the fall, declined to a comatose state during hospitalization , and expired in the hospital on [DATE] with a [DIAGNOSES REDACTED]. An extended survey was completed on [DATE]. An acceptable allegation of compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on [DATE] at 6:57 PM. Corrective actions were validated onsite by the surveyors on [DATE] and [DATE]. Validation of the credible A[NAME] was accomplished onsite [DATE] and [DATE], through review of facility documents, review of in-service records, observations, and interviews with nursing staff. The surveyors validated the corrective actions stated in the A[NAME] were implemented which removed the immediate jeopardy. The facility provided evidence of in-service training with sign-in sheets for all charge nurses on completion of the Transfer Form to include the Safety Risk Assessment, including report to the transport driver, and signature of nurse, patient (if able), and driver, for every resident upon transfer off the facility premise; and to include an escort to accompany the resident in the event the driver refused to sign the Transfer Form. Interviews with the charge nurses conducted in the facility confirmed the nurses understood the transfer process was always to include the safety assessment with documentation. The facility was cited an Immediate Jeopardy at F280-[NAME] The noncompliance continues at F280-D for monitoring of the corrective actions to ensure sustained compliance. The facility is required to submit a plan of correction.",2020-09-01
2842,MAGNOLIA CREEK NURSING AND REHABILITATION,445461,1992 HWY 51 S,COVINGTON,TN,38019,2018-06-06,842,D,1,0,H44C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview the facility failed to ensure an accurate medical record by failing to accurately document pain medication for 2 of 4 (Resident #1 and #5) sampled residents reviewed for pain. The findings included: Review of the facility's Administering Medications with a revision date of 12/2012 policy documented .The individual administering the medication must initial the resident's MAR (Medication Administration record) on the appropriate line after giving each medication and before administering the next one .As required or indicated for a medication, the individual administering the medication will record in the resident's medical record:a. The date and the time the medication was administered;b. The dosage; c. The route of administration; .g. The signature and title of the person administering the drug . 1. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Admission Minimum Date Set ((MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating that she was cognitively intact. The Resident was assessed for having frequent pain rated an 8 (Numeric Rating Scale-zero to ten scale, with zero being no pain and ten as the worst pain). The physician's orders [REDACTED].TAKE 1 TABLET BY MOUTH EVERY 4 HOURS AS NEEDED (PAIN). The CONTROLLED SUBSTANCE record for (MONTH) (YEAR) documented that 38 tablets of [MEDICATION NAME]-APAP 10-325 mg were signed out as given. The MEDICATION RECORD for (MONTH) (YEAR) documented that 43 tablets of [MEDICATION NAME]-APAP 10-325 mg were documented as given resulting in a discrepancy of 5 tablets. The CONTROLLED SUBSTANCE record for (MONTH) (YEAR) documented that 57 tablets of [MEDICATION NAME]-APAP 10-325 mg were signed out as given. The MEDICATION RECORD for (MONTH) (YEAR) documented that 53 tablets of [MEDICATION NAME]-APAP 10-325 mg were documented as given resulting in a discrepancy of 4 tablets. The CONTROLLED SUBSTANCE record for (MONTH) (YEAR) documented that 29 tablets of [MEDICATION NAME]-APAP 10-325 mg were signed out as given. The MEDICATION RECORD for (MONTH) (YEAR) documented that 26 tablets of [MEDICATION NAME]-APAP 10-325 mg were documented as given resulting in a discrepancy of 3 tablets. The facility failed to maintain an accurate record for controlled substance pain medication administration. 2. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] revealed Resident #5 had a BIMS score of 11 indicating moderately impaired cognition. The Resident was assessed for having occasional pain rated at 7 on a numeric rating scale. The physician's orders [REDACTED]. The CONTROLLED SUBSTANCE record for (MONTH) (YEAR) documented that 43 tablets of [MEDICATION NAME]-APAP 10-325 mg were signed out as given. The MEDICATION RECORD for (MONTH) (YEAR) documented that 34 tablets of [MEDICATION NAME]-APAP 10-325 mg were documented as given resulting in a discrepancy of 9 tablets. The CONTROLLED SUBSTANCE record for (MONTH) (YEAR) documented that 41 tablets of [MEDICATION NAME]-APAP 10-325 mg were signed out as given. The MEDICATION RECORD for (MONTH) (YEAR) documented that 15 tablets [MEDICATION NAME]-APAP 10-325 mg were documented as given resulting in a discrepancy of 26 tablets. The CONTROLLED SUBSTANCE record for (MONTH) (YEAR) documented that 36 tablets of [MEDICATION NAME]-APAP 10-325 mg were signed out as given. The MEDICATION RECORD for (MONTH) (YEAR) documented that 11 tablets of [MEDICATION NAME]-APAP 10-325 mg were documented as given resulting in a discrepancy of 25 tablets. The facility failed to maintain an accurate record for controlled substance pain medication administration. Interview with the Director of Nursing (DON) on 5/31/18 at 2:12 PM, in the business office, the DON was asked to look over the Controlled Substance records and the Medication Records for Resident #5. She then confirmed that there were discrepancies. Interview with the DON on 6/5/18 at 11:30 AM, in the business office, the DON was asked to look over the Controlled Substance records and the Medication Records for Resident #1. The DON was asked are there discrepancies. The DON stated, Yes .",2020-09-01
3737,ALLENBROOKE NURSING AND REHABILITATION CENTER,445485,3933 ALLENBROOKE COVE,MEMPHIS,TN,38118,2017-03-02,511,D,1,0,CJSQ11,"**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 physician timely of radiology results for 1 of 4 (Resident #188) sampled residents reviewed for physician notification. The findings included: 1. The facility's NOTIFICATION OF A CHANGE IN A RESIDENT'S STATUS policy documented, .The attending physician/responsible party will be notified of a change in a resident's condition, per standards of practice and Federal and/or State Regulations .RESPONSIBILITY .All Licensed Nursing Personnel .Guideline for notification of physician / responsible party .Emesis .Abnormal lab findings .Document in the Interdisciplinary Team (IDT) notes .Resident change in condition .Physician notification . 2. Medical record review revealed Resident #188 was admitted to the facility on [DATE] with admitting [DIAGNOSES REDACTED]. The PHYSICIAN'S TELEPHONE ORDERS dated 10/11/16 documented, .KUB (Kidneys Ureters and Bladder) .(a diagnostic medical imaging technique of the abdomen) .Person Transcribing Order for Nurse .10/11/ 11:22:00 PM . The Departmental Notes dated 10/11/16 at 9:43 AM, documented, FNP (Family Nurse Practitioner) to see resident to f/u (follow up) on KUB completed last night. KUB shows moderately distended small bowl loops. FNP gave new order to send resident out to (Named) ER for evaluation and tx (treatment) .c/o (complains of) abdominal vomiting . The Radiographics .Radiology Interpretation report documented, .FAXED [NAME]T (October) 12 (YEAR) (name of radiology staff) @ (at) 730 am .SIGNIFICANT FINDINGS KUB X-Ray Kidney, Ureter, Bladder .IMPRESSION .Findings .compatible with partial or early small bowel obstruction .Electronically Signed .10/12/2016 0:15:13 . The PROGRESS NOTE dated 10/12/16 and created by (Named Nurse Practitioner) documented, .Upon arriving at facility, KUB results noted in book and it is noted that there is concern for partial or early small bowel obstruction with clinical correlation requested. Per nurse on this morning, pt (patient) continues to to vomit and pt noted to appear ill and frequently shifting around in bed with hypoactive bowel movements noted. Will send to ER (emergency room ) for further evual (evaluation) and tx (treatment) .LABS/RADIOLOGY/TESTS Imaging .10/11/16 KUB There is gas in moderately distended loops (maximum diameter 3.6 cm (centimeters)) of small bowel with stacked coin appearance. Moderate stool in distal colon .Impression .Findings compatible with partial or early small bowel obstruction .[DIAGNOSES REDACTED].Constipation .Small Bowel Obstruction .Plan .Stat KUB .[MEDICATION NAME] 25 mg (milligrams)IM (Intramuscular) x (times) 1 .MOM (Milk of Magnesia) 30 ml (milliliters) po (per mouth)Q (every)6hrs (hours)prn (as needed) .Send to ER today . The .GI SPECIALISTS FOUNDATION . note dated 10/13/16 at 9:42 AM documented, .REASON FOR CONSULT .Ileus .CT (Cat Scan) reveals Large amount of stool in the rectosigmoid suggesting a fecal impaction .Findings are suggestive of a diffuse ileus . Interview with the Director of Nursing (DON) on 1/11/16 at 3:10 PM, in the admissions office, the DON was asked the notification process of an abnormal or critical lab value. The DON stated, .notify FNP or doctor immediately and notify the family of any new order. The DON was asked if this included X rays. The DON stated, Yes. The DON was asked what time frame is considered immediately. The DON stated, In a hour . Interview with the FNP on 1/17/16 at 2:05 PM, in the conference room, the FNP was asked if she had been notified of the KUB results that had been completed on 10/11/16. The FNP stated, I was notified that night that Resident #7 had nausea and vomiting and had ordered KUB and [MEDICATION NAME]. I was not notified of the the KUB results. When I was in the building the next morning I pulled the communication book at the desk and after reviewing the KUB results and he was symptomatic, I decided to send him out .They did not notify . The FNP was asked if the facility should have notified her of the results. The FNP stated, .I should have been notified . The FNP or physician were not notified of a change in resident's condition.",2020-03-01
4934,COUNTRYSIDE HEALTHCARE AND REHABILITATION,445280,3051 BUFFALO ROAD,LAWRENCEBURG,TN,38464,2016-06-26,279,D,1,0,MKNE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to complete a comprehensive care plan for 1 of 4 (Resident #2) sampled residents. The findings included: 1. The facility's Care Plans - Comprehensive policy documented, .1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS) .An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs Is developed for each resident . Medical record review revealed Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set admission assessment with an Assessment Reference Date of 3/9/16 was completed on 4/1/16. There was no comprehensive care plan developed for Resident #2. Interview with Licensed Practical Nurse (LPN) #1 in the dining room on 6/25/16 at 3:10 PM, LPN #1 was asked if Resident #2 had a comprehensive care plan completed. LPN #1 looked in the medical record then stated, (Named resident) has no care plan .She has a temporary one, but not one that includes every area .No there is no care plan.",2019-06-01
4171,AHC HARBOR VIEW,445428,1513 N 2ND STREET,MEMPHIS,TN,38107,2016-12-22,312,E,1,0,XY5611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to ensure Activities of Daily Living (ADLs) related to baths and oral care were provided for 6 of 6 (Resident #1,2, 3, 4, 5 and 7) sampled residents. The findings included: 1. The facility's Care Plans policy documented .Care Planning is an essential part of healthcare providing a road map of sorts, to guide all who are involved with the patient's care . 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 7/5/16 documented Resident #1 required extensive assistance with personal hygiene related to weakness and [MEDICAL CONDITION] with goals to have personal hygiene needs met daily. a. The facility was unable to provide documentation oral care was provided on the following dates: August: 8/18/16, 8/19/16, 8/20/16, 8/23/16, 8/27/16, and 8/31/16 September: 9/2/16, 9/10/16, 9/12/16, 9/16/16, 9/17/16, 9/18/16, 9/19/16, 9/20/16, 9/21/16, 9/22/16, 9/23/16, 9/25/16, 9/27/16, and 9/28/16 October: 10/1/16, 10/3/16, 10/7/16, 10/13/16, 10/15/16, 10/16/16, 10/18/16, 10/19/16, 10/20/16, 10/21/16, 10/23/16, 10/24/16, 10/28/16, 10/29/16, and 10/30/16 November: 11/3/16, 11/4/16, 11/5/16, 11/6/16, 11/8/16, 11/9/16, 11/10/16, 11/11/16, 11/13/16, 11/15/16, 11/16/16, 11/17/16, 11/18/16, 11/19/16, 11/20/16, 11/21/16, 11/22/16, 11/24/16, 11/25/16, and 11/26/16 December: 12/3/16, 12/5/16, 12/6/16, 12/9/16, 12/10/16, 12/11/16, 12/12/16, 12/15/16,12/17/16,12/18/16, 12/19/16, and 12/20/2016. b. The facility was unable to provide documentation a bath or shower was provided on the following dates: September: 9/16/16, 9/17/16, 9/18/16, 9/19/16, 9/20/16, 9/21/16, 9/22/16, 9/23/16 November: 11/3/16, 11/4/16, 11/5/16, 11/6/16, 11/7/16, and 11/15/16, 11/16/16, 11/17/16, 11/18/16, 11/19/16, and 11/20/16. 3. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE], revealed Resident #2 was cognitively intact and required extensive assistance for personal hygiene and bathing. The quarterly MDS dated [DATE], revealed Resident #2 had moderate cognitive impairment and required extensive assistance for personal hygiene and bathing. The care plan dated 6/22/16 and revised on 9/6/16 documented, .Problems .Self-care deficit .Assistance required with bed mobility, transfers, toileting, bathing, hygiene, dressing, grooming .Interventions .Bathe/shower .Frequency .3 Times Weekly Starting 06/22/2016 .Interventions .Clean mouth, brush teeth/dentures after meals and at bedtime .Frequency 4 times Daily Starting 06/22/2016 . The facility was unable to provide documentation a bath and oral care was provided on the following dates: August: 8/27/16, 8/28/16,8/29/16, 8/30/16, and 8/31/16 September: 9/6/16, 9/7/16, 9/8/16, 9/9/16, 9/10/16, 9/11/16, 9/17/16, 9/18/16, 9/19/16, 9/20/16, 9/21/16, 9/23/16, 9/24/16, 9/25/16, 9/26/16, 9/27/16, 9/28/16, 9/29/16, and 9/30/16 October: 10/6/16, 10/7/16, 10/8/16, 10/9/16,10/11/16, 10/12/16, 10/13/16, 10/14/16, 10/15/16, 10/16/16, 10/17/16, 10/18/16, 10/19/16, 10/20/16, 10/21/16, 10/22/16, 10/23/16, 10/24/16, 10/25/16, 10/26/16,10/27/16, 10/28/16, 10/29/16, 10/30/16, and 10/31/16 November: 11/1/16,11/2/16, 11/3/16, 11/4/16, 11/6/16, 11/7/16, 11/8/16, 11/9/16, 11/10/16, 11/11/16, 11/12/16,11/13/16, 11/14/16,11/15/16, 11/16/16, 11/17,16, 11/18/16, 11/19/16, 11/20/16, 11/22/16, 11/23/16, 11/24/16, 11/25/16, 11/26/16, 11/27/16, 11/28/16, and 11/29/16 December: 12/2/16, 12/3/16, 12/4/16, 12/5/16, 12/6/16, 12/7/16, 12/8/16, 12/11/16, 12/12/16, 12/13/16, 12/14/16, 12/16/16,12/17/16, 12/18/16 and 12/19/16. 4. Medical record review revealed Resident #3 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 #3 was cognitively intact, required extensive assistance for bathing and oral care. The care plan documented, .6/20/16 . and updated on 11/28/16 .Problem .Requires extensive to total assistance with personal hygiene related to .[MEDICAL CONDITION] .Interventions .set-up items for personal hygiene .will have oral hygiene .daily . The facility was unable to provide documentation baths and oral care was provided on the following dates: August: 8/5/16, 8/6/16,8/7/16, 8/8/16, 8/19/16, 8/20/16, and 8/21/16 September: 9/6/16, 9/7/16, 9/8/16, 9/9/16, 9/10/16, 9/11/16, 9/16/16, 9/17/16, 9/18/16, 9/27/16, 9/28/16, 9/29/16, and 9/30/16 October: 10/18/16, 10/19/16, 10/20/16, 10/21/16, 10/28/16, 10/29/16, 10/30/16, and 10/31/16,11/6/16 November: 11/7/16, 11/8/16, 11/9/16, 11/10/16, 11/11/16, 11/12/16,11/13/16, 11/14/16,11/15/16, 11/17,16, 11/18/16, 11/19/16, 11/24/16, 11/25/16, 11/26/16, and 11/27/16 December: 12/5/16, 12/6/16, 12/7/16, 12/9/16, 12/10/16, 12/11/16, 12/12/16, 12/14/16, 12/15/16,12/17/16, 12/18/16 and 12/19/16. 5. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE], revealed Resident #4 was cognitively intact and required extensive assistance for personal hygiene. The annual MDS dated [DATE], revealed Resident #4 had moderate cognitive impairment and required extensive assistance for personal hygiene. The care plan dated 11/29/16 documented, .Problems .Requires extensive assistance with personal hygiene related to generalized weakness .Interventions .Set-up items for personal hygiene .Allow .to complete as much of the task as possible . The facility was unable to provide documentation that baths and oral care were provided on 10/6/16, 10/7/16, 10/8/16, 10/9/16, 10/10/16, 10/11/16, 10/12/16, 10/13/16, 10/14/16, 10/15/16, 10/16/16, 10/17/16, 10/18/16, 10/19/16, 10/20/16, 10/21/16, 10/22/16, 10/23/16, 10/25/16, 10/26/16, and 10/27/16. 6. Medical record review revealed Resident #5 was admitted to the facility on [DATE] and readmitted with [DIAGNOSES REDACTED]. The Care Plan dated 5/18/16 documented Resident #5 required extensive assistance with personal hygiene with the goal to have oral and personal hygiene needs met daily. a. The facility was unable to provide documentation oral care was provided on the following dates: August: 8/21/16, 8/23/16, 8/27/16, 8/28/16, 8/29/16, and 8/31/16 September: 9/1/16, 9/3/16, 9/6/16, 9/7/16, 9/9/16, 9/11/16, 9/17/16, 9/18/16, 9/19/16, 9/20/16, 9/21/16, 9/23/16, 9/24/16, 9/25/16, 9/26/16, 9/27/16, and 9/30/16 October: 10/1/16, 10/2/16, 10/7/16, 10/11/16, 10/12/16, 10/13/16, 10/18/16, 10/21/16, 10/22/16, 10/23/16, 10/24/16, 10/25/16, 10/26/16, 10/27/16, and 10/28/16 November: 11/2/16,11/3/16, 11/8/16, 11/9/16, 11/13/16, 11/14/16, 11/15/16, 11/16/16, 11/17/16, 11/18/16, 11/19/16, 11/20/16, 11/21/16, 11/22/16, 11/23/16, 11/24/16, 11/26/16, 11/28/16, and 11/29/16 December: 12/2/16, 12/3/16, 12/4/16, 12/5/16, 12/7/16, 12/14/16, 12/15/16, 12/18/16, and 12/19/2016. b. The facility was unable to provide documentation a bath or shower was provided on the following dates: September: 9/17/16, 9/18/16, 9/19/16, 9/20/16, 9/21/16, 9/23/16, 9/24/16, 9/25/16, 9/26/16, and 9/27/16 October: 10/21/16, 10/22/16, 10/23/16, 10/24/16, 10/25/16, 10/27/16, 10/27/16, and 10/28/16 November: 11/13/16, 11/14/16, 11/15/16, 11/16/16, 11/17/16, 11/18/16, 11/19/16, 11/20/16, 11/20/16, 11/21/16, 11/22/16, 11/23/16, and 11/24/16. 7. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] documented Resident #7 had severe cognitive deficits, required extensive to total assistance for ADLs including oral care, bathing and Resident #7 was always incontinent of bowel and bladder. The quarterly MDS dated [DATE] documented a Brief Interview of Mental Status (BIMS) of 4 which indicated Resident #7 was severely impaired cognitively, Resident #7 was total assist for ADLs including oral care, bathing, and was always incontinent of bowel and bladder. Resident #7 was also impaired on both sides' upper and lower extremities. The care plan dated 9/19/16 revealed Resident #7 was totally dependent for Toileting, Resident #7 was extensive assist with personal hygiene with goals to have hygeine needs meet daily. a. The facility was unable to provide documentation that oral care was provided on 8/2/16, 8/4/16, 8/5/16, 8/6/16, 8/7/16, 8/8/16, 8/9/16, 8/10/16, 8/11/16, 8/12/16, 8/14/16, 8/15/16, 8/17/16, 8/19/16, 8/20/16, 8/22/16, 8/24/16, 8/25/16, 8/27/16, 8/28/16, 8/29/16, 8/30/16, and 8/31/16. The facility was unable to provide documentation that a bath or shower was provided on 8/5/16, 8/6/16, 8/7/16, 8/8/16, 8/9/16, 8/10/16, 8/17/16, 8/18/16, 8/19/16, 8/20/16, 8/27/16, 8/28/16, 8/29/16, 8/30/16, and 8/31/16. b. The facility was unable to provide documentation that oral care was provided on 9/1/16, 9/2/16, 9/3/16, 9/4/16, 9/5/16, 9/7/16, 9/8/16, 9/9/16, 9/18/16, 9/20/16, 9/21/16, and 9/26/16. The facility was unable to provide documentation that a bath or shower was provided on 9/2/16, 9/3/16, 9/4/16, and 9/5/16 . c. The facility was unable to provide documentation that oral care was provided on 10/2/16, 10/10/16, 10/17/16, 10/18/16, 10/19/16, 10/21/16, 10/23/16, 10/24/16, 10/25/16, and 10/31/16. The facility was unable to provide documentation that oral care was provided on 11/2/16, 11/3/16, 11/4/16, 11/6/16, 11/7/16, 11/10/16, 11/15/16, 11/16/16, 11/17/16, 11/18/17, 11/19/16,11,22/16, 11/23/16, 11/24/16, 11/25/16, 11/27/16, and 11/28/16. The facility was unable to provide documentation that oral care was provided on 12/2/16, 12/4/16, 12/5/16, 12/8/16, 12/10/16, 12/11/16,12/14/16, 12/17/16, and 12/19/16. 8. Interview with the Director of Nursing (DON) on 12/20/16 at 7:00 PM, in the conference room, the DON was asked how the Certified Nursing Assistance's (CNA's) know what they were to do for their assigned residents. The DON stated, .the kiosk lists the resident care needs and it's updated as things change for the resident . The DON was asked what the blanks on the ADL records meant. The DON stated, The blanks mean the care was not given or it wasn't documented that it was given. The DON was asked if the care plans document that ADL needs are to be met daily, was the care plans followed. The DON stated, No.",2019-11-01
873,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2017-05-25,225,D,1,0,K3HH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to ensure a complete, thorough, and timely investigation was conducted for resident to resident altercations for 2 of 4 (Resident #3 and 6) sampled residents. The findings included: 1. The facility's Abuse, Neglect, Misappropriation of Resident Funds policy documented .Reporting of abuse, Neglect, or Misappropriation/Procedure 1. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the administrator or Director of Nursing (DON) .The names of any witnesses to the incident .7. Upon receiving information concerning a report of abuse, neglect, misappropriation, the Administrator or designee will investigate, obtain statements, and ensure the residents are safe and receive quality care . 2. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an incident documented, On 2/19 (2/19/17 at 10:40 AM) resident (Resident #3) was witnessed by other residents in the dining room running into the chair of resident (Resident #6). During this event resident (Resident #6)attempted to hit resident (Resident #3) causing a small scratch on lip. Residents were separated and monitored throughout the day. Mobile Crisis notified as was the DON (Director of Nursing) and Administrator . Review of the POS [REDACTED].Immediate Post-Incident Action: CNAs (Certified Nursing Assistant) informed to keep the 2 separated for today and to be [MEDICAL CONDITION] .Immediate actions Taken: Assessed for injuries, separated the 2 involved to different rooms, vital signs taken, asked him about what happened . 3. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the POS [REDACTED].Narrative of incident: When in dining room, elder was hit in the face by another elder. No employees were present. 3 other elders were able to report the incident. Immediate Post-Incident action: Try to keep elders involved separated in the dining area. Assessed for injuries and separate to different rooms . Interview with the Assistant Director of Nursing (ADON) on 5/23/17 at 2:38 PM, in the DON's office, the ADON was asked to describe the incident between Resident #3 and Resident #6. The ADON stated, I do not know who the other 3 residents were that witnessed it and the nurse that filed the report is no longer here . Interview with the Administrator on 5/23/17 at 2:43 PM, in the DON's office, the Administrator was asked to describe the incident between Resident #38 and Resident #6, the investigation, and who were the 3 other residents that witnessed the incident. The Administrator stated, .I don't have a witness statement in there (looking through the investigation report) .I sure thought the statements were in there .I have had some renovation done to my office and they moved my desk around and may have slipped out of the file .I first put down that she was hit in the mouth but actually that was a growth on her lip area. She did not get hit in the mouth .the second altercation is when he hit her and I kept him in my office until the paramedics could come and get him out .when we have someone that has an altercation like that we separate them .make sure everyone is ok .get statements .monitor them .redirect them . Interview with the Administrator on 5/23/17 at 3:58 PM, in the DON's office, the Administrator was asked if he had statements from the witnesses. The Administrator stated, No .that is my fault for not following up on it .(the witnesses) they would have been able to tell you what happened right then but the next day they couldn't have told you . The facility failed to complete a thorough investigation of the incident that occurred between Resident #38 and 6.",2020-09-01
2711,AHC SAVANNAH,445444,1645 FLORENCE RD,SAVANNAH,TN,38372,2019-05-22,689,D,1,0,589R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to ensure a fall was documented and an investigation initiated timely for 1 of 3 (Resident #1) sampled residents reviewed for falls. The findings included: 1. The facility's Occurrence Reporting policy documented, The facility will complete an occurrence report to document the details of an accident/incident/occurrence/unusual event effecting the resident. (Named Nursing Facility) requires completion of an occurrence report that triggers an immediate and on-going investigation .Occurrence reports should be completed regardless if the resident sustained [REDACTED]. 2. Medical record review revealed Resident #1 was originally admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the facility's investigation revealed Resident #1 was found on the floor on 3/9/19 shortly after midnight on the 3/8/19 6:00 PM to 6:00 AM shift with no noted injuries and was assisted back to bed. The Nurse's Event Note dated 3/9/19 at 12:00 PM documented, Notified by residents (resident's) wife that resident stated he had fallen the previous night (03/08/19) (the fall on 3/9/19 early morning) and was assisted back into bed by staff . Medical record review revealed there was no documentation on the 3/8/19 6:00 PM to 6:00 AM shift of the fall that occurred on 3/9/19 shortly after midnight and the Event Note was not completed until 3/9/19 at 12:00 PM, which was when the investigation was initiated. Interview with the Director of Nursing (DON) on 5/22/19 at 2:39 PM, in the Conference Room, the DON was asked when should a fall be documented. The DON stated as soon as the nurse becomes aware, after assessing the resident.",2020-09-01
1331,LIFE CARE CENTER OF CENTERVILLE,445252,112 OLD DICKSON RD,CENTERVILLE,TN,37033,2017-05-24,425,D,1,0,BTMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to ensure an accurate system to account and document for narcotic medications for 2 of 5 (Residents #5 and 54) sampled residents for unnecessary medications and closed records. The findings included: 1. The facility's Administration of Medication policy documented .initial each medication in the correct box on the MAR after the medication is given .PRN (as needed) medication is charted with initials, and time is given in the corner of the box . 2. Medical record review revealed Resident #5 admitted [DATE] with [DIAGNOSES REDACTED]. Review of the care plan, with a target date of 7/14/17, identified the resident had chronic pain related to Arthritis, Restless Leg Syndrome and Constipation. The goal was that the resident would state/demonstrate relief or reduction in pain intensity within one hour after receiving interventions. Approaches included, administer/observe for effectiveness and for possible side effects from routine and PRN pain medication (narcotic and over the counter). Review of the physician's orders [REDACTED].Lortab four times a day PRN (as needed) . Review of the Controlled Drug Record from 4/1/17 through 5/23/17, revealed staff documented 35 occasions in which they removed a PRN dose of Lortab from the medication cart to be administered for the resident. Review of the Medication Administration Records (MAR) from 4/1/17 through 5/23/17 revealed staff documented on the front, 31 occasions on which the Lortab was administered. The back of the MARs, where nurses were to document the date, time, reason for administration and result of each dose of PRN medication, identified 21 occasions on which the nurse documented the relevant information. The Pain Flow Sheet, for the same time period, revealed 30 occasions when the Lortab was administered. 2. Closed medical record review revealed Resident #54 admitted on [DATE] and expired 3/3/17 with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Roxanol 20 mg (milligram) / (per) cc (cubic centimeter) .0.5 cc po q (every) 2 h (hours) pain . Review of the Controlled Drug Record revealed between 3/3/17 and 3/6/17 a nurse documented eight occasions in which a dose of Roxanol was removed from the medication cart to be administered. Review of the MAR revealed between 3/3/17 and 3/6/17 the nurse documented the administration of the Roxanol only five times on the front of the MAR. Review of the back of the MAR revealed the nurse did not document the administration of the medication on any occasion. Interview with Licensed Practical Nurse (LPN) #4 on 5/24/17 at 9:00 AM, at Hope's Place unit nurses station, LPN #4 was asked what is the process for giving a PRN pain medication. LPN #4 stated, .once the nurse assesses and determines the resident needs a PRN pain medication, the nurse should document the administration time and date on the front of the MAR, the time, date, reason for administration and effectiveness of the dose on the back of the MAR, the time, date, amount given and number of pills remaining on the Controlled Drug Record and the time, date, intensity, aggravating factors, non-medication interventions, effectiveness and side effects of the dose on the Pain Flow Sheet .all four documents should match for date and time of the medication administration . Interview with the Director of Nursing (DON) on 5/24/17 at 10:05 AM, in the DON office, the DON was asked if medications signed out on the Controlled Drug Record should also be documented on the MAR. The DON stated, Absolutely.",2020-09-01
3738,ALLENBROOKE NURSING AND REHABILITATION CENTER,445485,3933 ALLENBROOKE COVE,MEMPHIS,TN,38118,2017-03-02,514,D,1,0,CJSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to ensure medical records were complete and accurate as evidenced by documenting a discontinued medication was given and an ordered medication was not on the medication administration record for 2 of 13 (Residents #123 and 188) residents reviewed during the survey. The findings included: 1. Review of facility's MEDICATION ADMINISTRATION-GENERAL GUIDELINES policy documented, Medications are administered as prescribed .1. medications are prepared, administered, and recorded only by licensed nursing .2. Medications are administered in accordance with written orders .3. Residents are allowed to self-administer medications when specifically authorized .in accordance with procedures for self-administration of medications .9. Only licensed or legally authorized personnel who prepare a medication may administer it .10. Medications are administered within the identified block of time .One hour before and one hour after scheduled time .11. The resident's MAR/TAR (Medication Administration Record/Treatment Administration Record) is initialed by the person administering a medication .14. If a dose of regularly scheduled medication is withheld, refused or given at other than the scheduled time .An explanatory note is entered .if several doses .withheld or refused, the physician and responsible party are notified and documentation of this notification is made in the nursing notes. For the eMAR (electronic Medication Administration Record), the dose is electronically marked as not administered with a reason as to why it was not given .18 .If the medication is discontinued, outdated, or unusable, remove the medication for proper disposal . Review of facility's PRINTED PHYSICIAN ORDERS policy documented, Physician orders, MAR's, TAR's for upcoming month will be accurately reconciled against the previous month's records .1. New Physician's Orders, MARs and TAR's will be printed, checked and corrections made necessary by licensed nurses prior to the implementation each month .The orders will reconcile thru the month end feature in software .2 .The reconciled orders MARs and TAR's will be signed by the nurse and dated when placed in the chart/books .eMAR, these records will be maintained electronically . Review of facility's MEDICATION DESTRUCTION . policy documented, .When medications are discontinued by physician order .the medications are destroyed .1. If a physician discontinues or changes a medication, the order is entered into the medical record .'Discontinued Medication' stickers is used or indicate 'D/C (Discontinue)' beside the medication . 2. Medical record review revealed Resident #123 was admitted to facility 10/2/13 with [DIAGNOSES REDACTED]. Review of Physician's Telephone Orders for Resident #123 dated 9/29/16 documented .discontinue [MEDICATION NAME] 250 mg, start Methazoleamide 25 mg PO (by mouth) tid (three times a day) . Review of the Medication Administration Record (MAR) for Resident #123 for 9/30/16 through 10/26/16 revealed Methazoleamide 25 mg PO tid was entered on the handwritten MAR and signed as given. Review of the electronic MARs dated 10/27/16 through 1/29/17 documented [MEDICATION NAME] 250 mg at bedtime as given or not given, documented as the resident refusing. Review of the physician orders for (MONTH) (YEAR) through (MONTH) (YEAR) revealed there were no physician orders to administer the [MEDICATION NAME] 250 mg. Review of the pharmacy CONSOLIDATED DELIVERY SHEETS on 1/31/17 on west hall for (MONTH) (YEAR) confirmed neither medication had been delivered, by the pharmacy, to the facility through 1/30/17. Interview with LPN #7 on 1/31/17 at 4:15 PM, on the west hall, LPN #7 was asked if she had been giving Resident #123 the [MEDICATION NAME] 250 mg at bedtime as documented on the MAR. LPN #7 stated, Yes. LPN #7 reviewed the order to discontinue [MEDICATION NAME] 250 mg on 9/29/16 and was asked if the medication was discontinued, how she gave it. LPN #7 stated, To be honest, I documented giving it when I saw him taking it himself or his family member gave it to him. LPN #7 was asked how she knew the family member was giving the correct medication and dosage. LPN #7 stated, I didn't. LPN #7 was provided the order to discontinue the [MEDICATION NAME] 250 mg and start Methazoleamide 25 mg tid. LPN #7 was asked if she was aware of the physician order. LPN #7 stated, No, it wasn't on the MAR. LPN #7 was asked if a resident should take his own medication if he had not been evaluated for self-administration. LPN #7 stated, No. LPN #7 documented she administered [MEDICATION NAME] 250 mg 10 times from (MONTH) (YEAR) through (MONTH) 30, (YEAR) on the following dates: 11/10/16, 12/6/16, 12/15/16, 12/20/16, 12/24/16, 12/26/16, 1/10/17, 1/11/17, 1/24/17, and 1/27/17. Telephone interview with LPN #14 on 2/1/17 at 9:48 AM, LPN #14 was asked about Resident #123's medications. LPN #14 was asked how [MEDICATION NAME] 250 mg was given by LPN #14 on 1/4/17 if it was discontinued on 9/29/16 and no other doses was sent from pharmacy since 9/24/16. LPN #14 stated, It had to be an error. Telephone interview with LPN #10 on 2/1/17 at 12:49 PM, LPN #10 was asked about Resident #123's medications. LPN #10 was asked how [MEDICATION NAME] 250 mg was given by LPN #10 on 1/5/17 if it was discontinued on 9/29/16 and no other doses was sent from pharmacy since 9/24/16. LPN #10 stated, it had to be an error. Telephone interview with LPN #11 on 2/1/17 at 12:49 PM, LPN #11 was asked about Resident #123's medications. LPN #11 was asked how [MEDICATION NAME] 250 mg was given by LPN #11 on 11/2/16 and 12/3/16 if it was discontinued on 9/29/16 and no other doses had been sent from pharmacy since 9/24/16. LPN #11 stated, it was an error. The [MEDICATION NAME] 250 mg was documented as given 23 times from 10/27/16 through 1/30/17. The [MEDICATION NAME] 250 mg was documented as not given 53 times from 10/27/16 through 1/30/17. Interview with the DON on 1/31/17 at 4:59 PM, in the DON's office, the DON was asked if she was aware that Resident #123 was receiving a medication that was discontinued and not receiving a medication that was ordered on [DATE]. The DON stated, Not until I received the email from pharmacy this morning. The DON was asked if the staff followed physician orders if they failed to give an ordered medication, the DON stated, No. 3. Medical record review revealed Resident #188 was admitted to the facility on [DATE] with admitting [DIAGNOSES REDACTED]. The physician's telephone order dated 10/11/16 documented, .[MEDICATION NAME] 25 MG (milligrams) IM (Intramuscular) NOW X (times) 1 .KUB .INDICATION .NAUSEA . Review of the (MONTH) (YEAR) Medication Administration Record revealed Resident #188 did not receive [MEDICATION NAME] 25 mg IM as ordered. Interview with the DON on 1/18/16 at 1:40 PM, in the conference room, the DON was asked if a medication was administered would you expect it to be signed out on the MAR. The DON stated, Yes",2020-03-01
3916,SIGNATURE HEALTHCARE OF PRIMACY,445140,6025 PRIMACY PARKWAY,MEMPHIS,TN,38119,2017-01-25,514,E,1,0,NGES11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to ensure medical records were complete and accurate as evidenced by failure to document daily Medicare skilled notes, weekly skin assessments, medications were administered, admission assessments, and accurate dates on nursing assessments for 6 of 18 (Residents #71, 97, 154, 202, 233, and 247) of the 33 residents included in the stage 2 review. The findings included: 1. The facility's Charting & (and) Documentation policy documented, .For skilled residents, documentation will occur at least daily . Medical record review revealed Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 5-day Prospective Payment System (PPS) Assessment for a Medicare Part A stay Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment. The start of the most recent Medicare stay was 8/29/16. There were no DAILY SKILLED NURSE'S NOTE forms documented for Resident #71 for (MONTH) 1,2,6,7,8,9,10,11,12,13, (YEAR). Interview with the Director of Nursing (DON) in the DON office on 01/25/17 at 6:24 PM, the DON was asked what was her expectation of the nurses documenting skilled nursing notes. The DON stated, I expect the nurses to chart daily on skilled residentsWe are now also reviewing that in the morning meeting . 2. Medical record review revealed Resident #97 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Weekly Skin Resident Information form dated 11/15/16 documented, .Left Buttock Open Area Ulcer L (length)-1, W (width)-1, D (depth)-1 Present On Admission True The Weekly Skin Resident Information form dated 11/16/16 documented, .Left Buttock Reddened Intact Skin Resolved .admitted with no open area noted to the left buttock upon admission . Interview with the DON on 1/25/17 at 11:31 AM in the conference room, the DON was asked about the Weekly Skin . dated 11/15/16. The DON stated .had open area on L (left) buttock on admission, L-1, W-1, D-1 . The 11/16/16 note documented .resolved, no open area noted to the L buttock upon admission. The DON stated, I will have to look in to that . Interview with the Assistant Director of Nursing (ADON) on 1/25/17 at 3:44 PM, at the 100 hall nurses' station, the ADON was asked about the conflicting assessments of the wound status in the Weekly Skin Resident Information forms on 11/15/16 and 11/16/16. The ADON stated, The Treatment (Tx) Nurse comes in, looks at the wound/open area and states if it is staged and if it's not a wound. Measurements have to be put in to flag the Tx Nurse and you have to put measurements in. But it won't allow you to use zeros . Interview with the Tx Nurse on 1/25/17 at 4:17 PM, the Tx Nurse was asked about the charting of wounds on admission by the nurses. The Tx Nurse stated, Only the Tx Nurse stages a wound, the nurse (charge nurse) can chart 'open area' where located. The nurse (charge nurse) don't generally stage them or measure them. The DAILY SKILLED NURSE'S NOTE dated: 12/17/16, 12/18/16, 12/22/1, 1/6/17, 1/9/17, and 1/20/17 all documented a bruise under the skin condition section with no explanation in the narrative. There were no daily skilled nursing notes for (MONTH) 1 through 13, 15, 16, 19, 20, 23, 25, 27, 28, 30, 3, (YEAR) and for (MONTH) 2, 4, 5, 7, 8, and 10 through 19, (YEAR). Interview with Licensed Practical Nurse (LPN) #1 on 1/25/17 at 3:41 PM at the 200 hall nurses station, LPN #1 was asked about the bruise documented on the DAILY SKILLED NURSE'S NOTE and how would someone know where the bruise was located, when it first was noted and how it occurred. LPN #1 stated, .It should be in the narrative but it's not . Interview with the ADON on 1/25/17 at 3:44 PM, at the 200 hall nurses' station was asked about the bruise on the DAILY SKILLED NURSE'S NOTE that was documented several times. The ADON stated, It doesn't say bruise on the wound since it has scabs instead. 3. The facility's Medication Administration General Guidelines policy documented, .Documentation .1. The individual who administers the medication dose, records the administration on the resident's MAR (Medication Administration Record) immediately following the medication being given . Medical record review revealed Resident #154 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Initial MDS dated [DATE] revealed a BIMS score of 6 which indicated severe cognitive impairment. A physician order [REDACTED].GLIMEPIRIDE 2 MG (Milligram) TABLET .GIVE ONE TABLET BY MOUTH ONCE DAILY . The MAR indicated [REDACTED]. Interview on 1/25/17 at 5:33 PM with the DON in the DON office , the DON was shown the December, (YEAR) MAR indicated [REDACTED]. The DON stated, .This is missed documentation .The policy is to run an omission report to ensure there are no documentation errors or omissions. They (medications) should be signed off at the time you administer the medication. 4. Medical record review revealed Resident #202 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Nursing Assessment for Resident #202 dated 9/9/16 documented .unwitnessed fall .Neurological assessment completed: No . Interview with the RCC on 1/25/17 at 9:46 AM in the conference room, the RCC was asked for the fall investigation for Resident #202 for 9/9/16. The RCC stated, .only 2 pages for that fall incident, investigation is missing . Interview with the DON on 1/25/17 at 10:35 AM on the 200 hall, the DON was asked for the fall investigation for Resident #202 that occurred on 9/9/16. The DON stated, The incident you requested for (named resident) was only the 2 pages, they failed to do the investigation . The facility documented a fall on 9/9/16. The resident was not admitted until 9/11/16. 5. Medical record review revealed Resident #233 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the NURSING ADMISSION INFORMATION for Resident #233 dated 12/15/16 was not completed. Interview with the DON on 1/24/17 at 5:40 PM, in her office, the DON was asked if the Nursing Admission Information sheets were completed for Resident #233. The DON stated, No ma'am it's not completed. The DON and ADON reviewed the Nursing Admission Information for Resident #233 and the DON stated, It's not in there either .Braden scale or Fall risk either . 6. Medical record review revealed Resident #247 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #247's Admission MDS dated [DATE] documented the resident was not interviewable. Interview with the Assistant Director of Nursing (ADON) on 1/25/17 at 3:13 PM, at the 200 Hall Nurses' Station, the ADON was asked how often should a Medicare resident be charted on. The ADON stated, .daily . The ADON was asked if Resident #247 was a Medicare or Medicaid resident, the ADON stated, Medicare. The ADON was asked when the last documentation was charted for Resident #247, the ADON stated, On the 24th (January)but the one before that was the 12th (January). The ADON was asked if Resident #247 should have been charted on daily between (MONTH) 12 and (MONTH) 24, the ADON stated, Yes .",2020-01-01
4650,HUNTINGDON HEALTH & REHAB CENTER,445210,635 HIGH STREET,HUNTINGDON,TN,38344,2016-08-05,309,E,1,0,Z4P511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to ensure medications were administered and accurately documented for 3 of 3 (Resident #1, 2 and 3)sampled residents. The findings included: 1. The facility's Administering Medications policy documented, .The individual administering the medication must initial the resident's MAR (Medication Administration Record) on the appropriate line after giving each medication and before administering the next ones .If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR indicated [REDACTED]. 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MAR indicated [REDACTED] a. .[MEDICATION NAME] 100 U(units)/ml(milliliter) per sliding scale ac(before meals) and hs (bedtime) . on 5/31/16 at 7 AM. b. .[MEDICATION NAME] 15mg(milligrams) 1 TAB(tablet) PO (per mouth)AT HS . on 5/30 and 5/31/16 at 8 PM. c. .Potassium CL(Chloride) 10 mEQ(milliequivalent) 1 cap(capsule) po once daily . on 5/30 and 5/31/16 at 8 PM. d. .[MEDICATION NAME] 10 mg 1 tab po BID(twice a day) x(times)14 days . on 5/30 and 5/31/16 at 8 PM. e. .[MEDICATION NAME] Sodium 100 mg Take 1 cap BID .on 5/30 and 5/31/16 at 8 PM. f. .[MEDICATION NAME] 325 mg take 1 tab po TID(three times a day) . on 5/30 and 5/31/16 at 8 PM. g. .[MEDICATION NAME] 40 mg 1 tab daily @(at) hs . on 5/30 and 5/31/16 at 8 PM. h. .Bactrim DS (Double Strength) 1 tab po BID . on 5/30 and 5/31/16 at 8 PM. i. .Zinc Sulfate 220 mg 1 tab po once daily . on 5/30 and 5/31/16 at 8 PM. j. .[MEDICATION NAME] 600 mg 1 capsule po TID . on 5/30 and 5/31/16 at 8 PM. k. Hydro([MEDICATION NAME]) 10/325 1 po QID(four times a day) . on 5/28/16 at 12 PM and 6 PM and on 5/31/16 at 12 AM and 6AM. l. .[MEDICATION NAME] 15 mg po 1 TAB Daily . on 5/31/16 at 8 AM. The MAR indicated [REDACTED] a. .[MEDICATION NAME] 100 U/ML PER SLIDING SCALE BEFORE MEALS AND AT BEDTIME, BLOOD SUGAR LESS,GIVE OJ(orange juice) OR ONE AMP ([MEDICATION NAME])D([MEDICATION NAME])50, 71-200= 0 UNITS, 201-250= 3 UNITS, 251-300= 5 UNITS, 301-350= 7 UNITS, 351-400= 9 UNITS, GREATER THAN 400= 12 UNITS AND CALL MD(physician) . on 6/13 and 6/14/16 at 5 PM, and 6/23/16 at 11 AM and 5 PM. b. .[MEDICATION NAME] 100 UNITS/ML VIAL .INJECT 24 UNITS SUBCUTANEOUSLY AT BEDTIME . on 6/14/16 at 8 PM. c. .CARVEDILOL 6.25 MG TABLET .1 TABLET BY MOUTH TWICE DAILY .on 6/19, 6/27, and 6/28/16 at 8 PM. d. .[MEDICATION NAME] 1 10 mg tab po BID . on 6/19, 6/23, 6/27 and 6/28/16 at 8 PM. e. .[MEDICATION NAME] SULF(Sulfate) EC([MEDICATION NAME] Coated) 325 MG TABLET .1 TABLET BY MOUTH THREE TIMES DAILY . on 6/19, 6/23, 6/27 and 6/28/16 at 8 PM. f. .[MEDICATION NAME] 40 MG TABLET .1 TABLET BY MOUTH TWICE DAILY . on 6/14, 6/15, 6/24, and 6/26/16 at 2 PM. g. .[MEDICATION NAME] 15 MG TABLET .1 TABLET BY MOUTH AT BEDTIME . on 6/19, 6/23, 6/27 and 6/28/16 at 8 PM. h. .POTASSIUM CL ER(Extended Release) 10 MEQ CAPSULE .1 CAPSULE BY MOUTH DAILY . on 6/16, 6/19, 6/23, 6/27, and 6/28/16 at 8 PM. i. .[MEDICATION NAME] 40 MG TABLET .1 TABLET BY MOUTH AT BEDTIME . on 6/16, 6/19, 6/23, 6/27, and 6/28/16 at 8 PM. j. .STOOL SOFTENER 100 MG SOFTGEL .1 SOFTGEL BY MOUTH TWICE DAILY . on 6/16, 6/19, 6/23, 6/27 and 6/28/16 at 8 PM. k. [MEDICATION NAME]-TMP(Trimeethoprim) DS TABLET .1 TABLET BY MOUTH TWICE DAILY . on 6/19, 6/23, 6/27 and 6/28/16 at 8 PM. l. .ZINC SULFATE 220 MG CAPSULE . 1 CAPSULE BY MOUTH DAILY . on 6/19, 6/23, 6/27 and 6/28/16 at 8 PM. m. .[MEDICATION NAME] 15 mg 1 po qd(every day) . on 6/19, 6/22, 6/23, 6/27 and 6/28/16 at 8 PM. n. .[MEDICATION NAME] 10/325 mg 1 po QID . on 6/4/16 at 12 PM and 6 PM, on 6/10, 6/20, 6/24, 6/28 and 6/29/16 at 12 AM and 6 AM. o. .[MEDICATION NAME] 600 mg 1 po QID . on 6/8/16 at 12 PM and 6 PM, on 6/10, 6/20, 6/28, and 6/29/16 at 12 AM and 6 AM. The MAR indicated [REDACTED] a. .[MEDICATION NAME] 600 MG TABLET .1 TABLET BY MOUTH four TIMES DAILY . on 7/21/16 at 6 PM. b. .[MEDICATION NAME] 15 mg TABLET .1 TABLET BY MOUTH DAILY on 7/26/16 at 8 PM. In an interview in the Family Conference room on 8/2/16 at 3:20 PM the Director of Nursing (DON) was asked about about the missing documentation for each medication not documented as administered. The DON confirmed medications should be signed out on the MAR indicated [REDACTED] 3. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MAR indicated [REDACTED] a. .[MEDICATION NAME]-[MEDICATION NAME] 5-325 .1 TABLET BY MOUTH EVERY 6 HOURS . on 5/5/16 at 12 PM and 6 PM. b. .[MEDICATION NAME] 25 MG TAB .1 TABLET BY MOUTH TWICE DAILY .on 5/2/16 at 8 PM. c. .[MEDICATION NAME] 100 UNITS/ML .INJECT 16 UNITS SUBCUTANEOUSLY DAILY BEFORE BREAKFAST . on 5/3/16 at 7 AM. d. .ACCU-CHEK BEFORE MEALS AND AT BEDTIME WITH [MEDICATION NAME] INSULIN SUBCUTANEOUSLY PER SLIDING SCALE: IF BLOOD SUGAR IS LESS THAN 70 GIVE OJ OR ONE AMP OF D50; 71-200= 0 UNITS; 201-250= 3 UNITS; 251-300= 5 UNITS; 301-400= 9 UNITS; BLOOD SUGAR GREATER THAN 400= 12 UNITS AND CALL MD .on 5/2 and 5/5/16 at 11AM and 5 PM, and 5/5/16 at 9 PM. e. .[MEDICATION NAME] 100 mg 1 po daily . on 5/26/16 at 8 PM. f. .[MEDICATION NAME] 20 mg 1 po BID . on 5/26/16 at 8 PM. g. .[MEDICATION NAME] 100 unit/per ml per Sliding Scale .on 5/26/16 at 9 PM, and 5/29/16 at 11 AM and 5 PM. h. .[MEDICATION NAME] 75 mg 1 po q(every) daily . on 5/26/16 at 8 PM. i. .[MEDICATION NAME] 25 mg one po BID .on 5/15/16 at 8 AM. The MAR indicated [REDACTED] a. [MEDICATION NAME] 100 mg 1 po daily . on 6/23/16, 6/27, and 6/28/16 at 8 PM. b. .[MEDICATION NAME] 800 mg 1 po TID 1 hr(hour) before meals . on 6/13/16 at 10 AM and 4 PM, and 6/14/16 through 6/29/16 at 7 AM, 10 AM and 4 PM. c. .[MEDICATION NAME] 20 mg 1 po BID . on 6/23/16 at 8 PM, 6/26 at 8 AM, 6/27 and 6/28 at 8 PM and 6/29/16 at 8 AM. d. .[MEDICATION NAME] 100 mg 1 po q day . on 6/26/16, 6/29/16 and 6/30/16 at 8 AM. e. .Acorbic Acid 500 mg po q day . on 6/26, 6/29 and 6/30/16 at 8 AM. f. .ASA 81 mg 1 po q day . on 6/26/16, 6/29 and 6/30/16 at 8 AM. g. .Atorvastatin 80 mg 1 po q day . on 6/23/16, 6/27, and 6/28/16 at 8 PM. h. .[MEDICATION NAME] 30 mg 1 TAB PO WITH SUPPER . on 6/19, 6/26, and 6/29/16 at 5 PM. i. [MEDICATION NAME] 40 mg 1 po q am . on 6/23, 6/26 and 6/29/16 at 7 AM. j. .[MEDICATION NAME] 1 po BID . on 6/26 and 6/29/16 at 8 AM and on 6/23, 6/27, and 6/28/16 at 8 PM. k. .[MEDICATION NAME] 75 mg 1 po q day . on 6/23, 6/27 and 6/28/16 at 8 PM. l. .[MEDICATION NAME] 120mg/24 .1 cap daily . on 6/26/16 at 8 AM. m. .[MEDICATION NAME] 100 mg 1 po TID . on 6/23/16 at 8 PM, 6/26/16 at 8 AM and 2 PM, 6/27 and 6/28 at 8 PM, and 6/29 and 6/30/16 at 8 AM and 2 PM. n. .[MEDICATION NAME] 100 mg Sodium 1 po BID . on 6/9/16 and 6/23, 6/27 and 6/28/16 at 8 PM, and 6/26 and 6/29/16 at 8 AM. o. .[MEDICATION NAME][MEDICATION NAME] 25 mg 1 po 1 (symbol for hour) prior to [MEDICAL TREATMENT] . on 6/26/16 and 6/29/16 at 8 AM. p. .[MEDICATION NAME] 1 po daily . on 6/26/16, 6/29 and 6/30/16 at 8 AM. q. .[MEDICATION NAME] 400 .1 po q day . on 6/26/16 at 8 AM. r. .Calcitrol ([MEDICATION NAME]) 025 mg 1 po q day . on 6/26/16 at 8 AM. s. .[MEDICATION NAME] 100 U/ml 16 U . daily on 6/26/16 at 7 AM. t. .[MEDICATION NAME] 100 U/ml .per sliding scale ac .hs .on 6/26/16 and 6/29/16 at 7 AM, 6/23/16, 6/25, 6/26, and 6/29/16 at 11 AM, and 6/25/16, 6/26, and 6/29/16 at 5 PM. The MAR indicated [REDACTED] a. .[MEDICATION NAME] .100 MG TABLET .1 TABLET BY MOUTH DAILY . on 7/21/16, 7/25 and 7/26/16 at 8 PM. b. .[MEDICATION NAME] 30 mg (symbol for 1)po with supper . on 7/15/16, 7/16, 7/17, 7/20 and 7/21/16 at 5 PM. 4. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MAR indicated [REDACTED] a. .ASPIRIN 81 MG CHEWABLE TABLET .1 TABLET BY MOUTH DAILY .on 6/28/16 at 8 AM. b. .[MEDICATION NAME] 24 HR .240 MG CAP .1 CAPSULE BY MOUTH DAILY . on 6/28/16 at 8 AM. c. .[MEDICATION NAME] SULFATE 325 MG TABLET .1 TABLET BY MOUTH DAILY . on 6/28/16 at 8 AM. d. .VITAMIN D3 1,000 UNIT TABLET .1 TABLET BY MOUTH DAILY . on 6/28/16 at 8 AM. In an interview in the Family Conference room on 8/2/16 at 4:10 PM, the DON was asked about the missing documentation for each medication not documented as administered. The DON confirmed medications should be signed out on the MAR indicated [REDACTED]",2019-08-01
2582,AHC HARBOR VIEW,445428,1513 N 2ND STREET,MEMPHIS,TN,38107,2019-07-16,684,E,1,0,LGSZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to ensure physician orders [REDACTED].#1) sampled residents and 3 of 3 (Random Resident (RR) #1, #2 and #3) random residents reviewed for medication administration and blood sugar monitoring. The findings include: 1. Review of the facility's Medication Administration policy dated 11/2018 documented, .Medications will be administered by licensed medical or nursing personnel acting within the scope of their practice and per the Physician's Signed Order . 2. 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) assessment dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact for decision making. Medical record review of Resident #1's physician orders [REDACTED]. a. [MEDICATION NAME] Insulin 7 units subcutaneously (SQ) three times a day (tid) before meals at 7:00 AM, 11:00 AM and 5:00 PM. b. [MEDICATION NAME] (used to treat muscle spasms) 5 milligrams (mg) by mouth (po) daily (qd) at 5:00 PM. c. Tylenol Extra Strength (ES) 500 mg - 2 tablets po qd at 5:00 PM. d. [MEDICATION NAME] ([MEDICATION NAME]) 10 mg po qd at 8:00 AM. e. Accucheck for Blood Sugar (BS) monitoring tid before meals at 6:30 AM, 11:30 AM and 4:30 PM. Medical record review of the (MONTH) 2019 Medication Administration Record (MAR) and the Treatment Administration Record (TAR) revealed the following medications were not administered and a treatment not performed on 7/8/19: a. The 7:00 AM and 5:00 PM doses of [MEDICATION NAME]. b. The 5:00 PM dose of [MEDICATION NAME]. c. The 5:00 PM dose of Tylenol ES. d. The 8:00 AM dose of [MEDICATION NAME]. e. The 6:30 AM Accucheck BS monitoring was not performed. Interview with Resident #1 on 7/15/19 at 10:40 AM in the resident's room, Resident #1 was asked if there had been a day when she had not received her morning medications and blood sugar monitoring. The resident looked at her calendar and confirmed that on 7/8/19 her medications had not been administered as ordered and her BS was not done as ordered. 3. Medical record review for RR #1 revealed RR #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE] revealed a BIMS score of 6 out of 15 which indicated severe cognitive impairment. Medical record review of the physician orders [REDACTED]. a. Gavilax (stool softener) 17 grams powder dissolved in 8 ounces of liquid by PEG qd at 8:00 AM. b. [MEDICATION NAME] (used to treat HTN) 10 mg by PEG qd at 9:00 AM. c. [MEDICATION NAME] 9 mg Iron/15 milliliters (ml) liquid, give 15 ml by PEG qd at 8:00 AM. d. [MEDICATION NAME] (used to treat HTN) 40 mg by PEG qd at 8:00 AM. e. Silodosin (muscle relaxant) 8 mg by PEG qd at 8:00 AM. f. Carvedilol (used to [MEDICAL CONDITION] Heart Failure) 25 mg by PEG bid at 8:00 AM and 4:00 PM. g. Levetiracetam (used to treat [MEDICAL CONDITION]) 100 mg/ml solution, give 5 ml by PEG bid at 8:00 AM and 4:00 PM. h. [MEDICATION NAME] ( Diabetes medication) 500 mg by PEG bid at 8:00 AM and 4:00 PM. i. Accucheck for BS monitoring tid before meals at 6:30 AM, 11:30 AM and 4:30 PM. Review of the (MONTH) 2019 MAR and TAR revealed the following medications were not administered and treatment not performed on 7/8/19: a. The 8:00 AM Gavilax. b. The 9:00 AM [MEDICATION NAME]. c. The 8:00 AM [MEDICATION NAME] with Iron. d. The 8:00 AM [MEDICATION NAME]. e. The 8:00 AM Silodosin. f. The 8:00 AM Carvedilol. g. The 8:00 AM Levetiracetam. h. The 8:00 AM [MEDICATION NAME]. i. The 6:30 AM, 11:30 AM and 4:30 PM Accucheck BS monitoring. 4. Medical record review revealed RR #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE] revealed a BIMS score of 4 out of 15 which indicated severe cognitive impairment. Medical record review of the physician orders [REDACTED]. a. [MEDICATION NAME] Insulin [MEDICATION NAME] 10 units SQ before meals tid at 6:30 AM, 11:30 AM and 4:30 PM. b. Accucheck for BS monitoring bid at 6:30 AM and 8:00 PM. Medical record review of the (MONTH) 2019 MAR and TAR revealed the following medications were not administered and treatments not performed on 7/8/19: a. [MEDICATION NAME] Insulin at 6:30 AM. b. BS monitoring at 6:30 AM and 11:30 AM. 5. Medical record review revealed RR #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE] revealed a BIMS score of 7 out of 15 which indicated severe cognitive impairment for decision making. Medical record review of the physician orders [REDACTED]. Medical record review of the (MONTH) 2019 MAR and TAR revealed the Accucheck BS monitoring was not done on 7/8/19 at 6:30 AM and 11:30 AM. Interview on 7/15/19 at 12:00 PM with the Director of Nursing (DON) in the Conference Room, the DON was asked if staff was available to administer resident medications and treatments on 7/8/19. The DON stated the Licensed Practical Nurse (LPN) scheduled for the 6:00 AM - 6:00 PM shift on 7/8/19 for the 700 hall called in and was unable to work that day. The Staffing Coordinator, who was no longer employed by the facility, failed to notify the DON that the LPN was absent that day until 10:00 AM, at which time Registered Nurse (RN) #1 assumed the duty of medication administration on the 700 hall. The Nurse Practitioner (NP) was present in the facility and was immediately notified of the failure to administer the medications or perform the treatments as ordered. RN #1 was instructed to administer the daily medications and stagger the medications and treatments that were ordered more than once daily to ensure correct administration in a 24 hour period. Telephone interview on 7/15/19 at 12:50 PM with the NP, the NP was asked if she had been made aware the medications had not been administered and the treatments had not been performed on 7/8/19 during the morning medication administration. The NP confirmed she had been notified. The NP also revealed there had been no negative outcomes for the residents. Interview on 7/15/19 at 2:15 PM with RN#1 in the Conference Room, RN #1 was asked if she had administered medications and treatments as ordered on [DATE]. RN #1 was unable to determine if the medications documented as not given and the treatment documented as not done were actually administered or done as ordered. RN #1 revealed she had worked at the facility 3 weeks and had been hired as a skilled documentation and admissions nurse. She stated she had not been trained on the electronic MAR/TAR system prior to 7/8/19 and had used a paper MAR/TAR to record the medications she administered and the treatments she performed. RN #1 stated she had shredded the paper document of the medications administered and the treatments done after she had completed her shift and had entered the paper documentation of the medications administered and the treatments done in the electronic MAR/TAR system. RN #1 was unable to validate what medications had been administered and what treatments had been done on 7/8/19.",2020-09-01
4066,THE KINGS DAUGHTERS AND SONS,445221,3568 APPLING ROAD,BARTLETT,TN,38133,2016-12-07,309,D,1,1,RHMQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to ensure physician's orders and care plans were followed for 1 of 11 (Resident #5) sampled residents reviewed of the 24 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #5 was admitted to the facility on [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. The care plan dated 3/23/16 documented Resident #5 was at risk for complications associated with Hyper or [DIAGNOSES REDACTED] with approaches to administer medications per physician's orders and perform accuchecks as ordered. The physician's orders dated 5/18/16 documented, .ACCUCHECK BEFORE MEALS AND HOUR SLEEP *NO SLIDING SCALE* . The EMAR (Electronic Medication Administration Record) dated (MONTH) (YEAR) did not document accuchecks were performed per physician's orders on (MONTH) 2, 4, 5, 7, 9, 11, 12, 14, 16, 18, 19, 21, 23, 25, 26, 28, or 30. The EMAR dated (MONTH) (YEAR) did not document accuchecks were performed per physician's orders on (MONTH) 2, 3, 5, 7, 9, 10, 12, 14, 16, 17, 19, 21, 23, 24, 26, 28, 30, or 31 The EMAR dated (MONTH) (YEAR) did not document accuchecks were performed per physician's orders on (MONTH) 2, 4, 6, or 7. Interview with the Director of Nursing (DON) on 12/7/16 at 4:19 PM, in the conference room, the DON was asked if the accuchecks were done according to the physician's orders. The DON stated, .It clearly says accuchecks before meals and hour of sleep daily .they (staff) are not following the physician's orders . The DON was asked if the staff was following the care plan. The DON stated, .No, and I would like to say they (blood sugars) were stable, but they are high .",2019-11-01
3743,"COLLIERVILLE NURSING AND REHABILITATION, LLC",445495,490 WEST POPLAR AVENUE,COLLIERVILLE,TN,38017,2017-03-02,323,D,1,0,4B1111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to ensure the resident's were free from accident hazards as evidenced by the facility's staff failure to follow policy for transferring residents for 1 of 3 (Resident #106) sampled residents reviewed for accident hazards of the 47 included in the stage two review. The findings included: 1. The facility's Lift policy documented, .Any resident that needs to be lifted and/or transferred MUST be lifted and/or transferred with the aid of the mechanical lifts provided and performed by two staff persons . 2. Medical record review revealed Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum (MDS) data set [DATE] revealed Resident #106 was totally dependent on staff for transfer. The LIFT EVALUATION FORM dated 11/4/16 documented, .Full Lift Transfer .Weight-bearing ability .None .Does Resident have upper body strength .No .Lift recommendations .Total body lift .Special considerations .Non-weight bearing . The NURSE AIDE'S INFORMATION SHEET documented, .Lift to chair .With 2 assist . The written statement by Certified Nursing Assistant (CNA) #2 dated 12/19/16 documented, .(named CNA #1) and I transfer (transferred) the Resident (referring to Resident #106) on the bed .lift (lifted) the resident under the arm (arms) . Interview with the Director of Nursing (DON) on 3/1/17 at 6:42 AM, in the Theater Room, the DON was asked about the incident concerning Resident #106. The DON stated, .When I did the investigation .what I think happened .2 CNAs transferred her the wrong way she was supposed to be transferred by lift .she's a lift to chair 2 assist (referring to care card) .CNA #1 transferred her alone . The DON was asked what happened to CNA #2. The DON stated, .no longer here, fired her because neither one of them looked at the care card, she also assisted with the transfer . A phone interview with Licensed Practical Nurse on (LPN) #5 on 3/1/17 at 1:15 PM, was asked about the incident concerning Resident #106. LPN #5 stated, (Named Resident) .was a person to 2 person assist .",2020-03-01
3732,ALLENBROOKE NURSING AND REHABILITATION CENTER,445485,3933 ALLENBROOKE COVE,MEMPHIS,TN,38118,2017-03-02,309,E,1,0,CJSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to follow facility policy and physician's orders for medication administration for 5 of 45 (Resident #13, 123, 141, 188 and 219) sampled residents included in the annual survey and complaint review. The findings included: 1. Review of facility's MEDICATION ADMINISTRATION-GENERAL GUIDELINES policy documented, Medications are administered as prescribed .1. medications are prepared, administered, and recorded only by licensed nursing .2. Medications are administered in accordance with written orders .3. Residents are allowed to self-administer medications when specifically authorized .in accordance with procedures for self-administration of medications .9. Only licensed or legally authorized personnel who prepare a medication may administer it .10. Medications are administered within the identified block of time .One hour before and one hour after scheduled time .11. The resident's MAR/TAR (Medication Administration Record/Treatment Administration Record) is initialed by the person administering a medication .14. If a dose of regularly scheduled medication is withheld, refused or given at other than the scheduled time .An explanatory note is entered .if several doses .withheld or refused, the physician and responsible party are notified and documentation of this notification is made in the nursing notes. For the eMAR (electronic Medication Administration Record), the dose is electronically marked as not administered with a reason as to why it was not given .18 .If the medication is discontinued, outdated, or unusable, remove the medication for proper disposal. Review of facility's PRINTED PHYSICIAN ORDERS policy documented, Physician orders, MAR's, TAR's for upcoming month will be accurately reconciled against the previous month's records .1. New Physician's Orders, MARs and TAR's will be printed, checked and corrections made necessary by licensed nurses prior to the implementation each month .The orders will reconcile thru the month end feature in software .2 .The reconciled orders MARs and TAR's will be signed by the nurse and dated when placed in the chart/books .eMAR, these records will be maintained electronically . Review of facility's ORDERING AND RECEIVING MEDICATIONS FROM PHARMACY . policy documented, .Medications are ordered and received from the pharmacy in a timely manner. The facility maintains accurate records of medications ordered and their receipt Receiving Medications . 2. A licensed nurse receives medications delivered to the facility and documents delivery on the shipping manifest. Check off each medication .sign at the bottom of the page . Review of facility's MEDICATION DESTRUCTION . policy documented, .When medications are discontinued by physician order .the medications are destroyed . 1. If a physician discontinues or changes a medication, the order is entered into the medical record . 2 .'Discontinued Medication' stickers is used or indicate 'D/C' beside the medication . 2. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's order dated 10/25/16 documented, .REPEAT UA (Urinalysis) WITH C&S (Culture and Sensitivity) FOR P/U (pick up) IN THE AM . Review of a urine culture collected 10/27/16 and reported on 10/29/16 revealed, .> (greater than) 100,000 CFU (colony forming units) / ML (milliliter} ESBL (Extended Spectrum Beta-Lactamase) Producing [DIAGNOSES REDACTED] pneumoniae . The physician's order dated 10/31/16 documented, .IMIPENEM 500 MG (milligrams) EVERY 8 HOURS TIMES 10 DAYS IV (Intravenously) .11/1/2106 2:09:00 AM . Review of the Medication Administration Record (MAR) for the month of (MONTH) (YEAR) revealed, Resident #13 did not receive the Imipenem 500 mg until 11/3/16 at 10:00 PM. Interview with the Director of Nursing (DON) on 1/18/16 at 10:30 AM, in the admissions office, the DON was asked what date the Imipenem IV should have been administered. The DON stated, According to this order should have started on antibiotics on (MONTH) 1st. Telephone interview with Pharmacist #3 on 1/18/16 at 12:50 PM, in the conference room, Pharmacist #3 was asked what the time the order for Imipenem 500 mg IV was received. Pharmacist #3 stated, We did not receive the order until 11/2/16 at 17:50. It was delivered on 11/2/16 at 11:31 PM, and was signed by (Named Nurse #7). 3. Medical record review revealed Resident #123 was admitted to facility 10/2/13 with [DIAGNOSES REDACTED]. Review of Physician's Telephone Orders for Resident #123 dated 9/29/16 documented .discontinue [MEDICATION NAME] 250 mg, start Methazoleamide 25 mg PO (by mouth) tid (three times a day) . Review of the Medication Administration Record (MAR) for Resident #123 for 9/30/16 through 10/26/16 revealed Methazoleamide 25 mg PO tid was entered on the handwritten MAR and signed as given. Review of the MARs dated 10/27/16 through 1/29/17 documented [MEDICATION NAME] 250 mg at bedtime as given when the resident didn't refuse the medication. Review of the physician orders for (MONTH) (YEAR) through (MONTH) (YEAR) revealed there were no physician orders to restart the [MEDICATION NAME] 250 mg. Review of the pharmacy CONSOLIDATED DELIVERY SHEETS on 1/31/17 on west hall for (MONTH) (YEAR) confirmed neither medication had been delivered to the facility through 1/30/17. Interview with LPN #7 on 1/31/17 at 4:15 PM, on the west hall, LPN #7 was asked to review Resident #123's MAR with the surveyor. LPN #7 was asked if she had been giving Resident #123 the [MEDICATION NAME] 250 mg at bedtime as documented on the MAR. LPN #7 stated, Yes. LPN #7 reviewed the order to discontinue [MEDICATION NAME] 250 mg on 9/29/16 and was asked if the medication was discontinued, how she gave it. LPN #7 stated, To be honest, I documented giving it when I saw him taking it himself or his family member gave it to him. LPN #7 was asked how she knew the family member was giving the correct medication and dosage. LPN #7 stated, I didn't. LPN #7 was provided the order to discontinue the [MEDICATION NAME] 250 mg and start Methazoleamide 25 mg tid. LPN #7 was asked if she was aware of the physician order. LPN #7 stated, No, it wasn't on the MAR. LPN #7 was asked if a resident should take his own medication if he had not been evaluated for self-administration. LPN #7 stated, No. LPN #7 documented she administered [MEDICATION NAME] 250 mg 10 times from (MONTH) (YEAR) through (MONTH) 30, (YEAR) on the following dates: 11/10/16, 12/6/16, 12/15/16, 12/20/16, 12/24/16, 12/26/16, 1/10/17, 1/11/17, 1/24/17, and 1/27/17. Telephone interview with LPN #14 on 2/1/17 at 9:48 AM, LPN #14 was asked about Resident #123's medications. LPN #14 was asked how [MEDICATION NAME] 250 mg was given by LPN #14 on 1/4/17 if it was discontinued on 9/29/16 and no other doses was sent from pharmacy since 9/24/16. LPN #14 stated, It had to be an error. Telephone interview with LPN #10 on 2/1/17 at 12:49 PM, LPN #10 was asked about Resident #123's medications. LPN #10 was asked how [MEDICATION NAME] 250 mg was given by LPN #10 on 1/5/17 if it was discontinued on 9/29/16 and no other doses was sent from pharmacy since 9/24/16. LPN #10 verified it was an error that she had signed out the administration of the [MEDICATION NAME]. Telephone interview with LPN #11 on 2/1/17 at 12:49 PM, LPN #11 was asked about Resident #123's medications. LPN #11 was asked how [MEDICATION NAME] 250 mg was given by LPN #11 on 11/2/16 and 12/3/16 if it was discontinued on 9/29/16 and no other doses was sent from pharmacy since 9/24/16. LPN #11 stated, it had to be an error, I couldn't have given it. The [MEDICATION NAME] 250 mg was documented as given 23 times from 10/27/16 through 1/30/17. The [MEDICATION NAME] 250 mg was documented as not given 53 times from 10/27/16 through 1/30/17. Interview with the DON on 1/31/17 at 4:59 PM, in the DON's office, the DON was asked if she was aware that Resident #123 was receiving a medication that was discontinued and not receiving a medication that was ordered on [DATE]. The DON stated, Not until I received the email from pharmacy this morning. The DON was asked if the staff followed physician orders if they failed to give an ordered medication, the DON stated, No. The facility failed to follow facility policy and physician's orders for medication administration. 4. Medical record review revealed Resident #141 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician's order dated 6/29/16 documented, .[MEDICATION NAME] 1 gram IVPB (intravenous piggyback) Q (every) 8 hrs Gangrene feet wounds Stop 8/4/16 . The MAR for the month of (MONTH) (YEAR) documented, .[MEDICATION NAME]-0.9 % (percent) NACL (Sodium Chloride) 1G (gram)/250 vial IVPB q (every) 12 hrs stop date 8/4/16 Dx (diagnosis) .Gangrene feet wound . was not documented as given on the [DATE]/1/16 at 9 PM. The physician's telephone order dated 7/13/16 documented, .Continue [MEDICATION NAME] 1gm IV (intravenously) Q 12 hours at 6am and 6pm stop date 8/4/16 . The physician's telephone order dated 7/26/16 documented, .Hold vanc ([MEDICATION NAME]) for 2 dose . The physician's telephone order dated 7/27/16 documented .Hold Vanc until trough 20 or less . The physician's telephone order dated 7/27/16 documented, .Restart [MEDICATION NAME] IV at 6pm . Review of the (MONTH) (YEAR) MARs revealed no documentation of [MEDICATION NAME] 1gm IV Q 12 hours on the MAR. The [MEDICATION NAME] was not documented as administered from 7/13/16 to 7/31/16. Interview with the DON on 1/18/16 at 1:40 PM, in the conference room, the DON was asked if a medication was administered would you expect it to be signed out on the MAR. The DON stated, Yes. The physician's telephone orders dated 8/2/16 documented, .Do not give Vanc until trough is back and less than 20 . The physician's telephone orders dated 8/3/16 documented, .Stat Vanc Trough .8/3/2016 at 0400 . Review of the (MONTH) (YEAR) MARS revealed .[MEDICATION NAME] 0.9% NACL @(at) 12pm . was documented as given on 8/2/16 at 11 PM, even though there was a physician's order to hold the [MEDICATION NAME]. Interview with the DON on 1/18/16 at 1:57 PM, in the conference room, the DON was asked if the [MEDICATION NAME] was on hold should the medication be documented as given. The DON stated, No, if it has a hold order. A physician's order dated 9/2/16 revealed .Mid line for IV (Intravenous) ABT (Antibiotic) TX (Treatment) . Wound infection of feet . Review of the Peripherally Inserted Central Catheter (PICC) Procedure Notes dated 9/6/16 revealed .Date/Time: 9-6-16 1750 . Review of a physician's order dated 9/6/16 revealed .[MEDICATION NAME] 1GM (gram) IV O (every) day .STAT (Immediately) . Interview with the DON on 1/18/16 at 1:40 PM, in the conference room, the DON was asked about the order for the mid line cath (catheter) ordered on [DATE], but not inserted until 9/6/16. The DON stated, Should be placed on the day of the order (9/2/16). 5. Medical record review revealed Resident #188 was admitted to the facility on [DATE] with admitting [DIAGNOSES REDACTED]. The Departmental Notes dated 10/11/6 at 11:08 PM documented, .RESIDENT NOTED WITH 3 EPISODES OF VOMITTING, DARK BROWN EMESIS, IN PAST 30 MINUTES .FNP (Family Nurse Practitioner) CALLED . The physician's Telephone Order dated 10/11/16 documented, .[MEDICATION NAME] 25MG (milligrams) IM (intramuscularly) NOW X (times) 1 .NAUSEA . Review of the MAR revealed [MEDICATION NAME] 25 mg was not documented as given as ordered. Interview with the DON on 1/18/16 at 1:40 PM, in the conference room, the DON was asked if a medication was administered would you expect it to be signed out on the MAR. The DON stated, Yes. 6. Medical record review revealed Resident #219 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The physician's Telephone Order dated 7/7/16 documented, .KAYEXELATE NOW .INDICATION .K LEVEL . Review of the MAR for the month of (MONTH) (YEAR) revealed no documentation that [NAME]exelate had been administered. Interview with the DON on 1/17/16 at 11:05 AM, in the administrative hallway, the DON was asked if she had found the information requested regarding the administration of the [MEDICATION NAME]. The DON stated, No, not on there. She shook her head No.",2020-03-01
4169,AHC HARBOR VIEW,445428,1513 N 2ND STREET,MEMPHIS,TN,38107,2016-12-22,282,G,1,0,XY5611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to implement interventions for constipation and activities of daily living (ADLs) for 6 of 7 (Resident #1, 2, 3, 4, 5 and #7 ) sampled residents. The failure to follow the care plan for constipation revealed Resident #1 suffered abdominal pain and was sent to the emergency room related to Severe Constipation resulting in actual harm to Resident #1. The findings included: 1. The facility's Care Plans policy documented .Care Planning is an essential part of healthcare providing a road map of sorts, to guide all who are involved with the patient's care .The care plan must describe the services that are to be furnished to attain and maintain the patient's highest practicable physical, mental and psychosocial wellbeing .Must address problems identified . 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The care plan dated 7/5/16 documented Resident #1 was at risk for constipation related to decreased mobility with the goal of .will not experience constipation . The interventions included to assess and document Resident #1's usual bowel movement history to include medication use, laxative use, diet, fluids, exercise, and personal remedies, and intervene with laxatives or stool softeners as ordered. The care plan dated 7/5/16 documented Resident #1 required extensive assistance with personal hygiene related to weakness and [MEDICAL CONDITION] with goals to have personal hygiene needs met daily. The Clinical Pathway (physician's standing orders) dated 7/20/16 documented, .Constipation: Check Bowel Movement record; Notify Provider of any abdominal distention. If no abdominal distention and no BM (bowel movement) in last 3 days: Milk of Magnesia (MOM) 30 cc (cubic centimeters) po (by mouth) .prn (as needed) constipation . a. The Activities of Daily living (ADL) Verification Worksheet revealed there was no documentation Resident #1 had a bowel movement on 8/19/16, 8/20/16, 8/21/16, 8/22/16, and 8/23/2016 and the facility was unable to provide documentation the bowel protocol was followed as outlined in the care plan. The ADL Verification Worksheet revealed there was no documentation Resident #1 had a bowel movement on 8/25/16, 8/26/16, 8/27/16, 8/28/16, and 8/29/2016. The facility was unable to provide documentation the bowel protocol was followed as outlined in the care plan. A Clinical Note dated 8/29/16 documented, .1200 Resident complained of abdominal pain. Resident's family called wanting her to be transported to ER (emergency room ) immediately. Nurse Practitioner called and gave verbal order to send resident to the hospital . A Physician Telephone Order dated 8/29/16 documented, .Send resident to ER for evaluation for complaints of abdominal pain . The (Named Hospital) Emergency Department Physician Documentation dated 8/29/16 documented, .Diagnosis: [REDACTED].History of Present Illness .The patient presents with abdominal pain. The course/duration of symptoms is constant. The character of symptoms is crampy. The degree at onset was moderate .The degree at present is moderate .Review of Symptoms .Gastrointestinal Symptoms: Abdominal pain, nausea, vomiting. No diarrhea .Differential Diagnosis: [REDACTED]. A (Named Long Term Care Facility (LTC) Vital Signs/Pain assessment dated [DATE] at 13:33 (1:33 PM) documented, .Pain .Yes .Pain Intensity .5 .Primary pain location .Other: ABD (abdominal) pain/buttocks pain .Primary pain character .Aching .Primary pain onset .gradual .Primary pain pattern .Constant . The (Named Hospital) History Forms dated 8/29/16 documented, .Chief complaint .pt (patient) brought in by (Named Ambulance Service) from (Named LTC facility) for c/o (complaints of) ABD pain. pt (patient) has history of ABD (abdominal) aneurysm . A (Named LTC Facility) Clinical Data Flowsheets .GASTROINTESTINAL assessment dated [DATE] at 14:15 .Stool Character .Hard .GI (gastrointestinal) symptoms .Constipation . The (Named LTC Facility) Clinical Data Flowsheets .GASTROINTESTINAL assessment dated [DATE] at 18:06 .Stool Character .Hard .GI symptoms .Constipation . The (Named Hospital) History Form dated 8/29/16 documented, .this nurse removed a very large, formed stool from patient's rectum . b. The ADL Verification Worksheet revealed there was no documentation Resident #1 received oral care on the following dates: August : 8/18/16, 8/19/16, 8/20/16, 8/23/16, 8/27/16, and 8/31/16 September: 9/2/16, 9/10/16, 9/12/16, 9/16/16, 9/17/16, 9/18/16, 9/19/16, 9/20/16, 9/21/16, 9/22/16, 9/23/16, 9/25/16, 9/27/16, and 9/28/16 October: 10/1/16, 10/3/16, 10/7/16, 10/13/16, 10/15/16, 10/16/16, 10/18/16, 10/19/16, 10/20/16, 10/21/16, 10/23/16, 10/24/16, 10/28/16, 10/29/16, and 10/30/16 November: 11/3/16, 11/4/16, 11/5/16, 11/6/16, 11/8/16, 11/9/16, 11/10/16, 11/11/16, 11/13/16, 11/15/16, 11/16/16, 11/17/16, 11/18/16, 11/19/16, 11/20/16, 11/21/16, 11/22/16, 11/24/16, 11/25/16, and 11/26/16 December: 12/3/16, 12/5/16, 12/6/16, 12/9/16, 12/10/16, 12/11/16, 12/12/16, 12/15/16,12/17/16,12/18/16, 12/19/16, and 12/20/2016 c. The ADL Verification Worksheet revealed there was no documentation Resident #1 received a bath or shower on the following dates: September: 9/16/16, 9/17/16, 9/18/16, 9/19/16, 9/20/16, 9/21/16, 9/22/16, and 9/23/16 November: 11/3/16, 11/4/16, 11/5/16, 11/6/16, 11/7/16, 11/15/16, 11/16/16, 11/17/16, 11/18/16, 11/19/16, and 11/20/16 3. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE], revealed Resident #2 was cognitively intact and required extensive assistance for personal hygiene and bathing. The quarterly MDS dated [DATE], revealed Resident #2 had moderate cognitive impairment and required extensive assistance for personal hygiene and bathing. The care plan dated 6/22/16, and updated on 9/6/16, documented, .Problems .Self-care deficit .Assistance required with .bathing, hygiene .grooming .Interventions .Bathe/shower .Frequency .3 Times Weekly Starting 06/22/2016 .Interventions .Clean mouth, brush teeth/dentures after meals and at bedtime .Frequency 4 times Daily Starting 06/22/2016 . The ADL Verification Worksheet revealed there was no documentation that baths and oral care were provided for the following dates: August: 8/27/16, 8/28/16,8/29/16, 8/30/16, and 8/31/16 September: 9/6/16, 9/7/16, 9/8/16, 9/9/16, 9/10/16, 9/11/16, 9/17/16, 9/18/16, 9/19/16, 9/20/16, 9/21/16, 9/23/16, 9/24/16, 9/25/16, 9/26/16, 9/27/16, 9/28/16, 9/29/16, and 9/30/16 October: 10/6/16, 10/7/16, 10/8/16, 10/9/16,10/11/16, 10/12/16, 10/13/16, 10/14/16, 10/15/16, 10/16/16, 10/17/16, 10/18/16, 10/19/16, 10/20/16, 10/21/16, 10/22/16, 10/23/16, 10/24/16, 10/25/16, 10/26/16,10/27/16, 10/28/16, 10/29/16, 10/30/16, and 10/31/16 November: 11/1/16,11/2/16, 11/3/16, 11/4/16, 11/6/16, 11/7/16, 11/8/16, 11/9/16, 11/10/16, 11/11/16, 11/12/16,11/13/16, 11/14/16,11/15/16, 11/16/16, 11/17,16, 11/18/16, 11/19/16, 11/20/16, 11/22/16, 11/23/16, 11/24/16, 11/25/16, 11/26/16, 11/27/16, 11/28/16, and 11/29/16 December: 12/2/16, 12/3/16, 12/4/16, 12/5/16, 12/6/16, 12/7/16, 12/8/16, 12/11/16, 12/12/16, 12/13/16, 12/14/16, 12/16/16,12/17/16, 12/18/16 and 12/19/16 4. Medical record review revealed Resident #3 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 #3 was cognitively intact, required extensive assistance for oral care and bathing, and was always incontinent of bowel. The care plan documented, .6/20/16 .and updated on 11/28/16 .Problem .Requires extensive to total assistance with personal hygiene related to .[MEDICAL CONDITION] .Interventions .set-up items for personal hygiene .will have oral hygiene .daily .is always incontinent of bowel movement .administer medications as ordered . The facility was unable to provide documentation that baths and oral care were provided for the following dates: August: 8/5/16, 8/6/16, 8/7/16, 8/8/16, 8/19/16, 8/20/16, and 8/21/16 September: 9/6/16, 9/7/16, 9/8/16, 9/9/16, 9/10/16, 9/11/16, 9/16/16, 9/17/16, 9/18/16, 9/27/16, 9/28/16, 9/29/16, and 9/30/16 October: 10/18/16, 10/19/16, 10/20/16, 10/21/16, 10/28/16, 10/29/16, 10/30/16, and 10/31/16 November: 11/6/16, 11/7/16, 11/8/16, 11/9/16, 11/10/16, 11/11/16, 11/12/16, 11/13/16, 11/14/16, 11/15/16, 11/17/16, 11/18/16, 11/19/16, 11/24/16, 11/25/16, 11/26/16, and 11/27/16 December: 12/5/16, 12/6/16, 12/7/16, 12/9/16, 12/10/16, 12/11/16, 12/12/16, 12/14/16, 12/15/16, 12/17/16, 12/18/16 and 12/19/16 The ADL Verification Worksheet revealed there was no documentation Resident #3 had a bowel movement on the following days: August: 8/2/16, 8/3/16, 8/4/16, 8/5/16, 8/6/16, and 8/7/16, 8/9/16, 8/10/16, 8/11/16, 8/12/16, and 8/13/16. The facility was unable to provide documentation the bowel protocol was followed. The ADL Verification Worksheet did not document Resident #3 had a bowel movement on the following days: 10/4/16, 10/5/16, 10/6/16, 10/7/16, 10/8/16, 10/9/16, and 10/10/16. The facility was unable to provide documentation the bowel protocol was followed. 5. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE], revealed Resident #4 was cognitively intact and required extensive assistance for personal hygiene. The annual MDS dated [DATE], revealed Resident #4 had moderate cognitive impairment, required extensive assistance for personal hygiene, and was occasionally incontinent of bowel. The care plan dated 11/29/16 documented, .11/29/2016 .Problems .Requires extensive assistance with personal hygiene related to generalized weakness .Interventions .Set-up items for personal hygiene. Allow .to complete as much of the task as possible .at risk for constipation .will have a bowel movement every three days .Intervene with laxatives or stool softeners .Monitor bowel movements . The facility failed to provide documentation that baths and oral care were provided for the following dates of 10/6/16, 10/7/16, 10/8/16, 10/9/16, 10/10/16, 10/11/16, 10/12/16, 10/13/16, 10/14/16, 10/15/16, 10/16/16, 10/17/16, 10/18/16, 10/19/16, 10/20/16, 10/21/16, 10/22/16, 10/23/16, 10/25/16, 10/26/16, and 10/27/16. The ADL Verification Worksheet revealed there was no documentation Resident #4 had a bowel movement on the following days 8/5/16, 8/6/16, 8/7/16, 8/8/16, 8/9/16, 8/10/16 and 8/12/16, 8/13/16, 8/14/16, and 8/15/16. The facility was unable to provide documentation the bowel protocol was followed. The ADL Verification Worksheet revealed there was no documentation Resident #4 had a bowel movement on the following days: 8/17/16, 8/18/16, 8/19/16, 8/20/16, 8/21/16, and 8/22/16. The facility was unable to provide documentation the bowel protocol was followed. The ADL Verification Worksheet revealed there was no documentation Resident #4 had a bowel movement on the following days: 9/5/16, 9/6/16, 9/7/16, 9/8/16, 9/9/16, 9/10/16, 9/11/16, 9/12/12, 9/13/16 and 9/20/16, 9/21/16, 9/22/16, 9/23/16, 9/24/16, 9/25/16, 9/26/16, 9/27/12, 9/28/16, and 9/29/16. The facility was unable to provide documentation the bowel protocol was followed. 6. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 5/18/16 documented Resident #5 required extensive assistance with personal hygiene with the goal to have oral and personal hygiene needs met daily. The ADL Verification Worksheet revealed there was no documentation Resident #5 had oral care on the following dates: August: 8/21/16, 8/23/16, 8/27/16, 8/28/16, 8/29/16, and 8/31/16 September: 9/1/16, 9/3/16, 9/6/16, 9/7/16, 9/9/16, 9/11/16, 9/17/16, 9/18/16, 9/19/16, 9/20/16, 9/21/16, 9/23/16, 9/24/16, 9/25/16, 9/26/16, 9/27/16, and 9/30/16 October: 10/1/16, 10/2/16, 10/7/16, 10/11/16, 10/12/16, 10/13/16, 10/18/16, 10/21/16, 10/22/16, 10/23/16, 10/24/16, 10/25/16, 10/26/16, 10/27/16, and 10/28/16 November: 11/2/16,11/3/16, 11/8/16, 11/9/16, 11/13/16, 11/14/16, 11/15/16, 11/16/16, 11/17/16, 11/18/16, 11/19/16, 11/20/16, 11/21/16, 11/22/16, 11/23/16, 11/24/16, 11/26/16, 11/28/16 and 11/29/16 December: 12/2/16, 12/3/16, 12/4/16, 12/5/16, 12/7/16, 12/14/16, 12/15/16, 12/18/16, and 12/19/16 The facility was unable to provide documentation that Resident #5 had received oral care. The ADL Verification Worksheet revealed there was no documentation Resident #5 received a bath or shower on the following dates: September: 9/17/16, 9/18/16, 9/19/16, 9/20/16, 9/21/16, 9/23/16, 9/24/16, 9/25/16, 9/26/16, and 9/27/16 October: 10/21/16, 10/22/16, 10/23/16, 10/24/16, 10/25/16, 10/27/16, and 10/28/16 November: 11/13/16, 11/14/16, 11/15/16, 11/16/16, 11/17/16, 11/18/16, 11/19/16, 11/20/16, 11/21/16, 11/22/16, 11/23/16, and 11/24/16. The facility was unable to provide documentation that Resident #5 received personal hygiene. 7. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] documented Resident #7 had severe cognitive deficits, required extensive to total assistance with ADLs including oral care and bathing, and was always incontinent of bowel and bladder. The quarterly MDS dated [DATE] documented severe cognitive impairment, required total assistance for ADLs including oral care and bathing, and was always incontinent of bowel and bladder. Resident #7 was also impaired on both sides of upper and lower extremities. The care plan dated 9/19/16 revealed Resident #7 was totally dependent on staff for toileting needs, and required extensive assistance with personal hygiene with goals to have hygiene needs meet daily. The (MONTH) (YEAR) ADL Verification Worksheet revealed there was no documentation Resident #7 received oral care on 8/2/16, 8/4/16, 8/5/16, 8/6/16, 8/7/16, 8/8/16, 8/9/16, 8/10/16, 8/11/16, 8/12/16, 8/14/16, 8/15/16, 8/17/16, 8/19/16, 8/20/16, 8/22/16, 8/24/16, 8/25/16, 8/27/16, 8/28/16, 8/29/16, 8/30/16, and 8/31/16. The (MONTH) (YEAR) ADL Verification Worksheet revealed there was no documentation Resident #7 received a bath on 8/5/16, 8/6/16, 8/7/16, 8/8/16, 8/9/16, 8/10/16, 8/17/16, 8/18/16, 8/19/16, 8/20/16, 8/27/16, 8/28/16, 8/29/16, 8/30/16, and 8/31/16. The (MONTH) (YEAR) ADL Verification Worksheet revealed there was no documentation Resident #7 received oral care on 9/1/16, 9/2/16, 9/3/16, 9/4/16, 9/5/16, 9/7/16, 9/8/16, 9/9/16, 9/18/16, 9/20/16, 9/21/16, and 9/26/16. The (MONTH) (YEAR) ADL Verification Worksheet revealed there was no documentation Resident #7 received a bath on 9/2/16, 9/3/16, 9/4/16, and 9/5/16 . The (MONTH) (YEAR) ADL Verification Worksheet revealed there was no documentation Resident #7 received oral care on 10/2/16, 10/10/16, 10/17/16, 10/18/16, 10/19/16, 10/21/16, 10/23/16, 10/24/16, 10/25/16, and 10/31/16. The (MONTH) (YEAR) ADL Verification Worksheet revealed there was no documentation Resident #7 received oral care on 11/2/16, 11/3/16, 11/4/16, 11/6/16, 11/7/16, 11/10/16, 11/15/16, 11/16/16, 11/17/16, 11/18/16, 11/19/16, 11/22/16, 11/23/16, 11/24/16, 11/25/16, 11/27/16, and 11/28/16. The ADL (MONTH) (YEAR) Verification Worksheet revealed there was no documentation Resident #7 received oral care on 12/2/16, 12/4/16, 12/5/16, 12/8/16, 12/10/16, 12/11/16, 12/14/16, 12/17/16, and 12/19/16. The facility was unable to provide documentation that Resident #7 received oral care , a bath or shower on these dates. 8. Interview with the Director of Nursing (DON) on 12/20/16 at 7:00 PM, in the conference room, the DON was asked how the Certified Nursing Assistants (CNAs) knew what they were to do for their assigned residents. The DON stated, .the kiosk lists the resident care needs, and it's updated as things change for the resident . The DON was asked what the blanks on the ADL records meant. The DON stated, The blanks mean the care was not given, or it wasn't documented that it was given. The DON was asked if the care plans document that ADL needs are to be met daily, were the care plans followed. The DON stated, No.",2019-11-01
3232,THE HIGHLANDS OF DYERSBURG HEALTH & REHAB,445497,350 EAST TICKLE STREET,DYERSBURG,TN,38024,2018-02-07,610,D,1,1,G1QP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to investigate an allegation of abuse for 1 of 5 (Resident #243) allegations of abuse reviewed. The findings included: 1. The facility's Abuse Prevention policy documented, .The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property .The CEO (Chief Executive Officer) and Director of Nursing are responsible for investigating and reporting . 2. Closed medical record review revealed Resident #243 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] revealed Resident #243 had a Brief Interview for Mental Status (BIMS) of 0, which indicated the resident was cognitively impaired. The Resident Incident Report for Resident #243 dated 9/4/17 documented, .Resident 115-1(Resident #91) discovered resident (Resident #243) had laid down in 115-1's bed. Resident 115-1 reacted in a hostile manner and attacked resident while yelling .Resident began to scream and nearby CNA (Certified Nursing Assistant) intervened and separated the two. resident sustained [REDACTED]. Resident's wounds were cleaned, treated, and bandaged . 3. Telephone interview with Licensed Practical Nurse (LPN) #1 on 1/3/18 at 2:26 PM, LPN #1 was asked if he was on duty the time of the resident to resident altercation. LPN #1 stated, Yes ma'am. LPN #1 was asked about the incident. LPN #1 stated, .early in evening, around 6:45 -7:00 PM .I was just beginning my shift .(Named Resident #243) had wandered into (Named Resident #91's) room and laid in (Resident #91's) bed .at the time (Named Resident #91) was up front wanting to smoke .(Named Resident #91) went back down to her room .(Named Resident #243) was found in (Named Resident #91's) bed .Resident #91 screamed something .(Named Certified Nursing Assistant (CNA) #6) shouted for me to come to (Named Resident #91's) room .she stated something was going on down here .when I got there the residents were already separated .(Named Resident #91) was toward the door .(Named Resident #243) was still in the room .(Named Resident #243) was crying and saying keep her away for me .I noticed a large amount of blood on her face and shoulders .we escorted (Named Resident #243) back to her room removing her from the situation .I had one aide sit with (Named Resident #243) .Another aide 1:1 with (Named Resident #91) .I ran to the front to get the treatment cart .I cleaned (Named Resident #243's) face and shoulders with wound cleanser .I discovered she had roughly a dozen injuries .I completed the TAR (Treatment Administration Record) for each of the wounds .face, right shoulder .her neck had claw marks .the injuries were superficial .It was just a lot of them .applied antibiotic ointment and opsite dressing .I called the son to inform him of the incident .he was concerned whether she needed to go the hospital .I told him the wounds were superficial .that I treated the wounds on site .I notified the doctor . LPN#1 was asked if he had reported the incident. LPN #1 stated, I reported it to the administrator the next morning. Interview with the Director of Nursing (DON) on 2/7/18 at 7:22 PM, in the admission office, the DON was asked if it she completed an investigation of the incident. The DON stated, No ma'am. The DON was asked if it was acceptable to not investigate a resident to resident altercation with injuries. The DON stated, No .the old Administrator told me it was not required .for me not to worry about it .that he would handle it .",2020-09-01
3603,REELFOOT MANOR HEALTH AND REHAB,445285,1034 REELFOOT DRIVE,TIPTONVILLE,TN,38079,2017-04-20,157,D,1,0,VW4711,"**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 physician after a change of condition for 2 of 16 (Resident #21 and 42) sampled residents of the 37 residents included in the stage 2 review. The findings included: 1. The facility's Charting and Documentation policy documented, All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record .Documentation of procedures and treatment shall include .Notification of family, physician . 2. Medical record review revealed Resident #21 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment, was at risk for developing pressure ulcers, but had no pressure ulcers at the time of the assessment. The WEEKLY WOUND TRACKING WORKSHEET dated 4/5/17 documented, L[NAME]ATION OF WOUND .R (right) heel .ONSET DATE 3/30/17 .WORST TISSUE .purple blister area .4.5 x 4.2 (not open) . The Weekly Skin Condition Report . dated 4/5/16 documented, .date first observed 3/30/17 .Right Heel .Suspected Deep Tissue Injury (SDTI) . The physician's phone order dated 4/19/17 documented, .sure prep to left heel every shift for wound care . The facility did not provide any documentation that the physician or the responsible party was notified of Resident #21's SDTI until 4/19/17. Interview with the Registered Nurse (RN) #1 on 4/19/17 at 3:08 PM, at the 100 Hall Nurse's Station, RN #1 was asked if there was any documentation that the physician and family had been notified of the SDTI. RN #1 looked in the computer and stated, Usually I document it .I dropped the bomb .very frustrated .nothing (documented) that they were notified . Interview with the Director of Nursing (DON) on 4/20/2017 at 1:18 PM, in the Conference Room, the DON was asked was it acceptable for the physician and family not to be notified of Resident's 21's SDTI. The DON stated, No .",2020-08-01
1028,HUNTINGDON HEALTH & REHABILITATION CENTER,445210,635 HIGH STREET,HUNTINGDON,TN,38344,2017-05-04,323,D,1,0,3EWH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to perform a timely and thorough investigation and failed to perform neuro checks for 1 of 3 (Resident #121) sampled residents reviewed for skin conditions and accidents. The findings included: 1. The facility's Accidents and Incidents - Investigating and Reporting policy documented, .Regardless of how minor an accident or incident may be, including injuries of an unknown source, it will be reported to the department supervisor .A report of incident/Accident will be completed .The following data .must be included .The name(s) of witnesses and their account of the accident or incident . Medical record review revealed Resident #121 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note dated 3/15/17 documented, .Pin size scab noted (right) posterior hand with quarter size bruise . Review of accident investigations for Resident #121 revealed that there was no investigation of the finding of the scab and the bruise on Resident #121's right hand. Interview with the Director of Nursing (DON) on 5/3/17 at 11:35 AM, in the conference room, the DON was asked if an investigation had been completed for the finding of the scab and bruise on Resident #121's right hand. The DON stated, I do not have an investigation for 3/15 for the scab on her hand . Review of a facility investigation report dated 3/25/17 documented, .Resident was sitting (at) table lying on table noted to have bruised area to forehead on (right) side . Interview with Licensed Practical Nurse (LPN) #4 on 5/2/17 at 6:24 PM, in the memory unit, LPN #4 was asked about Resident #121's accident that resulted in a hematoma to her forehead. LPN #4 stated, On 3/25/17 around 8:00 she had been to the shower. (Named Certified Nursing Assistant (CNA) #1), she brought her to the dining room and she showed me a reddened area to her forehead .she had been sitting at the table in the dining room before she went to the shower and (Named CNA #1) noticed it in the shower. She had been sitting at the table with her head down on the table without a pillow or arm support .her face against the table. Nobody saw her hit her head against the table but that's the only thing that we could figure out it was right where she had been laying or if she had bumped her head on the table, that's the spot it would have left She's very confused. She'll be sitting there and suddenly plop her head down. (Named CNA #1) came to get me. Interview with CNA #1 on 5/3/17 at 10:06 AM, in the conference room, CNA #1 was asked about the day she found the bruise on Resident #121's forehead. CNA #1 stated, I came in around 8:15 am, she had her head on the table in the dining room and the other aides were picking up the rest of the breakfast trays. I helped finishing pick up trays. I went back, got her and took her to the central bath in her wheel chair and assisted her to the toilet. While she was sitting on the toilet, I washed her up and changed her clothes and got her dressed for the day. I was doing her hair and I slid my hand across her forehead to pull her hair back so I could wet it, and she cringed, and that's when I noticed the bruise. You could see the bump on the right side of her forehead that was a bluish white color. I finished getting her dressed, put her in her wheelchair and rolled her out of the bathroom. I was standing in the hallway with her in the wheel chair and (Named LPN #4) was at her med cart and I asked her had she seen or did she know (Resident #121) had a bump on her head. And she assessed her . CNA #1 was asked if the facility had her write a statement of the incident. CNA #1 stated, No. Interview with the DON on 5/3/17 at 11:50 AM, the DON was asked if CNA #1 was asked to write a statement for the investigation about Resident #121's forehead bruise. The DON stated, She's the one that got the nurse when she saw it? Yes, she should have. I don't have the statement here so, no. 2. The facility's Neurological Assessment policy documented, .Neurological assessments are indicated .Following .other accident/injury involving head trauma . Review of the medical record revealed there were no neuro checks performed after the bruise was discovered on Resident #121's forehead. Interview with the DON on 5/3/17 at 11:52 AM, in the conference room, the DON was asked if neuro checks were performed for Resident #121 on 3/25/17 when the bruise was found on her forehead. The DON stated, I cannot locate the neuro checks on 3/25.",2020-09-01
2107,LAUDERDALE COMMUNITY LIVING CENTER,445354,215 LACKEY LANE,RIPLEY,TN,38063,2017-05-05,223,G,1,0,QMFO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to protect 1 of 13 (Resident #55) residents of the 34 residents included in the stage 2 review for abuse from verbal abuse and fear of retaliation. Resident #55 suffered verbal abuse resulting in psychological harm as evidenced by her tearful, emotional response during interview. The findings included: Review of the facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Policy documented, .The resident has the right to be free from abuse .Residents must not be subjected to abuse by anyone .facility staff .Psychosocial harm- Include but are not limited to extreme embarrassment, ongoing humiliation . Medical record review revealed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set ((MDS) dated [DATE] and a Quarterly Review assessment dated [DATE] revealed Resident #55 had a Brief Interview of Mental Status (BIMS) of 15 indicating she was cognitively stable for daily decision making and was not on a physician prescribed weight loss regimen. A PSYCHIATRIC PROGRESS NOTE dated 9/12/16 revealed Resident #55 had a depressed and flat mood/affect and indicated no change in response to treatment. [MEDICATION NAME] (anti-depressant) was increased to 20 milligram (mg) every (q) day. A PSYCHIATRIC PROGRESS NOTE dated 10/26/16 revealed Resident #55's mood/affect was within normal limits (WNL) and was improving in response to treatment. [MEDICATION NAME] was continued. A PSYCHIATRIC PROGRESS NOTE dated 4/3/17 revealed mood/affect WNL, stable response to treatment, and no change in medications. A Social Services note dated 11/3/16 documented, .Resident refuses to get up some days and states she just doesn't feel like it . A physician's progress note dated 1/18/17 documented, Psychiatric: Insight: good judgement .Memory: recent memory normal and remote memory normal . A physician's progress note dated 3/1/17 documented, .PSYCH (psychology) sleep disturb (disturbance) . Review of the monthly Medication Administration Records (MARS) from admission date of [DATE] through 5/4/17 revealed Resident #55 received [MEDICATION NAME] as ordered. Interview with Resident #55 on 4/24/17 at 3:41 PM during Stage 1 resident interviews, Resident #55 was asked if she was treated with respect and dignity. Resident #55 started to say something, hesitated and stated, It would make things worse, if I made them mad. During this interview Resident #55 would not answer the questions related to staff treatment or tell the surveyor any specific concerns she had related to being intimidated, mentally or verbally mistreated. The survey team re-entered the facility on 5/3/17 to continue the investigation and it was discovered the Director of Nursing, the Social Worker, Certified Nursing Assistant #1, #2 and #7 were suspended pending allegations of abuse and intimidation. The Administrator had also resigned. Interview with Resident #55 on 5/3/17 at 4:42 PM in the resident's room, the resident was asked if she was ever mistreated or had someone speak harshly to her while she was in the facility. The resident stated, .I've been treated okay since y'all (you all) came .it's just the ones before y'all came they used to hurt my feelings and make me cry and say hateful things to me . The resident was asked who said those things to her. The resident stated, DON (Director of Nursing). The resident was asked what the DON said. The resident stated, One time .She said is there any way you can call your boyfriend, I need to talk to him. I called and said the DON wants to speak to you. She said, Hi, Mr. (Named Boyfriend), I just want to make sure we're on the same page, (Named Resident) she's getting too big and you need to stop bringing her pizza .I don't hate this place just the people that were here. The resident was asked if anyone else had talked to her like that. The resident stated, Uh-uh (No) .she was the only one, ma'am. The resident was asked if there is anyone who is still here that is mistreating her. The resident stated, No ma'am, I've not seen those people since y'all been here so whatever y'all are doing, you're doing a good job . The resident became visibly upset, tearful, and agitated during the interview when she was relating the telephone conversation the DON had with her boyfriend and apologized for becoming so upset. Interview with Confidential Interviewee (CI) #5 on 5/4/17 at 9:04 AM, in the hallway outside Resident #55's room, CI #5 was asked if Resident #55 had ever expressed to her that staff had hurt her feelings and made her cry. CI #5 stated, Sometimes when I go in the room .she's crying and I ask her to talk to me. She says .her feelings have been hurt and I say tell me Ms. (Named Resident) but she won't . CI #5 was asked if she had reported that to anyone. CI#5 summarized that she had heard it discussed in shift report and when staff went in the room they could tell the resident was upset. CI #5 stated, .Since I've been working with her I've seen her crying several times . Interview with CI #16 on 5/4/17 at 2:59 PM, in the DON office, CI #16 was asked what were her expectations when a resident is frequently tearful. CI #16 stated, I would expect that they would address and identify what is causing her to be tearful, notify Social Services, notify the doctor, but first and foremost find out why they're tearful. There was no documentation the facility provided appropriate care and services to prevent verbal abuse and derogatory remarks made to Resident #55. The failure to prevent verbal abuse and fear of retaliation, resulted in Psychological Harm to Resident #55 when she was belittled and treated rudely by the DON.",2020-09-01
677,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-03-10,842,D,1,0,TO3W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to provide and maintain accurate, complete medical records for 2 of 12 (Resident # 5 and 7) sampled residents. The findings include: 1. The facility's Charting and Documentation policy documented, .All observations, medications administered, services provided, etc., must be documented in the resident's clinical records .All incidents, accidents, or changes in the resident's condition must be recorded . The facility's Change in a Resident's Condition or Status policy documented, .The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . The facility's Clinical Pathways (standing orders) protocol documented, .[MEDICAL CONDITION]: (Chest pain) Begin oxygen 2L (liters) by nasal cannula and notify Provider .Dyspnea: Oxygen 2L by nasal cannula .Heartburn: [MEDICATION NAME] suspension (or house equivalent) 30 cc (cubic centimeters) po (by mouth) . 2. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed there was no documentation of an assessment of Resident #5 on 2/16/19 or 2/17/19 and no documentation of the administration of oxygen or TUMS to the resident. During an interview with Respiratory Therapist (RT) #1 on 2/27/19 at 3:25 PM in the respiratory therapy office, RT #1 stated, .Monday he was wheezing .Nurse put O2 (oxygen) on him because he was winded .the RT on Sunday night had put O2 on him as precaution . During an interview with RT #2 on 2/28/19 at 11:38 AM in the conference room, RT #2 stated, .went and got a concentrator for O2 . RT #2 was asked why the O2 was administered to the resident. She stated, Because I'm an RT and he rubbed his stomach without description. It's just what I do .I didn't document it. I should have put it in a general note . RT #2 was asked if the resident had chest pain or shortness of breath. RT #2 stated, No. During an interview with Licensed Practical Nurse (LPN) #2 on 2/28/19 at 2:18 PM at the 200 Hall nurses' station, LPN #2 stated, .He was in his room, rubbing his stomach, wanted something for stomach. I gave him TUMS . LPN #2 was asked if she documented the administration of TUMS and she stated, I wrote it on a piece of paper. I didn't document in the computer. I didn't document in his record. LPN #2 was asked if there was a physician's orders [REDACTED]. LPN #2 stated, I thought it was on standing orders. I know [MEDICATION NAME] is on it . During an interview with the Director of Nursing (DON) on 3/5/19 at 3:10 PM in the conference room, the DON was asked how staff would know the oxygen and TUMS were administered if there was no documentation. The DON stated, We don't. Should be documented. The DON was asked what the expectation was for documentation of assessments and changes in a resident's condition. The DON stated, Chart skilled assessments daily and chart every shift at times . During a telephone interview with the Physician on 3/1/19 at 7:33 AM, the Physician was asked if TUMS was on the facility's standing orders. The Physician stated, There are protocols for them to give [MEDICATION NAME] . The Physician was asked if [MEDICATION NAME] and TUMS were the same drugs. The Physician stated, No. They are different drugs. 3. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a [MEDICAL CONDITION] Note dated 2/26/19 documented, .Resident complain of SOB (shortness of breath) and requested to be on a little o2 (oxygen). RT checked his o2 sats (oxygen saturation) they were 92%, HR (heart rate) 88, rr (respiratory rate) 20. RT placed resident on 2L (liter) bnc (by nasal cannula). SPo2 (peripheral capillary oxygen saturation) came up to 98%, HR 38, rr 20. No distress noted . During a telephone interview with RT #3 on 3/5/19 at 4:22 PM, RT #3 stated, I charted that wrong. That's an error. Heart Rate was 83 . During an interview with the DON on 3/5/19 at 11:10 AM in the Administrator's office, the DON was asked if the heart rate of 38 was correct as documented. The DON looked at the [MEDICAL CONDITION] note and stated, That can't be correct .",2020-09-01
829,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2017-06-04,319,E,1,1,35VZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to provide behavioral care and services for 2 of 2 (Resident #205 and 232) residents with behaviors reviewed in the stage 2 review. The findings included: 1. The Behavior Assessment and Monitoring policy documented, .Problematic behavior will be identified and managed appropriately . 2. Medical record review revealed Resident #205 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed that Resident #205 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition, had delusions, physical behavioral symptoms, and had wandering behaviors that placed Resident #205 at risk of getting to a dangerous place. A PHYSICIAN'S TELEPHONE ORDERS dated 2/27/17 documented, .consult psych (psychiatric) services NP (nurse practitioner) . Review of Resident #205's medical record revealed no documentation of a psychiatric nurse practitioner evaluation. Interview with the Administrator on 6/3/17 at 7:56 PM, in the conference room, the Administrator was asked if Resident #205 had been seen by the psychiatric nurse practitioner. The Administrator stated, No. The Administrator was asked if there was a reason Resident #205 was not evaluated as ordered. The Administrator stated, He should have been . 3. Medical record review revealed Resident #232 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of NURSE'S NOTES dated 2/20/17 at 4:00 PM, revealed that Resident #232 was being admitted to the facility at that time and that the wife told the nurse during the nursing admission assessment that Resident #232 became very agitated and anxious when he did not get his nerve pill and pain pill. A Psychiatric Progress Note dated 2/24/17 documented, .Good medication compliance is noted. He needs assistance or cues for self care tasks. He is socializing less with family and friends. More angry outbursts are occurring. Impulsive behaviors continue to be displayed. He needs to be coaxed to eat and drink .is sometimes confused . The care plan dated 3/7/17 documented, PROBLEM .PERSISTENT MOOD STATE AND BEHAVIORAL ISSUES R/T (related to) DX (diagnoses) OF [MEDICAL CONDITION], DEPRESSION, ANXIETY, AND [MEDICAL CONDITION] .OPIATE AND BENZODIAZEPINE DEPENDENCE AND ABUSE .INTERVENTIONS .Family/caregiver to stay (with) resident during HS (hour of sleep), family agreed to provide 1:1 (one to one) (care) . The care plan signature page did not include a family/caregiver signature. A NURSE'S NOTES dated 3/7/15 at 12:15 AM, documented, .This nurse contacted wife to see if she could come to facility and sit with resident to assist in behaviors .contacted (former) DON (Director of Nursing) . A NURSE'S NOTES dated 3/7/17 at 12:30 AM, documented, .Residents son called this nurse back and stated wife could not come sit (with) resident because 'he hates her and it will only make it worse' . A NURSE'S NOTES dated 3/7/17 at 12:40 AM, documented, .Contacted (former) DON to make her aware that resident's son stated wife could not come up here. Spoke at length (with) (former) DON and agreed to contact son again to see if anyone in the family could come to facility to sit with resident . A NURSE'S NOTES dated 3/7/17 at 12:45 AM documented, .Called son back .asked if anyone could come sit with resident . A NURSE'S NOTES dated 3/7/17 at 2:00 AM, documented, .Resident's son arrived and resident appeared to be resting in bed with his eyes closed. Son waited approximately 10 minutes then went ahead and left . Review of NURSE'S NOTES revealed the following: 3/8/17 2:00 AM Resident sat up in bed and yelled out, pain pill! pain pill! pain pill! There was no documentation of one on one care. 3/11/17 7:30 PM Resident was found on the floor after the nurse witnessed him placing himself there. He told the nurse if she would give him his medicine he wouldn't put himself on the floor. There was a family member with Resident #232. 3/12/17 6:10 AM The nurse witnessed the resident stand up and put himself on the floor and he told her that he wouldn't throw himself in the floor if he got his pills. There was no documentation of one on one care. 3/12/17 7:00 PM The resident was continuously yelling out for his pills and the nurse told him his pills were due at 8 PM and that she always brings him his medication at 8 PM. The resident continued to yell out until he received his medication at 8 PM and he rested the rest of the shift. There was no documentation of one on one care. 3/14/17 2:05 AM Resident #232 was intermittently yelling out, yelling out for medications. The nurse told him no medications were due. There was no documentation of one on one care. 3/14/17 3:00 AM The resident threw urine on one of his roommates and told another roommate that if he didn't shut up he was going to throw his urinal at him. The former DON was contacted by the nurse and the former DON advised the nurse to send the resident to the hospital because he was a danger to himself and others. The resident refused to go to the hospital. Mobile Crisis was called. They came to the facility. There was no documentation of one on one care. 3/14/17 6:00 AM Mobile Crisis representative in facility to evaluate resident. 3/14/17 1:00 PM The daughter was told by the nurse that Resident #232 would need one on one care from family during the night, 9 PM to 7 AM. 3/15/17 6:40 PM to 9:30 PM Resident #232 was yelling out, putting himself on the floor. At 9:30 PM, the family arrived to stay with him. 3/16/17 7:45 PM The resident told his daughter he wanted to kill his wife. A one on one sitter was provided by the facility. 3/17/17 7:25 PM The resident's wife came to the nurse and told her she was not going to stay the night with him per the agreement due to him attempting to hit her and cursing and yelling at her. The nurse held his 8:00 PM medications because she was concerned for her own safety. She did not administer the medications until 10:30 PM. He did have a nurse sitting one on one with him. 3/17/17 9:50 PM Resident poured coke on himself, yelling out. There was no documentation of one on one care. 3/17/17 11:20 PM The resident's daughter told the nurse that the family was not going to sit with the resident as agreed. The family talked with the former DON and the Mobile Crisis representative and left the building. 3/17/17 11:50 PM to 1:45 AM The resident yelled, dumped contents of his urinal out in the drawer and on the floor. There was no documentation of one on one care. 3/20/17 9:10 PM Resident #232 was yelling for help. Asking for pain pill. There was no documentation of one on one care. 4/11/17 1:00 AM Resident #232 was yelling out. There was no documentation of one on one care. Phone interview with LPN #5 on 6/1/17 at 5:55 PM, LPN #5 was asked if it was a normal facility practice to get the family to come and sit one on one with residents when they have behaviors. LPN #5 stated, If they can, yes. LPN #5 was asked if Resident #232's family family appreciated having to do that. LPN #5 stated, No, absolutely not. The wife was so upset that the family was asked to stay with him. They were upset with that, they didn't want to do it. LPN #5 was asked about how the family interacted with Resident #232. LPN #5 stated it was normal family dynamics for the family to yell, curse and make threats to one another. LPN #5 was asked if the facility ever had a staff member sit with him one on one. LPN #5 stated, No. After that was put in effect his wife came to me in tears and said she couldn't stay, he just cussed her and tried to hit her. The (former) DON told them they had to stay, it was in their contract or their agreement. Interview with the Administrator on 6/01/17 at 7:15 PM, in the conference room, the Administrator was asked if she was aware that Resident #232 had some violent behaviors. The Administrator stated, I knew he threw the urinal at the nurse. The Administrator was asked about the care plan intervention that the family provide one on one care for the resident from 9 PM to 7 AM. The Administrator stated, Because of his behaviors, we asked the family to assist. Sometimes the wife would yell back at him, we encouraged her when it would escalate to just leave. He seemed better when the family was there. The Administrator was asked if she was aware that the staff had reported that his behaviors increased when his family was here. The Administrator stated, His behaviors did increase with the wife .We wanted them to help us care for him, I think it's reasonable, we needed some help to provide care for him .I have 170 other patients I have to worry about. The Administrator was asked if it was safe to leave Resident #232 in his room with 2 roommates. The Administrator stated, There's a potential .for everything .he could have woken up and thrown another urinal. The Administrator was asked what kind of training the staff received about behavioral interventions. The Administrator stated, .we do general training on abuse, resident on resident, as well as staff to resident, dementia care tips, how to approach the situation, how to handle outbursts, how to step away, that sort of thing. That's the orientation I do. Interview with LPN #6 on 6/02/17 at 9:51 AM, at Station 1 Nurses' Station, LPN #6 was asked if Resident #232 ever exhibited behavior problems when he provided his care. LPN #6 stated, (Resident #232) .had something against women, if he had behaviors they were directed toward women. LPN #6 stated, He didn't have behaviors when I was here. He was a whole lot different behavior wise. He had a different respect for me. LPN #6 was asked if he was the only male nurse on staff. LPN #6 stated, No. LPN #6 then named 3 other male nurses on staff. Interview with the Administrator on 6/03/17 at 10:22 AM, in the conference room, the Administrator was asked if the secure unit in the facility was a behavior unit. She stated, It's secure and behavior, all of the above. The Administrator was asked if there was a reason the facility didn't utilize the behavior unit as an intervention for Resident #232. The Administrator stated, I don't know the answer to that. I didn't think of that at the time. The Administrator was asked if that would have been an option for Resident #232. The Administrator stated, To put him in the behavior unit? I don't see why it wouldn't be. The Administrator was asked if she was aware that the family was not doing the one on one for Resident #232. The Administrator stated, I met with the daughters and they said they were not going to do it. The Administrator was asked what was put in place when the family refused to do the one on one. The Administrator stated, He was by the nurses' station, so he had much more supervision; the room was very accessible. Interview with the Administrator in the conference room on 6/03/17 at 7:55 PM, the Administrator was asked if placing a resident closer to the nurses' station was considered one on one supervision. The Administrator stated, No.",2020-09-01
1910,"THE WATERS OF CHEATHAM, LLC",445318,2501 RIVER ROAD,ASHLAND CITY,TN,37015,2019-07-31,609,D,1,0,0PK511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to report allegations of abuse and neglect within 2 hours for 2 of 3 (Resident #1 and #2) sampled residents reviewed. Review of the facility's Abuse Prevention Policy documented, .When an alleged or suspected case of abuse or neglect is reported to the Administrator, the Administrator, or person in charge of the facility, will notify the following persons or agencies of such incident immediately .State Licensing and Certification Agency . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment revealed Resident #1 scored a 5, which indicated severe cognitive impairment on the Brief Interview of Mental Status (BIMS). Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment revealed Resident #2 scored a 4, which indicated severe cognitive impairment on the BIMS. Review of the Event Report dated 7/9/19 documented, .Administrator was notified of allegation of abuse on 7/9/19 at approximately 5:50 PM by (Named Person) LPN (Licensed Practical Nurse) .(Resident #1) and (Resident #2) were found in (Resident #1's) bed partially dressed and conversing . Review of the Facility Reported Incident (FRI) reported to the State Agency revealed the incident was reported to the State Agency on 7/12/19 at 9:39 PM. Interview with Certified Nursing Assistant (CNA) #1 in the Conference Room, on 7/31/19 at 1:45 PM, CNA #1 confirmed her witness statement. She stated, .I entered Ms. (Resident #1) room and saw them (Resident #1 and 2) in her bed, both of them partially dressed .I called for help and stayed with them .I immediately reported to my LPN . Interview with LPN #1 in the Conference Room on 7/31/19 at 12:57 PM, LPN #1 confirmed her witness statement. She stated, .I was called by (Named Person) (CNA #1), entered the room, and witnessed them (Resident #1 and 2) in the bed .I immediately informed the Assistant Director of Nursing of the incident . Interview with the Administrator in the Conference Room, on 7/31/19 at 5:00 PM, the Administrator confirmed the abuse allegation was reported to the State on 7/12/19. The Administrator stated, .I was notified on 7/9/19 and I wasn't clear it was reportable .I reported to the State on 7/12/19 .",2020-09-01
2641,WEAKLEY COUNTY NURSING HOME,445437,700 WEAKLEY COUNTY NURSING HOME ROAD,DRESDEN,TN,38225,2019-06-17,609,D,1,0,NRO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to report allegations of abuse related to injury of unknown origin within 2 hours for 1 of 3 (Resident #1) sampled residents. Review of the facility's Abuse, Neglect, Misappropriation of Resident Property and Exploitation Policy dated (MONTH) (YEAR) documented, .13. a. Ensure that all alleged violations involving .injuries of unknown source .are reported immediately, but not later than 2 hours after the allegation is made . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident Accident of Incident Report dated 6/9/19 at 10:30 AM documented, .CNA (Certified Nursing Assistant) discovered right shoulder was swollen the size of a softball and purplish discoloration noted to area 5 cm (centimeters) wide and 9 cm long going down along bicep Resident complained of pain all over . The Nurse's Note dated 6/9/19 at 1:46 PM documented, .Xray results received Conclusion: Impacted humeral fracture .Send to ER (emergency room ) for evaluation and treatment . The Grievance Form dated 6/10/19 documented, .(Named Spouse) stated that he believes wife was dropped and employee was afraid to report it due to injury . Interview with the Administrator in the Conference Room on 6/17/19 at 2:15 PM, the Administrator stated, .we report in 24 to 48 hours of incident .my bad .",2020-09-01
1072,GRACE HEALTHCARE OF CORDOVA,445218,955 GERMANTOWN PKWY,CORDOVA,TN,38018,2019-05-02,609,D,1,0,4NVS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to report allegations of sexual abuse and neglect within 2 hours for 2 of 6 (Resident #1 and #6) sampled residents reviewed. The findings include: Review of the facility's Abuse Prevention Policy and Procedure documented, .Immediately means as soon as possible, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse .Report to State Health Department and other regulatory agencies immediately .Administrator Guidance for Investigations .The initial report to the State Agency may be made by phone, fax, or electronic submission to meet the 2 hour reporting requirement . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #1 scored 6 on the Brief Interview of Mental Status, which indicated severely impaired cognition for decision making tasks. Review of the Resident Incident Report dated 4/22/19 at 8:35 PM documented, .IT WAS REPORTED TO CHARGE NURSE THAT RESIDENT WAS SEEN BY CNA (Certified Nursing Assistant) IN ROOM INAPPROPRIATELY TOUCHING ANOTHER RESIDENT GENITALS THAT WERE EXPOSED TO HIM . Review of the Nurse's Note dated 4/23/19 documented, .Late entry for 4/22/19 8:35pm. Cna reported resident 516b in bed propped up on right side holding resident 508a (Resident #1) penis in hand .Supervisor and DON (Director of Nursing) were immediately notified. DON immediately notified Administrator . Review of the Facility Reported Incident (FRI) reported to the State Agency revealed the incident was reported to the State Agency on 4/22/19 at 11:38 PM. Interview with Licensed Practical Nurse (LPN) #1 on 5/2/19 at 2:08 PM, revealed LPN #1 checked her cell phone to determine the time the DON was notified. LPN #1 stated, .I called and talked to (Named DON) at 8:35 (PM). Interview with the Administrator on 5/2/19 at 3:12 PM, in the Conference Room, the Administrator stated, I know its 2 hours, but that's a lot to do. I knew at 9:01 (PM). When the Administrator was asked if the allegation was reported within 2 hours, she stated, No. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Concern/Comment Report dated 4/30/19 documented .RR (Resident Representative) states that resident was found in floor when he visited .RR feels that staff was neglectful .DATE/TIME OF INITIAL CONTACT WITH CONCERNED PARTY 4/23/19 1:35PM . Interview with the Social Worker (SW) on 5/2/19 at 11:30 AM, in the Conference Room, the SW confirmed she had talked with Resident #6's son and filled out the Concern/Comment report dated 4/23/19 at 1:35 PM. When asked what time the allegation of neglect was reported, the SW looked at the fax confirmation sheet and stated, .1644 (4:44 PM) (3 hours and 9 minutes after the staff became knowledgeable of the neglect allegation) .I had to wait on the Administrator to approve what I had written and get back to me. She had to proofread it first. It was a little longer than 2 hours. Interview with the DON on 5/2/19 at 1:55 PM, in the Conference Room, the DON confirmed she was knowledgeable of the allegation of neglect by Resident #6's son at the time of the call at 1:35 PM or right after. The DON confirmed attempts were made to contact the Administrator, but were unable to reach by phone until approximately 3:43 PM.",2020-09-01
3231,THE HIGHLANDS OF DYERSBURG HEALTH & REHAB,445497,350 EAST TICKLE STREET,DYERSBURG,TN,38024,2018-02-07,609,D,1,1,G1QP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to report an allegation of abuse to the State Agency for 1 of 5 (Resident #243) allegations of abuse reviewed. The findings included: 1. The facility's Abuse Prevention policy documented, .The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property .The CEO (Chief Executive Officer) and Director of Nursing are responsible for investigating and reporting . 2. Closed medical record review revealed Resident #243 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] revealed Resident #243 had a Brief Interview for Mental Status (BIMS) of 0, which indicated the resident was cognitively impaired. The Resident Incident Report for Resident #243 dated 9/4/17 documented, .Resident 115-1(Resident #91) discovered resident (Resident #243) had laid down in 115-1's bed. Resident 115-1 reacted in a hostile manner and attacked resident while yelling .Resident began to scream and nearby CNA (Certified Nursing Assistant) intervened and separated the two. resident sustained [REDACTED]. Resident's wounds were cleaned, treated, and bandaged . 3. Telephone interview with Licensed Practical Nurse (LPN) #1 on 1/3/18 at 2:26 PM, LPN #1 was asked if he was on duty the time of the resident to resident altercation. LPN #1 stated, Yes ma'am. LPN #1 was asked about the incident. LPN #1 stated, .early in evening, around 6:45 -7:00 PM .I was just beginning my shift .(Named Resident #243) had wandered into (Named Resident #91's) room and laid in (Resident #91's) bed .at the time (Named Resident #91) was up front wanting to smoke .(Named Resident #91) went back down to her room .(Named Resident #243) was found in (Named Resident #91's) bed .Resident #91 screamed something .(Named Certified Nursing Assistant (CNA) #6) shouted for me to come to (Named Resident #91's) room .she stated something was going on down here .when I got there the residents were already separated .(Named Resident #91) was toward the door .(Named Resident #243) was still in the room .(Named Resident #243) was crying and saying keep her away for me .I noticed a large amount of blood on her face and shoulders .we escorted (Named Resident #243) back to her room removing her from the situation .I had one aide sit with (Named Resident #243) .Another aide 1:1 with (Named Resident #91) .I ran to the front to get the treatment cart .I cleaned (Named Resident #243's) face and shoulders with wound cleanser .I discovered she had roughly a dozen injuries .I completed the TAR (Treatment Administration Record) for each of the wounds .face, right shoulder .her neck had claw marks .the injuries were superficial .It was just a lot of them .applied antibiotic ointment and opsite dressing .I called the son to inform him of the incident .he was concerned whether she needed to go the hospital .I told him the wounds were superficial .that I treated the wounds on site .I notified the doctor . LPN#1 was asked if he had reported the incident. LPN #1 stated, I reported it to the administrator the next morning. Interview with the Director of Nursing (DON) on 2/7/18 at 7:22 PM, in the admission office, the DON was asked if she reported the resident to resident altercation with injuries to the State. The DON stated, No, I did not. The DON was asked if it was acceptable to not report resident to resident altercation with injuries to the state agency. The DON stated, No.",2020-09-01
3079,SOMERFIELD AT THE HERITAGE,445488,900 HERITAGE WAY,BRENTWOOD,TN,37027,2019-07-11,609,D,1,0,YIL311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to report an injury of unknown origin to the State Survey Agency within 2 hours for 1 of 4 (Resident #1) sampled residents reviewed for potential abuse. The findings include: Review of the facility's Abuse Prevention Policy documented, .Required to report to a law enforcement agency if there is a reasonable suspicion of a crime against a resident .The TN Department of Health .must be contacted within two (2) hours of forming the suspicion . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set Assessment (MDS) revealed Resident #1 scored a 3 on the Brief Interview of Mental Status (BIMS), which indicated the resident was severely impaired for decision making. Review of the Event Report dated 6/28/19 at 12:00 PM documented, .Reported to DON (Director of Nursing) by Senior Helpers Supervisor that resident had a bruise to right wrist .deep purple discoloration circular to top of right wrist .area 4 x 4 x 0 (centimeters) . The DON completed her assessment and reported the injury of unknown origin/potential abuse to the Assistant Administrator at 12:30 PM. Medical record review of a Nurses' Note dated 6/28/19 at 3:33 PM documented, .Reported by private sitter (Resident #1) had a bruise to his top right wrist . resident noted with a 4 x 4 x 0 (centimeter) dark purple area of discoloration to the top of his right wrist .Son (named person) called and message left for him requesting a return call. (named person) notified . Review of the Facility Reported Incident (FRI) reported to the State Agency revealed the incident was reported to the State Agency on 7/1/19 at 9:07 AM, 3 days after the injury of unknown origin was identified. Interview on 7/11/19 at 10:30 AM in the conference room, the DON stated, .(Named person) came to me at approximately 12 noon (6/28/19) and informed me that (Resident #1) had a reddened area to his upper right wrist .I saw (Resident #1) at 12:15 PM and noted on top of his right wrist was a 4 x 4 x 0 cm (centimeter) dark purple bruise .After leaving them, at 12:30 PM (6/28/19) I alerted (named person) (Assistant Administrator) of potential abuse . Interview with the Administrator on 7/11/19 at 2:00 PM in the conference room, the Administrator confirmed the abuse allegation was reported to the State on 7/1/19. He stated, .I thought I had five days to report it to the State. I got confused and read it wrong .",2020-09-01
2212,HARDIN CO NURSING HOME,445372,935 WAYNE ROAD,SAVANNAH,TN,38372,2019-05-30,609,D,1,1,6CXE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to report an injury of unknown origin within 2 hours for 1 of 3 (Resident #55) sampled residents reviewed for alleged abuse. The findings include: The facility's Abuse, Neglect, Misappropriation of Funds policy documented, .2 Hour Limit: the facility shall report the suspicion immediately, but not later than 2 hours after forming the suspicion . Medical record review revealed Resident #55 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 scored 15 on the Brief Interview for Mental Status, which indicated no cognitive impairment for decision making. Medical record review revealed Resident #55 was hospitalized [DATE] - 5/7/19 with the [DIAGNOSES REDACTED]. Resident #55 was readmitted to the facility on [DATE] and complained of left hip pain. Review of the x-ray of the left hip and pelvis dated 5/7/19 revealed, .Possible [MEDICAL CONDITION] process hip joint . Record review revealed Resident #55 continued to complain of pain and the physician ordered a Computerized [NAME]ography (CT) Scan of the left hip and pelvis. Interview with Resident #55 on 5/20/19 at 10:30 AM in the resident's room, Resident #55 stated, .I was in the hospital and came back here .I have not fallen while in the hospital .I have not fallen here .I came back from the hospital complaining of pain and that is why they did the x-rays . Review of Resident #55's CT Scan report dated 5/10/19 at 5:56 PM documented, .XR (X-Ray) Hip Left with Pelvis non-displaced oblique right sacral .fracture .Severe diffuse osteopenia .Severe [MEDICAL CONDITION] changes of the hip joints .Severe [MEDICAL CONDITION] disc changes at L (Lumbar) 5-S (Sacral) 1 . An addendum by the physician dated 5/14/19 at 5:03 PM documented, .Given the patient's osteopenic status, it is difficult to discern fracture age; however the right sacral fracture does appear acute in the setting . Medical record review revealed this was a fracture of unknown origin. This injury of unknown origin was not reported to the Administrator or State Agency within 2 hours of identification. Interview with the Administrator on 5/20/19 at 7:45 AM in the Administrator's Office, the Administrator stated, .Staff received the CT results Friday 5/10/19 of the right sacral fracture .They reported to me on Monday 5/13/19. I started my investigation when I was made aware on 5/13/19. However, I did not submit because I was still investigating .I submitted it to the system 5/15/19 when the investigation was completed .",2020-09-01
2584,AHC HARBOR VIEW,445428,1513 N 2ND STREET,MEMPHIS,TN,38107,2018-07-25,689,E,1,1,6ZPH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to safely transfer a resident with 2 people assisting the resident, and failed to perform neurological (neuro) checks after a fall as required by the facility's policy, for 2 of 3 (Resident #32 and #143) sampled residents. The findings included: 1. Medical record review revealed Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change Minimum Data Set ((MDS) dated [DATE] and the admission MDS dated [DATE] documented Resident #32 had moderate cognitive impairment, required extensive assistance with activities of daily living, and had functional limitations in range of motion with impairment in a lower extremity. The care plan dated 1/16/18 last reviewed 5/17/18 documented, .Transfers .(Named Resident) requires extensive assistance . The Nursing Note dated 5/2/18 documented, .Orders received from (Named Nurse Practitioner) to transfer resident to hospital due to abnormal knee xray . The Nursing Note dated 5/5/18 documented, .Resident returned to facility .Brace noted on right leg due to femoral fracture . The Physician's Progress Note dated 5/8/18 documented, .ASSESSMENT: 1. status [REDACTED]. Interview with the Assistant Director of Nursing (ADON) on 7/25/18 at 12:52 PM, in the Harbor Club Room, the ADON was asked how Resident #32 was to be transferred. The ADON stated, .she was supposed to be transferred with 2 person assist . Interview with Certified Nursing Assistant (CNA) #2 on 7/25/18 at 2:28 PM, in the Harbor Club Room, CNA #2 was asked how resident #32 was to be transferred. CNA #2 stated, .I have transferred her just me. That was not the way she (Resident #32) was supposed to be transferred .she is a 2 person assist .I did not check her orders in the kiosk . 2. The facility's Neurological Check policy dated 7/2014 documented, .Falls that occur and a patient hits their head or if the fall was unobserved and the possibility is there that a patient may have hit their head, a neurological assessment must be conducted .The checks must be done according to the guidelines at the top of the form . Medical record review revealed Resident #143 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 4/5/18 documented Resident #143 was at risk for non-compliance with requesting assistance. The Nursing Note dated 5/8/18 at 5:30 PM, documented, .Pt (patient) had an unwitnessed fall in her room found on left side with left arm extended. Pt states that she fell attempting to go to bathroom. Pt states that she hit her head but has no feel any pain (had no pain) to her head area. Pt complains of left arm and shoulder pain. Pt assessed for other injuries and alertness. Pt is alert and oriented able to communicate all concerns. B/P (blood pressure) 200/106 HRT (heart rate) 86 O2 (oxygen saturation) 99 (percent) respirations 20. Family called .FNP (Family Nurse Practitioner) notified ordered Xray of left humerus and left shoulder also ortho-static vitals in one hour. Will monitor pt for changes . The Nursing Note dated 5/8/18 at 6:45 PM, documented, .Pt found lying in bed with large amount of vomit in the floor near her head and a small amount in the bed. Pt breathing was labored and she soiled her brief with urine and feces. Pt was able to make eye contact but could not speak. Pts B/P was 178/102 HRT 89 Temp 97.6 sat (oxygen saturation) 98 (percent) . FNP notified of Pt's condition and ordered be sent ER (emergency room ) for evaluation . Interview with the ADON on 7/24/18 at 2:40 PM, in the Harbor Club Room, the ADON was asked what the facility's policy was when a resident had an unwitnessed fall. The ADON stated, .perform neuro checks . The ADON was asked if neuro checks had been performed after Resident #143 fell . The ADON stated, .I didn't notice the neuro checks were performed . Interview with the Regional Nurse Consultant (RNC) on 7/24/18 at 3:26 PM, the RNC was asked if neuro checks had been performed on Resident #143 after her unwitnessed fall. The RNC shook her head indicating no.",2020-09-01
1077,GRACE HEALTHCARE OF CORDOVA,445218,955 GERMANTOWN PKWY,CORDOVA,TN,38018,2017-12-05,684,D,1,1,7XFX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to schedule a follow up physician's appointment for 1 of 3 (Resident #325) sampled residents. The findings included: 1. The facility's PHYSICIAN STANDING ORDERS policy documented, .Physician orders [REDACTED]. 2. Medical record review revealed Resident #325 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Discharge Activity Follow Up Instructions from (Named Hospital) dated 8/4/17 documented, .call for follow up appointment in 12 days . Interview with the Social Service Director, (SSD) on 12/6/17 at 9:15 AM in the conference room, the SSD was asked whose responsibility it was to make follow up physician appointments. The SSD stated, .I made the ortho (orthopedic) appointment as soon as the daughter brought it to my attention .normally the nurses will let me know when a resident is to have a follow up appointment . Interview with the Director of Nursing (DON) on 12/6/17 at 9:20 AM in the conference room, the DON was asked what the procedure was for making follow up physician appointments. The DON stated, .the nurses let social service know when a new resident gets an order for [REDACTED].",2020-09-01
4972,LIFE CARE CENTER OF MORRISTOWN,445314,501 WEST ECONOMY ROAD,MORRISTOWN,TN,37814,2016-06-15,514,G,1,0,SVOA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, and interview, the facility failed to transcribe the physician's order correctly on the Medication Administration Record [REDACTED]. This failure resulted in Harm for Resident #174. The findings included: Review of a facility Clinical Services Policies & Procedures, Nursing Volume 1, Physician's Orders/Transcription revised 10/04 revealed .to ensure accurate delivery of medications .confirm that the order is correct . Medical record review revealed Resident #174 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician/Prescriber order dated 6/29/15 revealed .Glimepiride (oral blood sugar lowering medication) 1 mg (milligram) PO (by mouth) BID (twice a day) (Hold if FS (finger stick blood sugar reading) = (less than or equal to) 100) per fax . Medical record review of the Fax Order Request/Notification form dated 6/29/15 revealed .OK (with) Glimepiride (Hold if FS = 100) . Medical record review of the Medication Administration Record [REDACTED].Glimepiride 1 mg po BID start 6/29/15 9 am 5 pm . Continued review revealed no documentation on the MAR indicated [REDACTED]= 100). Medical record review of the Sliding Scale Insulin Form dated (MONTH) (YEAR) revealed on 7/2/15 at 6:00 AM, Resident #174 had a blood sugar of 91. Continued review revealed at 4:00 PM the residents blood sugar was 74. Continued review revealed no documentation to hold Glimepiride 1 mg if the BID fingerstick blood sugar was 100 or less. Medical record review of the MAR indicated [REDACTED]. Medical record review of the Nurses Note dated 7/2/15 at 10:56 PM revealed .less responsive, drooling from right side of mouth. No hand grips .Checked pt (patient) blood sugar .72. Transported by .EMS (Emergency Medical Service) .Sent out at 8:45 pm. Medical record review of the EMS record dated 7/2/15 at 8:47 PM revealed, .upon arrival found unresponsive female setting in wheel chair .nursing staff said they had checked her blood sugar and read 72 .ordering [MEDICATION NAME] (medication for severe low blood sugar) to be given .Meds given and blood sugar checked and read 31 . Continued review revealed EMS transported the resident to a local hospital emergency department. Interview with the Director of Nursing on 6/15/16 at 12:52 PM, in the conference room confirmed the facility failed to transcribe the physician's order correctly on the MAR indicated [REDACTED]. Refer to F 333",2019-06-01
2936,JEFFERSON COUNTY NURSING HOME,445473,914 INDUSTRIAL PARK RD,DANDRIDGE,TN,37725,2018-09-19,610,D,1,1,9RNK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, facility documentation review, and interview the facility failed to complete a thorough investigation for 1 resident (#247) of 26 residents reviewed for abuse of a total of 45 sampled residents. The findings include: Review of the facility policy Abuse, Neglect, Misappropriation Protocol revealed .The individual conducting the investigation will possibly include some or all of the following steps, depending upon the circumstances: .Interview the person(s) reporting the incident .witness reports will be reduced to writing. Witnesses will be required to sign and date such reports . Medical record review revealed Resident #247 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of facility documentation dated 7/27/18 revealed .charge nurse reported that resident (Resident #247) was in altercation with another resident (Resident #248). Residents wheel chairs became tangled up CNA (certified nursing assistant) separated residents Nurse reports that no contact was witnessed between residents nurse assessed resident (#247) from head to toe with no visible red marks, bruising, or scratches . Interview with the Quality Assessment (QA) nurse on 9/19/18 at 7:48 AM, at the 300 hall nurse's desk, revealed the QA nurse was asked by the Director of Nursing (DON) to complete the investigation on 7/27/18 of the residents. Continued interview revealed the QA nurse was not told or aware initially of Resident #247 being struck by Resident #248 on 7/27/18. Interview revealed the facility became aware of the resident to resident contact between Resident #247and #248 when visited by local police department. Interview with CNA #1 on 9/19/18 at 8:14 AM, by phone, revealed the CNA observed the two residents' wheelchairs tangled up, and observed Resident #248 hitting Resident #247 in the back 3 times. Continued interview revealed the residents were separated and the CNA reported to the Charge Nurse what had happened. Interview with the Charge Nurse on 9/19/18 at 8:27 Am, by phone, revealed the Charge Nurse assessed both the residents with no visible marks, or bruising present. Continued interview revealed the Charge Nurse seperated the residents and reported the incident to the DON. Interview with the Administrator and DON on 9/19/18 at 1:33 PM, in the Administrators office, revealed the Administrator and DON were informed of the incident and initially thought residents only got wheelchairs stuck together until visited by the local police department. Continued interview confirmed the facility failed to complete a thorough investigation, and failed to follow the facility policy for Abuse investigations.",2020-09-01
1700,REELFOOT MANOR HEALTH AND REHAB,445285,1034 REELFOOT DRIVE,TIPTONVILLE,TN,38079,2019-03-06,610,D,1,1,9JYF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, facility investigation review, and interview, the facility failed to thoroughly investigate an allegation of abuse for 1 of 1 (Resident #52) residents reviewed for allegations of abuse. The findings include: 1. Review of the facility's Operational Policy and Procedure Manual .Abuse policy revised on 9/2012, documented, Abuse Investigations .4 .Witness reports will be obtained in writing. Witnesses will be required to sign and date such reports .Reporting Abuse to Facility Management .9 .Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident .Findings of the examination must be recorded in the resident's medical record .1 .written statements from witnesses .must be provided to the Administrator . 2. Review of the facility's Accident and Incidents-Investigating and Reporting policy revised on 4/2010 documented, .5 .The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident /Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident . 3. Medical record review revealed Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 14 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #52 was cognitively intact with behaviors. Medical record review for Resident #52 revealed no documentation of the examination conducted after the alleged abuse allegation on 2/25/19. 4. Review of the facility's abuse allegation investigation dated 2/26/19 revealed: a. Licensed staff failed to document events related to the abuse allegation for Resident #52 in Resident #52's medical record. b. The facility failed to follow the facility's Accident and Incidents-Investigating and Reporting policy to complete an incident/accident report. c. The Abuse Coordinator failed to obtain witness statements from staff members on the shift of the alleged abuse occurrence, from staff members on the shift following the alleged occurrence, or from the staff on the shift that the allegation was reported. Interview with the Director of Nursing (DON) on 3/5/19 at 11:32 AM, in the Conference Room, the DON was asked if witness statements were obtained from the staff who worked the shift the abuse allegation allegedly occurred, statements from the staff that worked the shift after the alleged occurrence, and from the staff on the shift the occurrence was reported. The DON stated, .We didn't, the staff members was already gone, I didn't have them to write a statement . Interview with the DON on 3/6/19 at 10:07 AM, in the DON office, the DON was asked if there was a completed incident report for the abuse allegation. The DON stated, No, we did not have one . Interview with the Administrator on 3/6/19 at 10:28 AM, in the Administrator's office, the Administrator was asked if the investigation was a complete and thorough investigation without witness statements. The Administrator stated, No . The facility failed to ensure a thorough investigation was completed on an allegation of abuse.",2020-09-01
2867,BELLS NURSING AND REHABILITATION CENTER,445463,213 HERNDON DRIVE,BELLS,TN,38006,2019-06-13,609,D,1,0,0IZJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, facility investigation review, observations, and interview, the facility failed to report an allegation of abuse for 1 of 5 (Resident #2) sampled residents reviewed for abuse. The findings include: 1. The facility's ALLEGED/SUSPECTED ABUSE PR[NAME]EDURE policy dated 04/2013, documented, .4 .Federal regulations require this facility to report alleged abuse in accordance with State Law to the Tennessee Department of Health .and the Long Term Care Ombudsman within 5 working days . The facility's Abuse Investigations policy dated (MONTH) 2009 documented, .The individual in charge of the investigation will notify the ombudsman that an abuse investigation is being conducted .The Administrator or designee will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others .within five (5) working days of the reported incident. 16. Should the investigation reveal that a false report was made/filed .ombudsman, state agencies, etc. will be notified of the findings . 2. 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 severely impaired cognition and required extensive assistance with Activities of Daily Living (ADLs) except eating. Observations in Resident #1's room on 6/6/19 at 11:35 AM, revealed Resident #1 was up in a wheelchair with constant movement of her arms, head, and legs. Resident #1 was verbally responsive and told the surveyor she was writing a dirty book. Resident #1 offered the surveyor a copy of her book once written and told her the bible is dirty. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #2 was rarely understood and rarely understood others, was severely cognitively impaired, and required extensive to total assistance with ADLs except eating. Resident #2's Care Plan dated 3/28/19 documented .is sometimes understood and sometimes understands. She can verbally respond but refuses to do so most days .Behavior symptom present at times .noted at times to refuse medication, supplements . Observations in Resident #2's room on 6/6/19 at 11:45 AM, revealed Resident #2 was up in a Geri chair feeding herself. Resident #2 did not verbally respond to the surveyor's attempts to interview her. 3. Review of the facility's investigation revealed that on 5/24/19 Certified Nursing Assistant (CNA) #1 entered Resident #2's room and found Resident #2 with her brief unfastened. Resident #1 was sitting with her pants halfway down and was fondling Resident #2. CNA #1 fastened Resident #2's brief and alerted a nurse. The Administrator was notified and initiated an investigation. Resident #2 was examined by staff and found to have redness to her vaginal area. Interview with the Treatment Nurse on 6/6/19 at 2:18 PM, in the Activity Department, the Treatment Nurse was asked if she was familiar with Resident #2. The Treatment Nurse stated, Yes. The Treatment Nurse was asked if Resident #2 is verbally responsive and able to answer questions. The Treatment Nurse stated, No. The Treatment Nurse confirmed that she was notified of the incident by CNA #1 and went immediately to the room. The Treatment Nurse was asked if Resident #1 said anything when she went into the room. The Treatment Nurse stated, She made the comment, 'Get out, my husband and I are trying to have sex'. Interview with the Long Term Care Ombudsman on 6/6/19 at 4:00 PM, via phone, the Long Term Care Ombudsman confirmed that she had not been notified of the allegation and that she had visited the facility on 5/31/19. Interview with the Director of Nursing (DON) on 6/6/19 at 4:45 PM, in the Activity Department, the DON confirmed the allegation had not been reported to the State. The DON stated, .If I get a call I will call her (the Administrator) because she is ultimately responsible. Interview with the Administrator on 6/6/19 at 5:15 PM, in the Activity Department, the Administrator confirmed the allegation had not been reported to the State.",2020-09-01
2679,GALLAWAY HEALTH AND REHAB,445440,435 OLD BROWNSVILLE RD,GALLAWAY,TN,38036,2017-09-21,323,G,1,1,XHU311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, kardex review and interview the facility failed to implement interventions to prevent falls and injury for 1 of 6 (Resident # 3) sampled residents reviewed for accidents. The failure to provide two person assist with care resulted in actual harm when Resident #3 sustained a fall which resulted in an intracerebral hemorrhage (an emergency condition in which a ruptured blood vessel caused bleeding inside the brain) that formed a subdural hematoma (a blood clot) on the brain and a left clavicular fracture (broken collar bone). The findings included: 1. The facility's Assessing Falls and Their Causes Guidelines policy documented, .Falls are a leading cause of morbidity and mortality among the elderly in nursing homes .If a resident has just fallen .nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine and extremities .Once an assessment rules out significant injury, nursing staff will help the resident to a comfortable sitting, lying or standing position . 2. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] and quarterly MDS dated [DATE] revealed Resident #3 was severely cognitively impaired, required extensive assistance with 2 person physical assist with bed mobility, transfer and was total dependent for bathing with two person assist. The care plan dated 7/11/17 revealed Resident #3 was an extensive assist and required two persons assist with bathing, bed mobility and transfers. Review of the Visual/Bedside Kardex Report revealed Resident #3 was extensive to total assist with bathing, transferring and two persons assist with transferring, turning, and positioning. Review of the Fall Risk Evaluation dated 8/8/17 revealed Resident #3 was a high fall risk. The Progress Notes dated 9/16/17 documented, .called to resident's room at approx. (approximately) 0540 (5:40 AM) by CNA (Certified Nursing Assistant) who stated resident had fallen out of her bed while CNA was providing care .resident noted to be laying supine, in her bed, with bed at waist high. Resident was assessed by this nurse .Resident guarding R (right) side of body, specifically R upper arm and R hip . Resident #3 was transferred to the hospital, later transferred to a higher level of care hospital and was admitted to the neurocritical care stepdown unit for every 2 hour monitoring. The computerized tomography (CT) report dated 9/16/17 documented, .Intracerebral Hemorrhage . The comparative CT dated 9/16/17 documented, .There is .small bilateral posterior Subdural hematomas measuring a maximum of 3 mm (millimeters) in thickness on the right and 5 mm on the left .These are non significant change compared to the prior study . The Radiology report dated 9/16/17 documented, .Left arm pain post fall .AP (anterior and posterior) .lateral views of the left humerus were obtained .IMPRESSION: Acute left clavicular fracture . Interview with Certified Nursing Assistant (CNA) #2 on 9/19/17 at 11:22 AM, in the conference room, CNA #2 was asked what happened that morning when Resident #3 fell . CNA #2 stated, .I went in to give her a bed bath .I proceeded to give her a bath .I turned her over to wash her bottom, I washed her up .I had reached back with one hand and had one hand on her, (I) was reaching back to get the diaper and I kind of loose (loosened) the hand I had on her .her legs was positioned off the bed when I turned her .I didn't have her tight .she flipped off the bed on to the floor I panicked and I looked on to the hall way there was an aide and a housekeeper that was standing in the hallway and I let both of them know that she had fell and to go get the nurse .I went back in there .she wasn't talking was awake .visible left side of her head a bump .no bleeding .I was waiting on the nurse she was laying on cold floor I picked her up . CNA #2 was asked did you pick her up by yourself. CNA #2 stated, Yes ma'am . CNA #2 was asked what happened then. CNA #2 stated, The nurse came in called the doctor . CNA #2 was asked if Resident #3 was one or two person assist for her bathing. CNA #2 stated, She is a two (two persons assist) for anything. CNA #2 was asked if anyone was helping her give Resident #3 a bath that morning. CNA #2 stated, No, ma'am. CNA #2 was asked how the facility lets the staff know if a resident was a one or two person assist. CNA #2 stated, It's in the ADLs (activity of daily living) we have to do . CNA #2 was asked if Resident #3 was mobile or could she turn herself. CNA #2 stated, No, ma'am . Interview with Registered Nurse (RN) #1 on 9/19/17 at 4:38 PM, in the conference room, RN #1 was asked if she could describe what happened to Resident #3. RN #1 stated, It was about 5:40 in the morning .one of the CNA working that night .yelled for me .said we need you in this room .walked into room Resident #3 was in her bed, there was one CNA in her room (named CNA #2) .she (Resident #3) was lying on her back on her bed .I saw she had a bruise on her forehead with swelling .asked what had happened .she (CNA #2) told me that she was giving (named Resident #3) a bed bath (named Resident #3) was on her right side of the bed naked and her words (CNA #2's explanation) the next thing she knew she fell out of the bed on the floor .when I started to do head to toe (assessment) on her that's when she started guarding her right upper arm, shoulder area .and right hip .I called the Nurse Practitioner .received orders for x-ray. RN #1 was asked if Resident #3 was one or two person assist. RN #1 stated, She is two person Hoyer lift and max assist for ADL .two (two persons assist) . RN #1 was asked how the CNAs are made aware what assistance residents need. RN #1 stated, It's put in their care plan and it shows up on the CNAs' P[NAME] (plan of care) . RN #1 was asked if a resident falls out of bed, what should happen. RN #1 stated, The nurse is supposed to immediately get notified before the resident gets moved .the resident has to be assessed by the nurse. RN #1 was asked how did Resident #3 get back in the bed. RN #1 stated, The CNA (referring to CNA #2) put her back in the bed by herself . A phone interview with Nurse Practitioner (NP) #1 on 9/20/17 at 7:15 AM, NP #1 was asked about the incident concerning Resident #3's fall. NP #1 stated, .I was on call .family wanted her to go to the hospital .ordered transfer . Interview with the Director of Nursing (DON) on 9/20/17 at 8:33 AM, in DON's office, the DON was asked how Resident #3 fell . The DON stated, .I questioned (named CNA #2) over the phone .said she was giving Resident #3 care and she was on her right side, had one hand on her hip, reached back with the other hand to get the adult brief, raised the other hand off the hip area and she fell . She did say her left leg was dangling off the bed . The DON was shown Resident #3's care plan and was asked if Resident #3 was one or two person assist with bathing, transfers and turning. The DON stated, She is an assist of two. The DON was asked if that morning, Resident #3 had one or two people assisting with Resident #3's bath. The DON stated, It was just (named CNA #2) .she was alone . The DON was asked did she follow the care plan. The DON stated, No .said she just panicked .I asked why she moved her .said she was naked and didn't want her on the cold floor .and she was scared . Interview with the Administrator on 9/20/17 on 10:21 AM, in the Administrator's office, the Administrator was asked about Resident #3's fall on (MONTH) 16th (YEAR). The Administrator stated, .had a bowel movement .had one hand on her side and turned to reach for something and legs were crossed over .and rolled off .said she panicked .she said she picked her up and put her back on the bed. I asked her why she picked her up and she said she (Resident #3) was laying there naked on the floor . The Administrator was asked what should have been done. The Administrator stated, Should have called for the nurse. The Administrator was asked if the facility's fall policy was followed. The Administrator stated, No, ma'am. A telephone interview with Resident #3's attending physician on 9/20/17 at 1:20 PM, the attending physician was asked if Resident #3 had a head injury or fracture before the 9/16/17 incident. The attending physician stated, Not that I'm aware of .don't think so The attending physician was asked would her falling from the bed contribute to Resident #3 having a subdural hematoma and a clavicular fracture. The attending physician stated, Yes of course . The failure to provide two person assist with care resulted in actual harm when Resident #3 sustained a fall which resulted in an intracerebral hemorrhage that formed a subdural hematoma on the brain and a left clavicular fracture.",2020-09-01
1975,THE PALACE HEALTH CARE AND REHABILITATION CENTER,445329,309 MAIN ST,RED BOILING SPRINGS,TN,37150,2017-07-25,315,D,1,0,W56811,"**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 proper care was provided for an indwelling urinary catheter for 1 of 3 (Resident #7) residents observed for catheter care and failed to ensure the catheter bag did not touch the floor for 2 of 3 (Resident #7 and 8) residents reviewed with an indwelling urinary catheter. The findings included: 1. The facility's Catheter Care, Urinary policy documented, .Wash perineal area with soap and water front to back. Rinse and dry. Clean Catheter tubing with soap and water, starting close to urinary meatus, cleaning in circular motion . 2. Medical Record review revealed Resident #7 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 1/26/17 documented, .HAS A CHRONIC FOLEY CATHETER WITH RISK FOR INFECTION .Approaches .Provide cath (catheter) care q (every) shift and prn (as needed) per policy . Review of the physician's orders [REDACTED].FOLEY CATH CARE Q SHIFT . Observations in Resident #7's room on 7/24/17 at 12:00 PM, at 1:37 PM and 4:49 PM, revealed the indwelling urinary catheter bag touching the floor. Interview with Licensed Practical Nurse (LPN) #1 on 7/24/17 at 4:51 PM, in Resident #7's room, LPN #1 was asked if the catheter bag should be lying on the floor. LPN #1 stated, .I know it's not supposed to be touching the floor . Observations in Resident #7's room on 7/25/17 at 2:18 PM, revealed Certified Nursing Assistant (CNA) #1 washed hands, donned clean gloves, removed Resident #7's brief, cleansed Resident #7's skin around the urinary meatus, wiped the catheter tubing with the same washcloth, obtained a new wash cloth dried the area around the urinary meatus and dried the catheter tubing using the same washcloth. CNA #1 failed to change the washcloth between cleansing the urinary meatus and the catheter tubing. Interview with CNA #1 on 7/25/17 at 3:12 PM, in room [ROOM NUMBER], CNA #1 was asked what she did with the washcloth after washing Resident #7's penis and CNA #1 stated Washed the catheter. CNA #1 was asked what the proper procedure would be for cleaning the catheter tubing and CNA #1 stated, Change wash cloths . Interview with LPN #1 on 7/25/17 at 3:25 PM, in room [ROOM NUMBER], LPN #1 was asked if the same cloth should be used to clean the catheter tubing after cleaning the urinary meatus and LPN #1 stated, .by using the same cloth would be to contaminate . Interview with the Director of Nursing (DON) on 7/25/17 at 4:25 PM, in the DON's office, the DON was asked if the same wash cloth should be used to perform catheter care after the urinary meatus was cleaned. The DON stated, No . 3. Medical record review revealed Resident #8 was admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 5/25/17 documented, .HAS A F/C (Foley Catheter) .IS INCONT (Incontinent) .REQ (Required) TOTAL CARE FOR ALL HIS TOILETING NEEDS .Approaches .F/C CARE QS (every shift) AND AS CLINICALLY INDICATED . Observations in Resident #8's room on 7/24/17 at 6:09 PM, and 7/25/17 at 10:50 AM, revealed the indwelling urinary catheter bag touching the floor. Interview with the DON on 7/25/17 at 10:55 AM, in Resident #8's room, the DON was asked if the indwelling catheter bag should be touching the floor. The DON stated, No ma'am we are having trouble with the low beds will fix that right now .",2020-09-01
4174,AHC HARBOR VIEW,445428,1513 N 2ND STREET,MEMPHIS,TN,38107,2016-12-22,520,G,1,0,XY5611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation and interview, the Quality Assurance (QA) Committee facility failed to ensure an effective and ongoing QA program that identifies deficient practices related to daily living (ADLs) and infection control practices and implements corrective actions that prevent repeat deficient practices. The QA Committee failed to ensure a system that identified and appropriately treated and prevented constipation for Resident #1. Resident #1 experienced constipation, pain and had to be transferred to the hospital emergency room , resulting in actual harm for Resident #1. The findings included: 1. The QA program failed to ensure a system to ensure all residents' with constipation were treated appropriately and in accordance with facility orders and protocol. The failure to ensure Resident #1's constipation resulted in the resident developing pain and constipation. Resident #1 was sent to the hospital emergency room for treatment of [REDACTED]. Refer to F309. 2. The QA program failed to ensure all residents are provided privacy during personal care. Refer to F164. 3. The QA program failed to ensure all residents' that required assistance with ADLs, received ADLs as appropriate. Refer to F312. The deficient practice of F312 is a repeat deficient practice. The facility failed to provide ADLs to all residents that required assistance with ADLs on the 4/21/16 recertification survey. 4. The QA program failed to ensure infection control practices and facility policies were followed. Refer to F441. The deficient practice of F441 is a repeat deficient practice. The facility failed to follow infection control practices on the 3/31/15 recertification survey. 5. The QA program failed to ensure documentation that care for bowel movements and ADLs were provided as appropriate. Interview with the Director of Nursing (DON) on 12/20/16 at 7:00 PM, in the conference room, the DON stated, The blanks mean the care was not given or it wasn't documented the care was given. The DON was asked if the care plans document that ADL needs are to be met daily, was the care plans followed. The DON stated, No. The facility's Certified Nurse Aide policy documented, .CNAs (Certified Nursing Assistant) are responsible for basic care services such as bathing, toileting, grooming . Refer to F514.",2019-11-01
2802,AMERICAN HEALTH COMMUNITIES OF CLARKSVILLE,445455,900 PROFESSIONAL PARK DRIVE,CLARKSVILLE,TN,37040,2017-12-06,697,D,1,0,ZCRB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation and interview, the facility failed to administer pain medications as ordered for 1 of 5 (Resident #1) sampled residents reviewed. The findings included: 1. Review of the facility's Medication Availability/Borrowing Policy, documented .Medications are available through a licensed pharmacy 24 hours a day/7 days per week. Medication needs should be immediately communicated to the Communities contracted pharmacy or to the backup pharmacy using back up pharmacy procedures if the need is for after hour services . Review of the facility's Controlled Substance Emergency Kit Policy and Procedure, documented .In an effort to increase the availability of controlled substance items to meet patients' needs in the long term care facility - (named pharmacy) will provide each facility a controlled substance Emergency Kit to be utilized for EMERGENCY SITUATIONS .EMERGENCY .An emergency for this purpose will be defined as to meet the IMMEDIATE THERAPEUTIC NEED OF THE PATIENT .Each box may have up to 40 doses of controlled substances II - V (two through five) .When a controlled substance is retrieved out of the emergency kit a hard copy prescription for the amount taken from the kit MUST be obtained .a new box for that community (facility) to be sent with the next scheduled delivery . The ER (Emergency) Control Kit list of included medications, documented .[MEDICATION NAME]/APAP ([MEDICATION NAME]) 5/325 (milligrams (mg)) .(Quantity) 10 .[MEDICATION NAME]/APAP 5/325 (mg) .(Quantity) 5 .[MEDICATION NAME] .25mcg (micrograms) .2 Patches .[MEDICATION NAME] 12mcg .2 Patches .[MEDICATION NAME] .50mcg .2 Patches . 2. Record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly Minimum (MDS) data set [DATE] documented the resident scored 15 of 15 on her Brief Interview for Mental Status, which indicated she was alert, oriented, and able to make daily decisions. There have been numerous pain medication dosage and administration changes for [MEDICATION NAME], and [MEDICATION NAME] since the resident's admission. Physician orders [REDACTED].[MEDICATION NAME] 10mg (milligrams)-[MEDICATION NAME] 325 mg tablet .po (by mouth) q (every) 4hrs (hours) PRN (as needed) r/t (related to) pain .[MEDICATION NAME] 50 mcg/hr (micrograms per hour) [MEDICATION NAME] .every 3 days . The (MONTH) (YEAR) Medication Administration Record [REDACTED].Medication not administered . An Emergency Kit Removal (order to replace medications taken from the ER box) form dated 8/8/17, documented .[MEDICATION NAME] ([MEDICATION NAME]) 5/325 (milligrams) 1 tab as needed q 4 (hours symbol) For Pain . Physician orders [REDACTED].[MEDICATION NAME] 37.5 mcg/hr [MEDICATION NAME] .Every Three Days Starting 10/10/2017 . The (MONTH) MAR indicated [REDACTED]. There was no documentation that a [MEDICATION NAME] was obtained from the ER box to administer to the resident. The patch was documented as being changed on 10/17/17. An Emergency Kit Removal (order to replace medications taken from the ER box) form dated 8/8/17, documented .[MEDICATION NAME] ([MEDICATION NAME]) 5/325 (milligrams) 1 tab as needed q 4 (hours symbol) For Pain .Quantity removed from box .1 . A slip dated 11/5/17 documented .[MEDICATION NAME] 5mg/325mg .Quantity Removed .5 .Order: [MEDICATION NAME] 10mg/325mg 1 tab PO PRN q 4hrs. Note: may give (2) 5mg/325mg . A slip dated 11/6/17, documented .[MEDICATION NAME]/ apap 5/325 .Quantity Removed .1 .Q4hrs prn for pain . Observation and interview in Resident #1's room on 12/4/17 at 3:10 PM, revealed a white female up in a motorized wheelchair. Resident #1 denied any mistreatment by staff, and stated that the staff took good care of her. When she was asked about getting pain medications, Resident #1 stated .pretty much when needed .got me on a pain patch now .still have some pain .need it before I go to bed .mostly my back .one night it was after midnight, but that was a new nurse .if I don't get it, I call my daughter and she takes care of it . Interview on the 600 hall with Nurse #1 on 12/5/17 at 10:05 AM, Nurse #1 was asked what she is supposed to do if a resident's narcotic is not available in the medication cart. She stated, .call the DON (Director of Nursing) .have to call the pharmacy .they give us the combination for the emergency narcotic box . She was then asked when she is supposed to request a refill for narcotics. She stated, .When it gets to the blue (indication on the card system that notifies staff when it is time to refill) .we pull the sticker (medication refill information on the card system) and send it to the pharmacy .if it doesn't come in the next delivery, I call .have two deliveries a day Monday through Friday .one on Saturday .no delivery on Sunday .we can go to the back-up pharmacy, but we have to have a hard script (prescription) . Interview at the A Hall nurses' station with Nurse #2 on 12/5/17 at 10:20 AM, Nurse #2 was asked about narcotic refills. Nurse #2 went to the medication cart and pulled a prescription card and showed this surveyor the 'blue' line on the card that indicated when it is supposed to be refilled, and the 'sticker' that is pulled to request a refill. When Nurse #2 was asked what she does if there is not a narcotic left in a resident's drawer, she stated .get it out of the emergency box .have to call the pharmacy and get the combination to unlock .must be signed by two nurses .have to get an order to replace that medication .call the pharmacy and let them know we need that medication on the next delivery . Interview in the private dining room with the DON on 12/5/17 at 3:50 PM, she was asked if there was any reason why a resident would go without medications. She stated, .no .if it's requested (from the pharmacy) by 11:00 AM it should be on the afternoon delivery .if it's requested by 4:30 PM, it should be on the night delivery .narcotics depend on if it needs a new script .if they are re-ordering like they (nurses) should be, they shouldn't run out .if narcotics run out, they should get it from the ER box .that's not what it's for, but they should use it if a resident needs meds (medications) .if it's (narcotic) in the box, they should call and get an order for [REDACTED].>Interview in the private dining room with the DON on 12/6/17 at 9:20 AM, she was asked if there would ever be any reason for a resident not to get their pain medications. She stated, .No .we have a limited supply in the ER box .if we didn't have their med, they (nurses) should call and get an order to give something else until we get their med . Interview in the private dining room with the DON on 12/6/17 at 10:30, the DON was asked specifically about Resident #1's pain medications not being available. She stated, .Honestly, I don't know why it happened .script ran out .ER box is not changed out on weekends .there's no med delivery on Sunday .we are changing the Unit Manager on that side (A side) .have had issues with scripts done timely .she (Resident #1) changes her mind on what she wants and then the family changes things .a lot of med changes .",2020-09-01
4266,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2016-10-13,176,D,1,1,LFXZ11,"**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 2 (Resident #150) residents observed were assessed by an interdisciplinary team (IDT) to self-administer medications. The findings included: 1. The facility's SELF-ADMINISTRATION BY RESIDENT'' policy documented, Policy .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 .Procedures .an assessment is conducted by the interdisciplinary team . 2. Medical record review revealed Resident #150 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 3. Observations in Resident #150's room on 10/11/16 beginning at 5:45 PM, revealed Licensed Practical Nurse (LPN) #2 began a breathing treatment on Resident #150 then exited the room while the breathing treatment was in progress. LPN #2 returned to the room at 6:06 PM and discontinued Resident #150's breathing treatment. There was no staff in the resident's room during the breathing treatment. 4. Interview with LPN #2 on 10/11/16 at 6:15 PM, in the hallway outside of room [ROOM NUMBER], LPN #2 was asked if it was this facility's process to begin a breathing treatment and leave the resident alone while the treatment is in progress. LPN #2 stated, Probably not .you're not supposed to leave the resident alone. LPN #2 was asked if she would expect to see a Self-Administration of Medication assessment form and a doctor's order for the resident to self-administer medications on the chart. LPN #2 stated I never thought about it . Interview with the Director of Nursing (DON) on 10/13/16 at 4:51 PM, in DON's office, the DON was asked if it is acceptable for a resident to self-administer medications without a Self-Administration of Medication Assessment. The DON stated, No. The DON was asked if there were any residents in the facility who currently had an assessment for Self-Administration of Medications. The DON answered, No.",2019-10-01
3183,"COLLIERVILLE NURSING AND REHABILITATION, LLC",445495,490 WEST POPLAR AVENUE,COLLIERVILLE,TN,38017,2019-07-11,689,E,1,0,3FM311,"**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 3 of 3 (Resident #1, #4 and #5) sampled residents were assessed for risk of falling and failed to ensure 1 of 3 (Resident #1) resident care plans were reviewed and modified to reflect the residents' current status following a fall. The findings include: 1. The facility's Falls Management Program Guidelines policy documented, .The fall risk assessment is included as part of the admission, quarterly and when a fall occurs .Care plan interventions should be implemented that address the resident's risk factors .Should the Resident experience a fall the attending nurse shall complete a post fall assessment .This includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode .The resident care plan should be updated to reflect, any new or change in interventions . 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set Assessment ((MDS) dated [DATE] revealed the resident had severe cognitive impairment, was non-ambulatory and dependent on staff for all activities of daily living (ADL). Review of the comprehensive care plan dated 9/30/18 revealed Resident #1 was at risk for falls due to being unaware of safety needs and was dependent on staff for ADLs. Review of a nursing progress note dated 6/17/19 revealed Resident #1 was found lying in the floor beside his bed. There was no injury noted. Medical record review revealed a post fall risk assessment had not been completed and the care plan had not been reviewed or updated. Observations in Resident #1's room on 7/8/19 at 1:15 PM, and on 7/9/19 at 10:35 AM and 12:20 PM, revealed the resident spoke no discernable words, had severe cognitive impairment without the ability to express his needs. He moved his arms above his head and legs randomly with no apparent purpose, received a continuous feeding via Gastrostomy tube and was dependent on staff for all of his needs. 3. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed the resident had moderate cognitive impairment, was non-ambulatory and required extensive assistance of staff for transfer and dressing, limited assistance for eating and was dependent for bathing. Review of the comprehensive care plan dated 10/30/18 revealed Resident #1 was at risk for falling due to gait and balance problems. Review of a nursing progress note dated 4/19/19 revealed the resident was found lying on the floor beside his bed. There was no injury noted. Medical record review revealed a quarterly fall risk assessment, which was due in (MONTH) 2019, was not completed. Observations on 7/8/19, 7/9/19, and 7/10/19 revealed Resident #4 was alert and oriented to person and place, propelled independently in a wheelchair after transfer assistance and interacted with staff and other residents appropriately. 4. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 60 day MDS dated [DATE] revealed the resident had severe cognitive impairment, was non-ambulatory, and required extensive assistance of staff for ADLs except supervision with eating. Review of a nursing progress note dated 4/30/19 revealed the resident was found in the floor of his room with no injury noted. Review of a nursing progress note dated 5/26/19 revealed the resident was found on the floor of his room with no injury noted. Medical record review revealed neither an admission or post-fall risk assessments had been completed. Observations in the central dining area on the resident's floor on 7/8/19 at 1:30 PM and 7/9/19 at 10:45 AM, revealed the resident was alert and oriented to person only, self propelled in a wheelchair after staff assistance with transfer, and interacted appropriately with staff and other residents. 4. Interview with the Director of Nursing (DON) on 7/9/19 at 4:10 PM, in the Admission Office, the DON was asked if admission, quarterly and post-fall risk assessments should be completed. The DON stated, Correct. When the DON was asked if care plans should be updated following a fall, the DON stated, Yes.",2020-09-01
3733,ALLENBROOKE NURSING AND REHABILITATION CENTER,445485,3933 ALLENBROOKE COVE,MEMPHIS,TN,38118,2017-03-02,312,D,1,0,CJSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance related to incontinence care, turning and repositioning, and privacy were provided for 1 of 3 (Resident #76) residents reviewed requiring assistance with ADLs. The findings included: 1. The facility's TURNING & REPOSITIONING PROGRAM policy documented .2. Charge Nurse is responsible for visually observing and assisting with turning and positioning as needed .5. All Residents (unless reasons documented in the care plan) are to face the same direction at the same time . 2. Medical record review revealed Resident #76 was admitted to the facility 7/15/16 with [DIAGNOSES REDACTED]. The Care Plan for Resident #76 dated 7/15/16 documented, .self-care deficit related to independently perform ADL's related to cognitive and functional limitations. 1. Goal was resident will be clean, dressed and free of odor . Interventions .staff was to provide necessary privacy, turn and reposition at least every two hours .and provide needed assistance with ADLs. 2. Resident requires Contact Isolation secondary to[DIAGNOSES REDACTED] ([MEDICAL CONDITION]). Staff was to follow contact isolation precautions before and after each interaction of care. 3. Incontinent of B & B (Bowel and Bladder.) .Staff was to provide privacy when providing incontinence care .check resident and provide care as needed q 2 h (every two hours) and PRN (whenever necessary) .Clean and dry thoroughly & change soiled clothing .Keep linens and pads clean and dry .Apply moisture barrier as needed. Admission Minimum Data Set (MDS) assessment dated [DATE] documented the BIMS was left blank, indicating severe cognitive impairment. Resident #76 was severely cognitively impaired and was totally dependent for Activity of Daily Living (ADL) care. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the Brief Interview of Mental Status (BIMS) score was left blank, indicating severe cognitive impairment. The updated Daily Care Guide documented, .CONTACT ISOLATION .2 person assist with Marissa lift .Get dressed daily and up in chair .Incontinent of B & B . Medical record review revealed Resident #76 was placed on contact isolation for ESBL (Extended-Spectrum beta-Lactamase) in urine on 7/24/16 and contact isolation for [MEDICAL CONDITION] on 12/1/16. Nurses notes from 9/2/16 through present documented resident required extensive assist with all activity of daily living functions. Observations in Resident #76's room on 1/11/17 at 9:00 AM, Certified Nursing Assistant (CNA)s #4 & #8 entered Resident #76's room after donning gloves and applying mask and gown. When the CNAs pulled back the bed linen, Resident #76's brief was heavily soiled with urine and liquid formed feces. Observations in Resident #76's room on 1/15/17 beginning at 2:20 PM, the surveyor noted a foul smell. The surveyor asked Licensed Practical Nurse (LPN) #2 what CNA was assigned to Resident #76. LPN #2 stated (CNA #4). LPN #2 changed her response after CNA #4 stated she was not assigned Resident #76 since 10 AM. LPN #2 then stated CNA #1 had Resident #76. At 2:25 PM, CNA #1 stated Ma'am, she (LPN #2) just told me I had her (Resident #76). I have not done anything for this lady today. I have not been in this room. CNA #1 entered Resident #76's room, donned gloves, pulled curtain and proceeded to uncover Resident #76. CNA #1 removed a wedge cushion from the left side of resident. Observations of Resident #76 after removing the covers revealed Resident #76 had feces on the top sheet, feces oozing from the adult brief from the front and from behind. There was noted dried and liquid feces in the vaginal area, buttocks and thigh areas. CNA #1 stated, I need to get some help. CNA #1 removed her gloves and went out into hall. CNA #1 did not wash her hands before leaving the room. CNA #1 returned to outside of Resident #76's room with CNA #2. Surveyor asked CNA #1 if Resident #76 was in contact isolation. CNA #1 stated, I didn't know, I never had her before. I just passed right by this isolation cart. CNA #1 was asked if she should do anything else other than wear gloves when changing the brief or providing care for Resident #76. CNA #1 stated, Yes, I should have put on a gown and a mask too. Interview with CNA #1 on 1/15/17 at 2:50 PM, across from Resident #76's room CNA #1 again confirmed she had not provided care for Resident #76 because she thought her assignment was the same as the day before when the assignment changed. CNA #1 stated, I have always stopped at room [ROOM NUMBER], I have never had room [ROOM NUMBER] (Resident #76's room) .we had 5 CNA's until a few minutes ago when I was told I had room [ROOM NUMBER] (Resident #76's room). CNA #1 stated, I did not get an updated Daily Care Guide on this lady, either. Interview with CNA #4 on 1/15/17 at 3:10 PM, in the hall between east and central halls by the time clock. CNA #4 was asked about her assignment this shift. CNA #4 stated, We started out with 6 CNA's on this hall but they pulled one. We, CNA #2 and me found out about 10 AM. We were walking by the nurses' station and LPN #1 told us. CNA #4 was asked if there were any other CNA's around when she and CNA #2 were told about the assignment change. CNA #4 stated, No, not at that time. CNA #4 was asked if she provided any care for Resident #76 before the assignment changed, CNA #4 stated, Yes ma'am, I did oral care, changed her brief and provided peri-care, and I repositioned her between 8:30-9:00 this morning. Interview with LPN #2 on 1/15/17 at 3:22 PM, in the east dining room, LPN #2 was asked to clarify the CNA assignment for today (1/15/17, 7-3 shift). LPN #2 stated, We started off with 6 CNAs at 7 AM. The nurse (LPN #5) on the west hall apparently pulled CNA #7 and failed to notify either nurse on the east hall of the change . LPN #2 was asked if Resident #76 had received care that day, LPN #2 stated, Yes. LPN #2 was asked who provided the care. LPN #2 stated, CNA #4 did something for her this morning. LPN #2 stated, She had been in Resident #76's room at 7:30AM, 8:00AM, 11:30 AM, and between 1-1:30 PM, to give tube feeding, meds stuff like that. LPN #2 was asked if she turned and repositioned Resident #76, LPN #2 stated, No. LPN #2 was asked if she noticed Resident #76 lying in the same position for greater than 5 hours. LPN #2 stated, I guess I didn't notice. Interview with CNA #6 in the front parking lot on 1/17/17 at 7:10 AM, CNA #6 was asked if she cared for Resident #76 last night (1/16/17) on the 3rd shift. CNA #6 stated, Yes, I just turned her before leaving for the day. CNA #6 was asked if she worked Saturday night 1/14/17. CNA #6 stated, No, I was off. CNA #6 was asked what time last rounds are performed by the 11-7 shift. CNA #6 stated, We start around 6 and finish around 7, sometimes a little later .I usually do everything for (named Resident #76) just before I leave around 7, when I have her. Interview with the Director of Nursing (DON) on 1/18/17 at 2:19 PM, in the conference room, the DON was asked what is the expectation of staff when providing incontinence or peri care for a resident on contact isolation. The DON stated, Staff should follow the isolation protocol, wash their hands, put on gloves, gown and mask as indicated. The DON was asked if staff did not provide care for Resident #76 for 5 hours or greater, did staff provide adequate ADL care and care per the resident's care plan. The DON stated, No, they did not. The facility failed to to provide Activity of Daily Living (ADL) Care related to incontinence care, turning and repositioning, and privacy.",2020-03-01
4651,HUNTINGDON HEALTH & REHAB CENTER,445210,635 HIGH STREET,HUNTINGDON,TN,38344,2016-08-05,514,E,1,0,Z4P511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation and interview, the facility failed to ensure a medical record that was accurate and complete for 3 of 3 (Resident #1, 2 and 3) sampled residents reviewed. The findings included : 1. The facility's Administering Medications policy documented, .The individual administering th medication must initial the resident's MAR (Medication Administration Record) on the appropriate line after giving each medication and before administering the next ones .If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR indicated [REDACTED]. 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. Review of the (MONTH) (YEAR) Recertification Physician orders [REDACTED].#1 to be administered [MEDICATION NAME] 600 mg tablet ([MEDICATION NAME]) 4 tablets (2400mg) orally four times daily. Observations on 8/2/16 at 11:05 AM revealed LPN #1 administered [MEDICATION NAME] 600 mg (1 capsule) and [MEDICATION NAME]- [MEDICATION NAME] T 10-325mg to Resident #1. In an interview in the hallway outside Resident #1's room on 8/2/16 at 11:17 AM, LPN #1 was asked if Resident #1 should have been given 2400 mg of [MEDICATION NAME] per MAR. LPN #1 stated, She has always gotten 1 tablet . Further medical record review revealed the most current signed physician's orders [REDACTED].#1 to be administered [MEDICATION NAME] 600 mg 1 po QID. In an interview in the Family Conference room on 8/2/16 at 3:20 PM the Director of Nursing (DON) was asked if Resident #1 should have received 2400 mg of [MEDICATION NAME]. The DON stated, It was a transcription error. The DON was asked if Resident #1 received 2400 mg four times daily on 8/1/16 and on 8/2/16 at 12 AM, 6 AM and 12 PM. The DON stated, The nurses work the other shift and are asleep now. The DON reviewed the Physician orders [REDACTED]. It was a transcription error. Review of Resident #1's MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. 3. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. 4. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's MAR indicated [REDACTED]. In an interview in the Family Conference room on 8/2/16 at 3:20 PM the Director of Nursing (DON) was asked about about the missing documentation for each medication not documented as administered. The DON confirmed medications should be signed out on the MAR indicated [REDACTED]",2019-08-01
2113,LAUDERDALE COMMUNITY LIVING CENTER,445354,215 LACKEY LANE,RIPLEY,TN,38063,2017-05-05,322,D,1,0,QMFO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation and interview, the facility failed to ensure a resident who is fed by a percutaneous endoscopic gastrostomy (PEG) tube receives nutrition without complications for 1 of 3 (Resident #61) sampled residents with PEG tubes included in the Stage 2 review. The findings included: The facility's ENTERAL FEEDING VIA CONTINUOUS PUMP policy documented, The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally .Use aseptic technique when preparing or administering enteral feedings .Position the head of the bed at 30-45 (degrees) for feeding . Medical record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimun Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] documented Resident #61 was severely cognitively impaired and required extensive assistance for all Activities of Daily Living (ADLs). Review of the Care Plan initiated on 11/18/16 and revised on 1/27/17 documented, The Resident requires TUBE FEEDING . with the intervention The resident needs the HOB (head of bed) elevated at least 30 degrees during and thirty minutes after tube feed . The physician order [REDACTED]. The physician order [REDACTED].@ (at) 45 CC/HR PER KANGAROO PUMP . Observations in Resident #61's room on 4/26/17 at 4:04 AM, revealed, Resident #61 lying in bed with the tube feeding pump off. [MEDICATION NAME] had 350 milliliters (ml) left in the bag dated 4/25/17 at 2:15 AM. A towel was wadded up under the resident's gown around the peg tube insertion site with greenish drainage noted on the towel. Interview with LPN #7 on 4/26/17 at 4:05 AM in Resident #61's room, LPN #7 was asked if the feeding pump should be turned off. LPN #7 stated, No ma'am. I turned it off cause if I don't it runs out a little bit and the son has a fit if (we) get something on her gown. Observations on 4/29/17 at 4:55 PM in Resident #61's room revealed, Resident #61 in a reclined geri-chair, coughing weakly with a gurgling sound. Observations in Resident #61's room [ROOM NUMBER]/29/17 at 5:35 PM, revealed the resident started coughing and gurgled .a lot of thick white secretions exploded out of her mouth running down her chin. Interview with Confidential Interviewee (CI) #4 on 4/25/17 at 9:53 AM in the conference room, CI#4 was asked about the care provided Resident #61 and if the feeding pump was ever turned off. CI #4 stated, Yes ma'am, I have seen them turn it off for 2-3 hours . Interview with CNA #5 on 4/26/17 at 2:05 PM in the conference room, CNA #5 was asked if Resident #61 was ever found wet with the tube feeding off. CNA #5 stated, .I have gone into a resident room and there has been a mess .I go in (named Resident #61's room) to make sure everything is fine. The feeding has been out .tell the nurse but it is still running . Interview with CI #2 on 4/27/17 at 4:35 PM, in the conference room, CI #2 was asked if the Director of Nursing (DON) was aware of any of the concerns. I have been to her 8-10 times .I've taken her to the room and showed her things, like the feeding pump not plugged up and off. When they get her up they hang it on the pole. That's all the time .The bed flat, not tilted at all . mucus in her throat . I'm afraid she is going to choke to death . But they don't suction her unless I go get them .April 17 you found .lying flat .CNA #7 said she was fixing to give her a bath . Hospital record review revealed Resident #61 was admitted to (named hospital) on 5/5/17, documented, History and Physical .CHIEF COMPLAINT: PEG tube malfunction and intractable nausea and vomiting, .The patient had a CT (Computerized [NAME]ography) scan of abdomen and pelvis done that shows significant fecal impaction as well as gastric obstruction .Here in the ED (Emergency Department) department, she is awake, she is alert, nonverbal. The patient's PEG tube site has a significant leakage of gastric contents around it .the patient's PEG tube site has had persistent leakage around her PEG tube for at least a year or 2 .",2020-09-01
3844,DYER NURSING AND REHABILITATION CENTER,445468,1124 NORTH MAIN,DYER,TN,38330,2017-02-15,280,D,1,0,NWHO11,"**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 comprehensive care plan was revised to reflect the current status for restraint use, an indwelling urinary catheter, and sleeping preferences for 3 of 17 (Residents #47, 61, and 110) sampled residents reviewed of the 37 residents included in the stage 2 review. The findings included: 1. The facility's Use of Restraint policy documented, .Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use . 2. The facility's Care Plan Policy documented, .Care plans should be reviewed, and revised as often as necessary in order to reflect the resident's current status . 3. Medical record review revealed Resident #47 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/13/16, revealed Resident #47 did not have a trunk restraint. The care plan dated 12/14/16 documented .Apply lap buddy when up in wheelchair for positioning or upper body due to forward leaning when propelling in wheelchair. There was no documentation that the lap buddy was used as a restraint Observations were conducted of Resident #47 on 2/13/17 at 7:05 AM and 9:30 AM, and on 2/14/17 at 7:35 AM and 7:50 AM, Resident #47 was observed utilizing a lap buddy while in her wheelchair. Interview with the Restorative Nurse on 2/14/17 at 1:35 PM, the Restorative Nurse confirmed that the current care plan does not reflect restraint use or that the resident needs to be released every 2 hours. 2. Medical record review revealed Resident #61 was admitted to the facility on [DATE], and readmitted 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 moderate cognitive impairment, and the presence of an indwelling urinary catheter. The physician's orders [REDACTED].Order Date .10/28/16 .FOLEY CATHETER . The care plan dated 1/9/17 documented, .incontinent of bowel and bladder at times, check with resident prn (as needed) for toileting needs . The care plan did not address the indwelling urinary catheter. Observations in Resident #61's room on 2/13/17 at 1:59 PM, and 2/14/17 at 10:17 AM, revealed a foley catheter draining to a bedside bag contained in a dignity bag hanging on the bedside. Interview with the Director of Nursing (DON) in the Day Room on 2/14/17 at 4:18 PM, the DON was asked whether she expected the presence of an indwelling urinary catheter to be included and addressed on the care plan. The DON stated, Yes. 3. Medical record review revealed Resident #110 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], and the annual MDS dated [DATE], documented Resident #110 had no cognitive impairment and required staff assistance for all activities of daily living (ADLs). The care plan dated 12/16/16 documented, .Self Care Deficit .Approaches .Assistance to turn and reposition resident prn while in bed and prn while in chair .See inside .closet door for current mode of transfer and assistance needed for ADLs .Keep bed linens free from moisture, wrinkles, and crumbs daily mattress intact for pressure reduction .Side rails down .Keep bed in lowest position, locked .Prefers to go to bed around 9 pm . There was no documentation that Resident #110 prefers to sleep in the recliner. The Assigned Tasks List located inside Resident #110's closet door documented, .Siderails down . There was no documentation that Resident #110 prefers to sleep in the recliner. Observations of Resident #110 in his room on 2/13/17 at 8:39 AM, 10:08 AM, 12:26 PM, and 1:51 PM; and on 2/14/17 at 10:06 AM and 1:44 PM, revealed Resident #110 was sitting in the bedside recliner. Interview with Resident #110 in his room on 2/13/17 at 10:04 AM, Resident #110 stated he slept in the recliner instead of the bed. Interview with LPN #1 on 2/13/17 at 10:38 AM, in the South Hall, LPN #1 was asked whether side rails were used for Resident #110. LPN #1 stated, No. Actually, he sleeps in his recliner . Interview with LPN #1 on 2/14/17 at 1:46 PM, at the South Hall Nurses' Desk, LPN #1 was asked how the Certified Nursing Assistants (CNAs) know what to do for each resident, and whether there was a CNA care plan for the residents. LPN #1 stated, .They have the ADL sheets. They are hanging in the residents' closets. Interview with CNA #7 on the South Hall on 2/14/17 at 1:55 PM, CNA #7 was asked how she knows what care to provide for the residents. CNA #7 stated, .read their careplan .in the closet door Interview with the DON in the Day Room on 2/14/17 at 4:18 PM, the DON was asked whether Resident #110's preference to sleep in the recliner instead of the bed should be on the care plan. The DON stated, It would be good.",2020-02-01
3731,ALLENBROOKE NURSING AND REHABILITATION CENTER,445485,3933 ALLENBROOKE COVE,MEMPHIS,TN,38118,2017-03-02,282,D,1,0,CJSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation and interview, the facility failed to follow care plan interventions for Activities of Daily Living (ADLs) for 1 of 30 (Resident #76) sampled residents of the 45 residents included in the survey. The findings included: 1. The facility's TURNING & REPOSITIONING PROGRAM policy documented .2. Charge Nurse is responsible for visually observing and assisting with turning and positioning as needed .5. All Residents (unless reasons documented in the care plan) are to face the same direction at the same time . Medical record review revealed Resident #76 was admitted to the facility 7/15/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the Brief Interview of Mental Status (BIMS) score was left blank, indicating severe cognitive impairment. Admission Minimum Data Set (MDS) assessment dated [DATE] documented the BIMS was left blank, indicating severe cognitive impairment. Resident #76 was severely cognitively impaired and was totally dependent for Activity of Daily Living (ADL) care. The Care Plan for Resident #76 dated 7/15/16 documented, .self-care deficit related to independently perform ADL's related to cognitive and functional limitations. 1. Goal was resident will be clean, dressed and free of odor . Interventions .staff was to provide necessary privacy, turn and reposition at least every two hours .and provide needed assistance with ADLs. 2. Resident requires Contact Isolation secondary to[DIAGNOSES REDACTED] ([MEDICAL CONDITION]). Staff was to follow contact isolation precautions before and after each interaction of care. 3. Incontinent of B & B (Bowel and Bladder.) .Staff was to provide privacy when providing incontinence care .check resident and provide care as needed q 2 h (every two hours) and PRN (whenever necessary) .Clean and dry thoroughly & change soiled clothing .Keep linens and pads clean and dry .Apply moisture barrier as needed. The updated Daily Care Guide documented, .CONTACT ISOLATION .2 person assist with Marissa lift .Get dressed daily and up in chair .Incontinent of B & B . Medical record review revealed Resident #76 was placed on contact isolation for ESBL (Extended-Spectrum beta-Lactamase) in urine on 7/24/16 and contact isolation for [MEDICAL CONDITION] on 12/1/16. Nurses notes from 9/2/16 through present documented resident required extensive assist with all activity of daily living functions. Observations in Resident #76's room on 1/11/17 at 9:00 AM, Certified Nursing Assistant (CNA)s #4 & #8 entered Resident #76's room after donning gloves and applying mask and gown. The CNA's did not close the door or pull the privacy curtain but proceeded to pull the covers back from Resident #76 and remove her brief. The surveyor asked the CNA's was there anything else they should have done before exposing the resident and CNA #4 stated, We should have pulled the curtain. CNA #4 pulled the curtain at that time but the resident was already exposed. When the CNAs pulled back the bed linen, Resident #76's brief was heavily soiled with urine and liquid formed feces. Interview with the Director of Nursing (DON) on 1/18/17 at 2:19 PM, in the conference room, the DON was asked what is the expectation of staff when providing incontinence or peri care for a resident in contact isolation. The DON stated staff should follow the isolation protocol, wash their hands, put on gloves, gown and mask as indicated. The DON was asked if it was acceptable for staff to provide peri care with the door open and the privacy curtain not pulled. The DON stated No, it is not acceptable. Observations in Resident #76's room on 1/15/17 beginning at 2:20 PM, the surveyor noted a foul smell. The surveyor asked Licensed Practical Nurse (LPN) #2 what CNA was assigned to Resident #76. LPN #2 stated (CNA #4). LPN #2 changed her response after CNA #4 stated she was not assigned Resident #76 since 10 AM. LPN #2 then stated CNA #1 had Resident #76. At 2:25 PM, CNA #1 stated Ma'am, she (LPN #2) just told me I had her (Resident #76). I have not done anything for this lady today. I have not been in this room. CNA #1 entered Resident #76's room, donned gloves, pulled curtain and proceeded to uncover Resident #76. CNA #1 removed a wedge cushion from the left side of resident. Observations of Resident #76 after removing the covers revealed Resident #76 had feces on the top sheet, feces oozing from the adult brief from the front and from behind. There was noted dried and liquid feces in the vaginal area, buttocks and thigh areas. CNA #1 stated, I need to get some help. CNA #1 removed her gloves and went out into hall. CNA #1 did not wash her hands before leaving the room. CNA #1 returned to outside of Resident #76's room with CNA #2. Surveyor asked CNA #1 if Resident #76 was in contact isolation. CNA #1 stated, I didn't know, I never had her before. I just passed right by this isolation cart. CNA #1 was asked if she should do anything else other than wear gloves when changing the brief or providing care for Resident #76. CNA #1 stated, Yes, I should have put on a gown and a mask too. Interview with CNA #1 on 1/15/17 at 2:50 PM, across from Resident #76's room CNA #1 again confirmed she had not provided care for Resident #76 because she thought her assignment was the same as the day before when the assignment changed. CNA #1 stated, I have always stopped at room [ROOM NUMBER], I have never had room [ROOM NUMBER] (Resident #76's room) .we had 5 CNA's until a few minutes ago when I was told I had room [ROOM NUMBER] (Resident #76's room). CNA #1 stated, I did not get an updated Daily Care Guide on this lady, either. Interview with CNA# 4 on 1/15/17 at 3:10 PM, in the hall between east and central halls by the time clock. CNA #4 was asked about her assignment this shift. CNA #4 stated, We started out with 6 CNA's on this hall but they pulled one. We, CNA #2 and me found out about 10 AM. We were walking by the nurses' station and LPN #1 told us. CNA #4 was asked if there were any other CNA's around when she and CNA #2 were told about the assignment change. CNA #4 stated, No, not at that time. CNA #4 was asked if she provided any care for Resident #76 before the assignment changed, CNA #4 stated, Yes ma'am, I did oral care, changed her brief and provided peri-care, and I repositioned her between 8:30-9:00 this morning. Interview with LPN #2 on 1/15/17 at 3:22 PM, in the east dining room, LPN #2 was asked to clarify the CNA assignment for today (1/15/17, 7-3 shift). LPN #2 stated, We started off with 6 CNAs at 7 AM. The nurse (LPN #5) on the west hall apparently pulled CNA #7 and failed to notify either nurse on the east hall of the change . LPN #2 was asked if Resident #76 had received care that day, LPN # 2 stated, Yes. LPN #2 was asked who provided the care. LPN #2 stated, CNA #4 did something for her this morning. LPN #2 stated, She had been in Resident #76's room at 7:30AM, 8:00AM, 11:30 AM, and between 1-1:30 PM, to give tube feeding, meds stuff like that. LPN #2 was asked if she turned and repositioned Resident #76, LPN #2 stated, No. LPN #2 was asked if she noticed Resident #76 lying in the same position for greater than 5 hours. LPN #2 stated, I guess I didn't notice. Interview with CNA #6 in the front parking lot on 1/17/17 at 7:10 AM, CNA #6 was asked if she cared for Resident #76 last night (1/16/17) on the 3rd shift. CNA #6 stated, Yes, I just turned her before leaving for the day. CNA #6 was asked if she worked Saturday night 1/14/17. CNA #6 stated, No, I was off. CNA #6 was asked what time last rounds are performed by the 11-7 shift. CNA #6 stated, We start around 6 and finish around 7, sometimes a little later .I usually do everything for (named Resident #76) just before I leave around 7, when I have her. Interview with the Director of Nursing (DON) on 1/18/17 at 2:19 PM, in the conference room, the DON was asked what is the expectation of staff when providing incontinence or peri care for a resident on contact isolation. The DON stated, Staff should follow the isolation protocol, wash their hands, put on gloves, gown and mask as indicated. The DON was asked if staff did not provide care for Resident #76 for 5 hours or greater, did staff provide adequate ADL care and care per the resident's care plan. The DON stated, No, they did not. The facility failed to provide Activity of Daily Living (ADL) Care related to incontinence care, turning and repositioning, and privacy per the resident's care plan.",2020-03-01
4272,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2016-10-13,325,G,1,1,LFXZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation and interview, the facility failed to follow physician orders [REDACTED].#53, and 90) sampled residents reviewed for nutrition of the 36 included in the stage 2 review. The failure to provide nutritional interventions resulted in an avoidable significant weight loss and harm to Residents #53 and #90. The findings included: 1. Review of the facility's Weight Monitoring policy documented, .Interventions for Weight Management .if significant weight change is identified .the physician and responsible party will be notified .Residents will be weighed weekly X 4, and reviewed until the resident's weight has stabilized or the issue is resolved . 2. Medical record review revealed Resident #53 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the DATA COLLECTION/EVALUATION NUTRITIONAL report dated 2/19/16 revealed, .Problem .Increased protein and calorie needs, unintentional wt (weight) loss, altered nutrition .Etiology .related to skin breakdown, possible protein calorie malnutrition .evidenced by pressure area, 5.7% wt loss upon readmission .Nutrition Plan .promod 4oz (ounces) BID (twice a day), med pass 4oz BID, amino acids, Vit (vitamin) C, Zinc Sulfate, MVI (multivitamins) . Review of the monthly weight records revealed the following: 4/6/16 the resident weighed 191.2 pounds (lbs) 5/4/16 the resident weighed 181.8 pounds lbs 6/8/16 the resident weighed 177 pounds lbs (revealing a 14.2 pound, 7.42% significant weight loss in 2 months). Review of the DATA COLLECTION/EVALUATION NUTRITIONAL report revealed, .06/16/16 .1.1% wt loss x (times) 30 days .4.3% x 90 days. Currently on weekly weights .med pass TID (three times a day) .Resident reported good appetite .no problem noted with chewing/swallowing . There was no documentation of interventions to address the weight loss until 6/16/16 when the med pass was increased to TID. Further review of the monthly weight records revealed the following: 7/6/16 the resident weighed 179 pounds lbs 8/5/16 the resident weighed 164 pounds lbs The annual Minimum Data Set ((MDS) dated [DATE] documented Resident #53 had a Brief Interview for Mental Status (BIMS) score of 13 indicating Resident #53 was cognitively intact per staff assessment and had weight loss. The care plan dated 7/17/15 and revised on 9/1/16 documented, .Problem .is at nutrition risk for unavoidable weight loss due to .poor PO intake, current unhealed pressure wound decreased protein status, .Approach .Weigh and monitor results .report any significant changes to physician . Review of the monthly weight records revealed on 9/7/16 the resident weighed 163.2 pounds lbs (revealing an additional 15.8 pound (8.8 %) significant weight loss in 2 months.) Review of the DATA COLLECTION/EVALUATION NUTRITIONAL report revealed, 09/24/2016 .Recent weight 162.2 .On weekly weights .Diet intake 25-100% with brk(breakfast) and lunch 0-25% with dinner .new order .assist pt (patient) with meals .wt loss per NP (nurse practitioner) .Pt welcomes assistance with intake. She reported that sometimes she gets tired. No new interventions at this time . Review of telephone orders revealed on 9/12/16 the physician ordered to assist Resident #53 with all meals due to weight loss. Observations in Resident #53's room on 10/12/16 at 8:35 AM, revealed Resident #53 lying in bed, with breakfast tray sitting on the bed table with no staff in room assisting her as ordered. Observations in Resident #53's room on 10/12/16 at 6:04 PM, revealed Resident #53 lying in bed, with her uneaten supper tray sitting on the bed table with no staff in room assisting her as ordered. Interview with Certified Nursing Assistant (CNA) #1 on 10/12/16 at 6:20 PM, by the third floor nurse's station, CNA #1 was asked if she assisted Resident #53 with her meals. CNA #1 stated, .no, she is just a set up . Interview with CNA #2 on 10/13/16 at 8:59 AM, by the third floor nurse's station, CNA #2 was asked if she assisted Resident #53 with her meals. CNA #2 stated, .we normally set it up for her and come back .sometimes she eats good and sometimes she don't . Observations and interviews revealed Resident #53 had not received the assistance with meals as ordered. There were no other interventions implemented to address the weight loss. Further review of the monthly weight record revealed continued significant weight loss on 10/4/16 with the resident weighing 150.8 pounds lbs. This was an additional 12.4 pounds (7.5%) significant weight loss in 1 month. The DATA COLLECTION/EVALUATION NUTRITIONAL report revealed, .10/10/2016 .Recent weight 150.8 .PO (by mouth) continues to be inadequate which is contributing to continued wt. loss .Diet order and supplements provided to meet needs if at least 75% consumed. Will continue with current P[NAME] (plan of care) .No further recommendations at this time . There was no documentation additional interventions were implemented to address the continued significant weight loss. Interview with Registered Dietician (RD) #1 on 10/12/16 at 11:59 AM, in the chapel, RD #1 was asked about Resident #53's weight loss. RD #1 stated, .has a history of [MEDICAL CONDITION] and current breast mass .not for sure if that's the contributing factor .on multiple supplements .25-50% intake from lunch and dinner .I have recommend appetite stimulate . RD #1 was asked when she had recommended it . RD #1 stated, .I don't see it . RD #1 was asked what a signification weight loss is. RD #1 stated, 5% in a month . RD #1 was informed Resident #53 lost 13 lbs from (MONTH) to (MONTH) (YEAR) and was asked what interventions she had put in place. RD #1 stated, .saw her on 9/24 was my last note .last intervention .6/16 .was fortified foods . RD #1 was asked what the weight loss percentage for Resident #53 was for the last 30, 90 and 180 days. RD #1 stated, .7.6% in one month for (MONTH) .for 3 month 15.8% .6 months .21.1% . RD #1 was asked if that was a significant weight loss. RD #1 stated, Yes, Ma'am . RD #1 stated, .she is on weekly weights . RD #1 was asked does she have a weight for the third week of September. RD #1 stated, No Ma'am . RD #1 was asked should there have been. RD #1 stated, Yes, Ma'am . RD #1 was asked what weight she used for her assessment on (MONTH) 24th. RD #1 stated, . 9/16 .I saw her on the 24th .we get weekly report we go through and circle the significant changes .but it wouldn't show significant for one week would be for two weeks . RD #1 returned to the chapel at 12:57 PM and presented the Resident Weight Report Weekly and stated, she wasn't circle .I should have reviewed it . RD #1 was asked if Resident #53 had an assessment that week. RD #1 stated, .not by me . RD #1 was asked with Resident #53's 9.2 lb recent weight loss should she have looked at her. RD #1 stated, .she should had been looked at . RD #1 was asked when was Resident #53's last assessment. RD #1 stated, .10/11 . RD #1 was asked was anything put in place for the recent weight loss of 12 lbs . RD #1 stated, .no . RD #1 was asked should there have been interventions put in place. RD #1 stated, .there will be when we get through talking . There was no documentation an appetite stimulant or fortified foods was recommended by the RD. The RD failed to identify, accurately reassess, and implement nutritional interventions to address the continued significant weight loss Resident #53 sustained. Interview with the Nurse Practitioner (NP) on 10/12/16 at 1:15 PM, on the 3rd floor nurses station, the NP was shown Resident #53 weekly weight report regarding her weight loss. The NP was working on Resident #53's history and physical with a weight of 163 lbs documented for 10/5/16, and was asked where she had gotten that weight. The NP stated, .I went by 9/7 . The NP was shown the weekly weight report that documented her current weight on 10/4 was 150.80 lbs which was a 13 lb weight loss. The NP was asked should there have been an intervention put in place for the 13 lb weight loss. The NP stated, .didn't know about all this .definitely going to do something about it . I'm just floored that this has got by us .we haven't done what we needed to do .I will be on top of this .I had no idea her weight had dropped .oh my gosh that's huge . The facility's failure to identify, accurately assess and provide nutritional interventions resulted in harm to Resident #53 who had an avoidable significant weight loss. 3. Medical record review revealed Resident #90 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the weight records revealed that Resident #90 weighed 91.3 pounds on 10/4/16 and 85.8 pounds on 10/12/16. Resident #90 had a 6% weight loss in 8 days which represented a severe weight loss. A physician's orders [REDACTED].D/C (discontinue) CCHO (controlled carbohydrate) portion of diet .Nepro (with) meals and HS (bedtime) .early lunch on [MEDICAL TREATMENT] days . Review of the Medication Administration Record [REDACTED]. Observations in Resident #90's room on 10/12/16, beginning at 10:10 AM, revealed CNA #3 preparing Resident #90 for [MEDICAL TREATMENT] transport. Resident #90 was transported to [MEDICAL TREATMENT] at 10:40 AM. Resident #90 did not receive an early lunch tray before he went to [MEDICAL TREATMENT]. Interview with Dietary Staff #1 on 10/12/16 at 10:46 AM, in the hallway outside the kitchen, Dietary Staff #1 was asked what Resident #90 received before he went to [MEDICAL TREATMENT]. Dietary Staff #1 stated, .a sack lunch .pudding, Ensure Clear and an applesauce .we always give pudding, 2 puddings, applesauce and Ensure Clear in his sack lunch for [MEDICAL TREATMENT] . Interview with Registered Nurse (RN) #1 on 10/12/16 at 6:28 PM, at the second floor nurses station, RN #1 was asked if the 10/7/16 physician's orders [REDACTED]. RN #1 looked at the electronic record for Resident #90 and stated, It's not in here. RN #1 was asked if Resident #90 had received an early lunch tray on [MEDICAL TREATMENT] days and had Resident #90 been receiving the Nepro as ordered. RN #1 stated, No ma'am .the nurse signed it off but she didn't put it in the computer .it makes me want to check all the orders written that day . Interview with the Director of Nursing (DON) on 10/13/16 at 11:25 AM, in the chapel, the DON was asked if nursing staff should put the physicians orders in the computer to make sure they get on the electronic MAR. The DON stated, Yes, they should. Interview with the DON on 10/13/16 at 1:43 PM, in the chapel, the DON was asked if nurses should transcribe orders on the MAR indicated [REDACTED]. The DON stated, .Well I don't think orders should be written late on Friday . The DON was asked if she expected nurses on every shift to be able to transcribe orders to make sure they get put in the electronic system and on the MAR. The DON stated, Yes, but there should still be some communication . The DON was asked if she thought there was a communication breakdown between the nurses and the registered dietician. The DON stated, With her .I sure do . The facility failed to provide recommended and ordered nutritional interventions that resulted in an avoidable significant weight loss and harm to Resident #90.",2019-10-01
544,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2018-09-25,684,D,1,1,B1UN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation and interview, the facility failed to follow physician's orders for medication administration for 2 of 3 (Resident #102 and 108) residents reviewed for administration of medications and failed to follow physician's orders for treatment for 1 of 6 (Resident #108) residents reviewed for wound care and treatment. The findings include: 1. The facility's MEDICATION ADMINISTRATING - GENERAL GUIDELINES policy documented, .Medications are administered as prescribed . 2. Closed medical record review revealed Resident #102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's comprehensive plan of care dated 3/23/18 documented, . 3/23/18 Arterial Ulcer to L (left) and R (right) lower legs .Surgical incision to the chest .Resident keeps pulling dressing off to bilateral legs and mid chest causing areas to reopen after healing .8/3/18 Resident rubbing right foot against sheets, causing blister (even after being redirected and educated by wound nurse) .non compliant with keeping heel Protectors on feet, and removing dressing from right foot . A physician's order dated 8/15/18 documented, .[MEDICATION NAME] Capsule 100 mg (milligram) .Give 1 capsule by mouth two times a day for anti-infective for 7 Days . Review of the medication administration record (MAR) dated 8/1/18 - 8/31/18 revealed the [MEDICATION NAME] was only documented as given on 8/15/18 and 8/22/18. Interview with the Director of Nursing (DON) on 9/25/18 at 3:30 PM in the Medical Director's Office, the DON confirmed the lack of documentation on the MAR and when asked why the [MEDICATION NAME] was not administered as ordered, the DON stated, .That I can not explain . 3. Medical record review revealed Resident #108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's comprehensive plan of care dated 6/30/16 reviewed quarterly and updated as needed documented, .(Named Resident #108) has Chronic [MEDICAL CONDITION] of the BLE (bilateral lower extremity) placing her at risk for repeated infections .9/30/18 [MEDICATION NAME] (anti-infective) BID (twice daily) x (times) 14 days for infection .Perform wound care as per order . The plan of care addressing inappropriate behaviors dated 3/31/17 documented, .(Named Resident #108) has a behavior of refusing care/refusing to take a shower .10/2/17 Not consistently allowing staff to change her - saturated briefs or dressings - leading to possibility of infections . a. The physician's order dated 9/16/18 documented, .[MEDICATION NAME] Tablet 500 - 125 MG .Give 1 tablet by mouth two times a day for Infection .x 14 days .Order Date .09/16/2018 .Start Date .09/30/2018 . Review of the MAR dated 9/1/18 - 9/30/18 revealed the [MEDICATION NAME] had not been documented as given. Interview with LPN #3, on 9/19/18 at 10:45 AM in the Administrator's Office, LPN #3 stated on 9/16/18 she had received a telephone order from the physician to begin [MEDICATION NAME] 500-125 mg twice daily for 14 days [MEDICATION NAME] (a preventive measure). LPN #3 continued the interview and revealed she had given the order to Resident #108's nurse, Registered Nurse (RN) #2 to enter into the electronic ordering system. Observation and interview with LPN #4 on 9/25/18 at 11:45 AM at the 300 hall nurses station, LPN #4 was asked if Resident #108 was receiving [MEDICATION NAME]. LPN #4 revealed the medication was in the resident's medication drawer and stated she had administered one that morning. LPN #4 opened the drawer which contained a prescription box of 26 [MEDICATION NAME] tablets. LPN #4 counted the tablets and there were 18 tablets left to count. Eight tablets of the prescription had been administered. The resident should have received 18 tablets by 9/25/18. LPN #4 checked the resident's electronic MAR to verify she had given the medication and then stated according to the MAR, the [MEDICATION NAME] could not be documented as given until 9/30/18. LPN #4 then stated, .I guess I didn't (give the medication) . The order was entered into the electronic physician's ordering system incorrectly with a start date of 9/30/18 instead of 9/16/18. Interview with the DON on 9/25/18 at 1:07 PM in the DON Office, the DON was asked if Resident #108's [MEDICATION NAME] had not been administered. The DON stated, .It was ordered [MEDICATION NAME] . When asked, if ordered [MEDICATION NAME] or not, should the medication have been given, the DON stated, Yes. Interview with LPN #3 on 9/25/18 at 2:05 PM in the Medical Director's Office, LPN #3 stated RN #2 had entered Resident #108's [MEDICATION NAME] order into the electronic ordering system incorrectly and the resident should have been receiving the medication twice daily starting 9/16/18. b. Review of the physician's wound treatment orders dated 8/9/18 revealed Resident #108's right and left lower leg arterial/venous ulcers were to be cleansed with wound cleanser, patted dry, Mafenide (a prescription anti-infective) applied to the wound bed, a barrier cream applied to the skin surrounding the wounds, covered with collagen dressings (promotes healthy tissue growth) and wrapped with Kerlix (gauze) daily. Review of the MAR dated 9/1/18-9/30/18 revealed Resident #108's wound treatments had not been documented as administered on 9/15/18. Observations in Resident #108's room on 9/20/18 at 2:00 PM revealed the treatment nurse, Licensed Practical Nurse (LPN) #3 performing wound care for the resident. The resident's right lower extremity had a large irregularly shaped open wound on the back and sides of the leg from inner ankle area to the upper calf/shin area with the tendon exposed at the back of the leg between the ankle and mid-calf. The wound measurements were: Length: 28.4 centimeters (cm) x (by) Width 18.5 cm x Depth 0.1 cm. There were scattered areas of necrotic tissue noted. However, approximately 95 percent of the wound was pink/granulation tissue. There was little drainage and no foul odor noted. The left lower extremity had 3 smaller scattered wounds with pink healthy tissue exposed, the largest of which measured: Length 1.8 cm x Width 1.8 cm x Depth 0.1 cm. There was little drainage and no foul odor was noted. Deficient practice was not observed during wound care. Interview with RN #2 on 9/19/18 at 10:45 AM in the Administrator's Office, RN #2 revealed she had been Resident #108's nurse on 9/15/18 and had not completed her wound care as ordered. Telephone interview with RN #3 on 9/20/18 at 11:23 AM, RN #3 was asked if she had completed the wound treatments for Resident #108. RN #3 revealed she had not. Continuing the interview RN #3 revealed she had worked as the Facility House Supervisor on 9/15/18. When asked if she was responsible for performing wound treatments as House Supervisor, RN #3 stated the nurses were responsible for treatments.",2020-09-01
4270,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2016-10-13,282,G,1,1,LFXZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation and interview, the facility failed to follow resident care plan interventions related to pressure ulcers, nutrition and behavior monitoring for 6 of 31 (Resident #2, 53, 49, 64, 92, and 135) sampled residents reviewed for care planning of the 36 residents included in the Stage 2 review. The facility's failure to follow pressure ulcer-related care plan interventions to provide treatments and assessments when the pressure ulcers worsened resulted in actual harm for Resident #2 and #53. The findings included: 1. The facility's Interdisciplinary Assessments policy documented, .Each resident shall have a plan of care developed by the interdisciplinary team. Disciplines shall include, but not be limited to, medical, nursing, social service, nutrition, activities and any other discipline indicated in treatment of [REDACTED].Plans of care shall include the care to be given, objectives to be accomplished (which are measurable and time limited) and the staff and/or professional discipline responsible for each element of care .Modifications to the interdisciplinary plans of care are done by licensed personnel .Changes in a resident's condition may indicate changes to be made in the plan of care .When changes in condition, medications, treatments or approaches occur, the plan of care will be updated .Problems that are no longer applicable will be discontinued . 2. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician orders provided for 9/14/16, 9/28/16 and 10/3/16 revealed the following: a. 9/14/16- .Cleanse sacral wound c (with) wound cleanse (WC). Pat dry. Apply a [MEDICATION NAME] dressing QOD (every other day) for 14 days . b. 9/14/16- .Calcium Alginate c [MEDICATION NAME] QOD for 14 days . c. 9/28/19- .Continue with Calcium Alginate and [MEDICATION NAME] to sacral wound until resolved . d. 10/3/16- .Continue Calcium Alginate c [MEDICATION NAME] QOD until resolved . Review of a treatment record for (MONTH) (YEAR) revealed there was no documentation of the treatments administered as ordered on 9/17, 9/18, 9/19, 9/20, 9/21, and 9/22/16. D/C (discontinue) was written on each date from 9/22/16 through 9/30/16. There was no physician's order to discontinue the wound treatment and the wound was still present on 10/4/16. Review of a treatment record for (MONTH) (YEAR) revealed there was no documentation the treatments were administered as ordered on [DATE], 10/2/16 or 10/3/16. A care plan dated 9/6/16 documented, .Problem .Resident has Pressure Ulcer (s) .SACRUM ONSET 09/06/2016 .STAGEII .Approach .9/20/16 wound treatment as ordered . The failure of the facility to follow the care plan interventions to provide wound care as ordered resulted in actual harm to Resident #2 when the wound deteriorated from a stage 2 to a stage 3. 3. Medical record review revealed Resident #53 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. a. The care plan dated 7/17/15 and revised on 9/1/16 documented, .Problem .is at nutrition risk for unavoidable weight loss due to .poor PO intake, current unhealed pressure wound decreased protein status .Approach .Weigh and monitor results .report any significant changes to physician .Assist resident to eat if he/she becomes fatigued during meals . Review of the weight work sheet revealed the following weekly weights for the month of September, (YEAR): On 9/7/16 the resident weighed 163.2 pounds (lbs). On 9/16/16 the resident weighed 162.2 (lbs). On 9/29/16 the resident weighed 154.0 (lbs). This resulted in a significant weight loss of 5.6 %. There were no weekly weights documented for the third week in September. A telephone order dated 9/12/16 documented, .assist with all meals due to weight loss . Observations in Resident #53's room on 10/12/16 at 8:35 AM, revealed Resident #53 lying in bed, with a breakfast tray sitting on the bedside table with no staff in room assisting her as ordered. Observations in Resident #53's room on 10/12/16 at 6:04 PM, revealed Resident #53 lying in bed, with her uneaten supper tray sitting on the bedside table with no staff in room assisting her as ordered. Interview with Certified Nursing Assistant (CNA) #1 on 10/12/16 at 6:20 PM, by the 3rd floor nurses station, CNA #1 was asked if she assisted Resident #53 with her meals. CNA #1 stated, .no, she is just a set up . Interview with CNA #2 on 10/13/16 at 8:59 AM, by the 3rd floor nurses station, CNA #2 was asked if she assisted Resident #53 with her meals. CNA #2 stated, .we normally set it up for her and come back .sometimes she eats good and sometimes she don't . Interview with Nurse Practitioner (NP) on 10/12/16 at 1:15 PM, on the 3rd floor nurses station, the NP was shown Resident #53 weekly weight report regarding her weight loss. NP was working on Resident #53 history and physical with a weight of 163 lbs documented for 10/5/16, and was asked where she had gotten that weight. The NP stated, .I went by 9/7 . The NP was shown the weekly weight report that indicated a weight on 10/4/16 of 150.80 lbs, a 13 lb difference. The NP was asked should there have been interventions put in place for a 13 lb weight loss. The NP stated, .didn't know about all this .definitely going to do something about it . I'm just floored that this has gotten by us .we haven't done what we needed to do .I will be on top of this .I had no idea her weight had dropped .oh my gosh, that's huge . The facility failed to assist the resident with all meals in accordance with the plan of care, ordered by the physician. b. The care plan dated 7/17/15 and revised on 9/14/16 documented, .Problem .at risk for developing skin breakdown due to needs assist with bed mobility .history of pressure ulcers, left above knee amputation .poor appetite .Approach .Provide treatments as ordered . A physician order dated 9/8/16 documented, .APPLY HYDRAGUARD BARRIER CREAM WITH EACH INCONTINENT EPISODE .SACRAL WOUND . There was no documentaion that wound care was administered as ordered from 9/7/16 through 9/29/16. Interview with LPN #1 on 10/4/16 at 5:24 PM, in the Chapel, LPN #1 was asked about Resident #53's pressure wound. LPN #1 stated, I got here .around the 6th of (MONTH) .it has progressed .not bad .it's a stage 4 now that's what I've known it as .it has undermining .the surface area is smaller .I think its deteriorated because of nutrition status and her comorbidities .she is heavy . LPN #1 was asked where do you document that you have performed wound treatments. LPN #1 stated, .should have a zero on it (MAR) .this is all new to me. LPN #1 confirmed treatments were not done. Interview with the Director of Nursing (DON) on 10/4/16 at 5:57 PM, in the Chapel, the DON was asked about Resident #53's pressure ulcer. The DON stated, .I don't think she had wounds when she came in. The DON was asked the stage of Resident #3's pressure ulcer. The DON stated, .I think it's a three . The DON was asked if empty spaces on the MAR mean that no wound care was provided. The DON stated, .means no documentation . The failure of the facility to follow care plan interventions for nutrition and wound care treatments as ordered resulted in actual harm to Resident #53 when the resident experienced a significant weight loss and the wound developed undermining. 4. Medical record review revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's order dated 9/6/16 documented .cleanse area to R (right) hip c (with) wound cleaner and pat wound dry. skin prep around area. apply xeroform to site and cover c [MEDICATION NAME] 4x4 . A physician's order dated 9/21/16 documented .xeroform daily to R hip wound x 14 days santyl to L hip wound daily x 14 days . A care plan dated 9/23/16 documented, .Problem .Pressure Ulcers xs 2 (times 2) Right Hip Left Hip .Approach .Wound Care as ordered by physician . A physician's order dated 9/29/16 documented .santyl daily to R right and L left hip wounds x 14 days . Review of the MAR indicated [REDACTED]. There was no documentation the facility provided treatments as ordered in accordance with the plan of care. 5. Medical record review revealed Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 8/25/16 documented, Problem .8/25/2016 .at risk for developing skin breakdown .8/29/16 .N.O. (new order) L left (and) R right buttock shearing .9/7/16 .tx (treatment) to sacral wound .As ord (ordered) .9/9/16 requires skilled level II care services D/T (due to) daily wound care for Sacral UTS (unstageable) .Problem .8/25/2016 .has disruption of surface .Left buttock fluid filled blister .Approach .Provide supplemental protein, amino acids .as ordered by the physician to promote wound healing .Treatment as ordered .Problem .9/7/2016 .has Pressure Ulcer .SACRUM .Stage 3 .wound treatment as ordered to sacral . A physician's telephone order dated 9/7/16 documented, .Santyl Daily to sacral wound x 14 days . Review of the MAR for (MONTH) (YEAR) revealed no documentation the Santyl treatment was completed on 9/11/16, 9/18/16, 9/19/16, or 9/20/16. A physician's telephone order dated 9/21/16 documented, .Santyl daily to Sacral/Intergluteal Wound x 14 days. Review of the MAR for (MONTH) (YEAR) revealed no documentation the Santyl treatment was completed on 9/23/16, 9/25/16, 9/27/16, or 9/29/16. A physician's telephone order dated 9/28/16 documented, .Santyl daily to Sacral/Intergluteal Wound x 14 days . Review of the MAR for (MONTH) (YEAR) revealed no documentation the Santyl treatment was completed on 10/2/16. The physician's orders signed 10/4/16 documented, .Order Date 9/7/2016 JUVEN PACKET .MIX 1 PACKET IN LIQUID GIVE ORALLY TWICE DAILY X 30 DAYS DX (diagnosis): Unstageable wound of the sacrum .Stop Date .10/8/2016 . Review of the MAR for (MONTH) (YEAR) revealed there was no documentation that the morning dose of Juven was administered on 9/22/16. Interview with LPN #1 on 10/4/16 at 6:38 PM, LPN #1 was asked about the missing treatment documentation. LPN #1 stated, That was me doing that EMR (electronic medical record) stuff thinking I was doing it right, but I was doing it wrong .It was documentation error, a computer error. Telephone interview with the Medical Director (MD) #1 on 10/13/16 at 5:45 PM, MD #1 was asked whether he expected nurses to perform wound assessments and treatments as ordered. MD #1 stated, Absolutely. MD #1 was asked whether he expected the nurses to document when a treatment or assessment was completed. MD #1 stated, Absolutely. If you've done the treatment, it needs to be documented. 6. Medical record review revealed Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 10/3/16 documented, .at risk for and/or experiencing depression .Taking medications as prescribed ([MEDICATION NAME] 25 mg (milligrams)daily) .Approach .10/3/2016 .Monitor behaviors per tracking tool . The facility was not able to provide documentation the behaviors were monitored in accordance with the plan of care. Interview with the Social Services Director (SSD) on 10/13/16 at 1:49 PM, in the Chapel, the SSD was asked how residents are monitored for behaviors related to depression. The SSD stated, We monitor them for behaviors and depression .The nurses let us know. They are supposed to check that on the nurses note . Interview with Registered Nurse (RN) #1 on 10/13/16 at 3:15 PM, in the Chapel, RN #1 was asked how the resident was monitored for behaviors. RN #1 stated, There is no documentation for behavior monitoring in this record. The nurse failed to check the box (in electronic medical records system) for side effect monitoring .There will be monitoring for the [MEDICATION NAME] side effects from now on. I know that won't help what occurred prior to today . 7. Medical record review revealed Resident #135 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's order dated 8/20/16 documented, .CLEANSE RIGHT INNER WIYH (with) NORMAL SALINE OR WOUND CLEANER, PAT DRY, COVER WITH FOAM DRSG (dressing) CHANGE EVERY OTHER DAY DX: WOUND . A physician's order dated 8/21/16 documented, .CLEANSE RIGHT MEDIAL ANKLE WITH WOUND CLEANER AND PAT DRY. APPLY WOUND GEL AND [MEDICATION NAME] NON-ADHESIVE AND SECURE WITH KERLIX EVERY 3 DAYS AND PRN (when necessary). DX: STAGE 2 . A physician's order dated 8/26/16 documented, .HYDROGEL CLEANSE RIGHT MEDIAL ANKLE WITH WOUND CLEANER AND PAT DRY. APPLY WOUND GEL AND [MEDICATION NAME] NON-ADHESIVE AND SECURE WITH KERLIX DAILY . The care plan dated 8/21/16 documented, Problem .Resident has pressure ulcer(s) .R. Medial Ankle .Stage 1 with a line drawn through it .Stage 2 with a line drawn through it .R. Medial Ankle .Stage 4 .Approach .Observe effectiveness of / response to treatment(s) as ordered - (see physician's orders and EZ-MAR .Wound care as ordered by physician - see current Wound Treatment and Progress Record . The (MONTH) (YEAR) MAR indicated [REDACTED].CLEANSE RIGHT MEDIAL ANKLE WITH WOUND CLEANSER AND PAT DRY. APPLY WOUND GEL AND [MEDICATION NAME] NON-ADHESIVE AND SECURE WITH KERLIX DAILY . This wound care was not documented as being performed on 8/29/16. The (MONTH) (YEAR) MAR indicated [REDACTED]. APPLY WOUND GEL AND [MEDICATION NAME] NON-ADHESIVE AND SECURE WITH KERLIX EVERY 3 DAYS . This wound care was not documented as being performed on 9/5/16 and 9/11/16. Interview with the DON on 10/12/16 at 4:55 PM, in the DON's office, the DON was asked if she expected her staff to follow the resident's care plan interventions. The DON stated, Yes.",2019-10-01
1642,COUNTRYSIDE HEALTHCARE AND REHABILITATION,445280,3051 BUFFALO ROAD,LAWRENCEBURG,TN,38464,2017-07-20,325,E,1,0,4V9N11,"**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 physician orders [REDACTED].#4, and 10) sampled residents reviewed for weight loss. The findings included: 1. The facility's Weight Assessment and Intervention policy documented, .Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian .Interventions .e. Chewing and swallowing abnormalities and the need for diet modifications .The use of supplementation . 2. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set ((MDS) dated [DATE] documented a BIMS score of 0 which indicated severe cognitive impairment and a weight of 160 lbs. Review of a DIETARY PROGRESS NOTES dated 6/1/17 revealed a current weight of 148 lbs and recommendation to offer fortified cereal at breakfast, offer fortified juice with each meal, offer fortified pudding at lunch and supper, and add extra margarine to vegetables. Review of the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of a physician's orders [REDACTED]. Review of meal cards for Resident #4 dated 7/19/17 did not document the fortified cereal ordered on [DATE]. Review of Resident # 4 weight records documented: a. 6/7/17-150 lbs. b. 6/14/17-146 lbs. c. 6/21/17-142 lbs. d. 6/28/17-142 lbs. e. 7/5/17-144 lbs. f. 7/12/17-147 lbs. g. 7/20/17-132 lbs Review of the Medication Administration Record [REDACTED]. Observations of the noon meal on 7/18/17 at 12:50 PM, revealed no fortified pudding on the meal tray or extra margarine on the vegetables as ordered by the physician. Observations of the breakfast meal on 7/19/17 at 7:54 AM and 7/20/17 at 8:20 AM, revealed no fortified cereal on the meal tray as ordered. Observations in the weight room on 7/20/17 at 8:21 AM, revealed Resident #4 current weight was 132 lbs resulting in an 15 lbs (10.2%) weight loss in 8 days. Interview with Dietary Manager on 7/19/17 at 9:54 AM, in the main dining room, the Dietary manager was asked if it was appropriate to not follow doctors order for fortified cereal and fortified pudding. The Dietary Manager stated, No . Interview with Licensed Practical Nurse (LPN) #1 on 7/19/17 at 12:09 PM, in the dining room, the LPN #1 was asked does the resident get fortified food items with his meal trays. The LPN #1 stated, Sometimes they send it .sometimes they don't . The LPN #1 was asked if it was acceptable to not follow doctors orders for diet supplements. LPN #1 stated, No. 3. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's .WEIGHT RECORD documented the following: a. 7/12/17: 154 lbs. b. 7/17/17: 148 lbs. c. 7/20/17: 144 lbs. Resident #10 had lost 10 lbs over a period of 8 days. A physician's orders [REDACTED]. mighty shake @ (at) q (every) meal 2. (symbol for change) diet to pureed consistency R/T (related to) unable to chew Review of the breakfast, lunch and dinner meal cards dated 7/19/17 for Resident #10 did not document a mighty shake as ordered for breakfast lunch and dinner. Review of the facility's Supplement Report dated 7/18/17 did not document a mighty shake for Resident #10. Observations in the secure unit dining room on 7/19/17 at 12:00 PM, revealed Resident #10 seated at the table in a wheelchair. Resident #10's tray was delivered with a pureed diet and no mighty shake on the tray. The meal card did not document a mighty shake. Interview in the main dining room on 7/19/17 at 5:55 PM, the Dietary Manager was asked if there was an order for [REDACTED]. Observations in the weight room on 7/20/17 at 8:27 AM, revealed Resident #10's current weight of 144 lbs. Interview with the DON on 7/20/17 at 8:45 AM, in the quiet room, she was asked did she expect her staff to follow physician orders [REDACTED]. Interview with the Registered Dietitian on 7/20/17 at 9:05 AM, at the Central Nursing Desk, she was asked if she was aware of the order for mighty shakes with meals for Resident #10. She stated, Yes, the nurses told me that day and I told them to write the order. I told (Named Dietary Manager) that day (7/13/17), but she was waiting on the order, I don't know what happened with that . Interview with the Registered Dietitian on 7/20/17 at 9:15 AM, at the Central Nursing Desk, she stated as she handed me a form, Here is the dietary communication, I found it, the nurse failed to write it on there . Interview with CNA #5 on 7/20/17 at 9:30 AM, at the West nursing desk, she was asked if she had seen any mighty shakes on Resident #10's meal tray. CNA #5 stated, No, I haven't seen any, I fed him yesterday and there wasn't one then. Interview with LPN #4 on 7/20/17 at 9:31 AM, at the West nursing desk, she was asked if she had seen a mighty shake on Resident #10's meal trays or given him a mighty shake in the last week. LPN #4 stated, I give him Med Pass (liquid supplement) but not a mighty shake . Interview CNA #6 on 7/20/17 at 9:35 AM, at the West nursing desk, she was asked if she had given Resident #10 a mighty shake at any time. CNA #6 stated, No, and there was not a mighty shake on his tray this morning .",2020-09-01
527,MAJESTIC GARDENS AT MEMPHIS REHAB & SNC,445150,131 N TUCKER,MEMPHIS,TN,38104,2018-07-19,773,D,1,0,0VM311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation and interview, the facility failed to obtain laboratory (lab) tests as ordered and failed to promptly notify the physician of a critical laboratory result for 1 of 3 (Resident #9) sampled residents reviewed for laboratory services. The findings included: Review of the undated (Named Facility) Lab Protocol documented, .Lab results are pulled from (Named Lab Company) system daily Monday-Friday by designated personnel and reviewed by DON (Director of Nursing) and ADON (Assistant Director of Nursing) .All critical labs are to be called to facility per (Named Lab Company) Monday-Friday. Nurses are to accept critical lab reports and call MD (Medical Doctor) with results. Monday-Friday if labs are called after hours then 3-11 supervisor/charge nurses are to take critical lab results and report to MD/DNP (Doctorate Nurse Practitioner) . Medical record review for Resident #9 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #9 was assessed with [REDACTED].#9 was severely cognitively impaired. Review of a physician order [REDACTED].[MEDICATION NAME] Suspension (generic [MEDICATION NAME]) 125 mg/5ml (125 milligrams in 5 milliliters) give 8 ml by mouth every 12 hours for anticonvulsant . Review of a physician order [REDACTED].[MEDICATION NAME] level every 3 months starting on 5/1/18 . The [MEDICATION NAME] level result dated 5/1/18 was low at 7.0 ug/ml (units per gram/milliliter) with a reference range of 10.0-20.0 ug/ml. The physician ordered a one time dose of [MEDICATION NAME] suspension 500 mg (milligram) to be given on 5/2/18. Review of a physician order [REDACTED].Repeat [MEDICATION NAME] level one time . There was no documentation this repeat [MEDICATION NAME] level was obtained as ordered. Review of a physician order [REDACTED]. This [MEDICATION NAME] level result was at a critical level high of 25.4 ug/ml. The physician was notified and gave an order to hold the [MEDICATION NAME] Suspension until 5/25/18 and to repeat the [MEDICATION NAME] level on 5/24/18. There was no documentation this repeat [MEDICATION NAME] level was performed. Review of a physician order [REDACTED].Repeat [MEDICATION NAME] level on 5/24/18 . There was no documentation that this repeat level was obtained. The physician visited the resident on 5/25/18 and ordered a STAT( immediate) [MEDICATION NAME] level to be drawn. This STAT [MEDICATION NAME] level result was high at 23.5 ug/ml. The physician decreased the [MEDICATION NAME] suspension dosage to 7 ml two times a day and ordered a repeat [MEDICATION NAME] level to be drawn in one week. There was no documentation this repeat [MEDICATION NAME] level was performed as ordered. A Nurses note dated 5/31/18 revealed the physician was notified again of the high [MEDICATION NAME] level result dated 5/25/18 with an order obtained to further decrease the [MEDICATION NAME] Suspension dose to 6 ml twice a day and to repeat a [MEDICATION NAME] level on 6/7/18. The 6/7/18 [MEDICATION NAME] level result was a critical high level of greater than 34. The laboratory result form documented the critical high level was called to (Named Licensed Practical Nurse) on 6/8/18 at 7:49 AM. There was no documentation the physician was notified of this critical high result until 6/9/18. The physician discontinued the [MEDICATION NAME] dose until 6/12/18 and ordered a recheck of the [MEDICATION NAME] level to be drawn on 6/11/18. The 6/11/18 level result was within normal limits of 12.7 ug/ml. The physician restarted the [MEDICATION NAME] suspension dosage at 5 ml two times a day on 6/12/18. Observations of Resident #9 on 7/18/18 at 10:30 AM revealed him to be alert, up in a geri chair at bedside watching television and voiced no complaints. Interview with the Unit Manager on 7/18/18 at 7:50 AM, in the Conference room, the Unit Manager was asked about the missed labs and delay in physician notification of the critical lab result and the Unit Manager stated, I am not sure what happened about the 5/2/18 lab order, I do know the 5/24/18 lab order was canceled by the laboratory and was not sure why was not aware of the redraw order for the first of (MONTH) .I saw that critical lab (on 6/9/18) for 6/7/18 and had the LPN handle that on 6/9/18. Not sure why the nurse did not inform the physician of that critical lab. The resident never displayed any symptoms of toxicity. Interview with the Nurse Practitioner on 7/18/18 at 10:00 AM, in the Conference room, the Nurse Practitioner (NP) involved in Resident #9's care was asked about the missed labs and delay in notification of the critical high [MEDICATION NAME] level and the NP stated, I was not aware the levels were not drawn on the first of June, (Named Resident #9) had no signs/symptoms during that time, I decreased his [MEDICATION NAME] slowly .I do expect to be notified of critical lab results. The facility failed to ensure that laboratory tests were obtained as ordered and failed to ensure prompt notification of a critical [MEDICATION NAME] level on Resident #9.",2020-09-01
1639,COUNTRYSIDE HEALTHCARE AND REHABILITATION,445280,3051 BUFFALO ROAD,LAWRENCEBURG,TN,38464,2017-07-20,314,D,1,0,4V9N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation and interview, the facility failed to promote healing and prevent infection when 1 of 1 (Licensed Practical Nurse (LPN) #5) staff members failed to use appropriate technique and appropriate hand hygiene while performing wound care for 1 of 1 (Resident #8) sampled residents observed for wound care. The findings included: 1. The facility's Dressing Change, Clean policy documented, .PR[NAME]EDURE .10. Remove soiled dressing and discard in plastic bag. 11. Dispose of gloves in plastic bag. 12. Cleanse hands by washing .13. Put on second pair of disposable gloves .15. Cleanse wound with prescribed solution. 16. Dispose of gloves in plastic bag .17. Cleanse hands by washing .put on gloves .19. Apply dressing & secure with tape . 2. The facility's Handwashing/Hand Hygiene policy documented, .Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-microbial soap and water .Before and after direct contact with residents .After removing gloves .After handling items potentially contaminated with blood, body fluids, or secretions .The use of gloves does not replace handwashing/hand hygiene . 3. Medical record review revealed Resident #8 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #8 was cognitively intact, and had two stage 2 and one stage 3 pressure ulcers. A PROVIDER ORDERS (Wound Care) order sheet dated 7/6/17 documented, .Sacrum .(Named Dressing) .Tue, Thurs, Sat/Sun, PRN, Bordered Foam Dressing .Left Trochanter .(Named Dressing) .Tue, Thurs, Sat/Sun, PRN, Bordered Foam Dressing . Observations in Resident #8's room on 7/18/17 at 3:50 PM, LPN #5 provided wound care to the sacral and left trochanteric pressure ulcers. LPN #5 washed her hands donned clean gloves and removed the dressing from the left trochanteric wound. Without removing her gloves or washing her hands, she picked up the scissors, cut a piece of the (Named Dressing), opened the foam dressing, pushed the (Named Dressing) into the wound to cover the wound bed, then covered it with the bordered foam dressing using the same soiled gloves. Interview with LPN #5 in Resident #8's room, LPN #5 was asked if she removed her gloves and washed her hands prior to placing the clean dressing on the wound. She stated, No, I knew I didn't, and it was in my mind that I messed up. She was asked if she should have removed the soiled gloves, and washed her hands after removing the dirty dressing. LPN #5 stated, Yes, I should have. Interview with the Director of Nursing (DON) on 7/18/17 at 5:45 PM, in the quiet room, the DON was asked if it was ok for the nurse to clean and pat dry a pressure ulcer, then put the clean dressing on it without washing her hands or changing gloves. The DON stated, No, they should clean their hands and put on clean gloves and then put the new dressing on.",2020-09-01
4269,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2016-10-13,280,D,1,1,LFXZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation and interview, the facility failed to revise the resident care plans for pressure ulcers, nutrition, and refusal of care for 4 of 31 (Resident # 2, 14, 24 and 64) sampled residents reviewed included in the stage 2 review. The findings included: 1. The facility's Interdisciplinary Assessments policy documented, .Each resident shall have a plan of care developed by the interdisciplinary team. Disciplines shall include, but not be limited to, medical, nursing, social service, nutrition, activities and any other discipline indicated in treatment of [REDACTED].Plans of care shall include the care to be given, objectives to be accomplished (which are measurable and time limited) and the staff and/or professional discipline responsible for each element of care .Modifications to the interdisciplinary plans of care are done by licensed personnel .Changes in a resident's condition may indicate changes to be made in the plan of care .When changes in condition, medications, treatments or approaches occur, the plan of care will be updated .Problems that are no longer applicable will be discontinued . 2. The facility's Care Plans policy documented, .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 . 3. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The weekly skin report dated 9/6/16 documented, Wound Location: .Sacrum .Wound Type .Open Area .Status: Ulcer .L (length) 0.8 x W (width) 0.9 x D (depth)0.1 . The report revealed the pressure ulcer was acquired in the facility and was not present on admission. Review of a care plan dated 9/6/16 documented, .Problem .Resident has Pressure Ulcer(s) .SACRUM ONSET 09/06/2016 .STAGE II .Approach .9/20/16 wound treatment as ordered . The Weekly Wound report dated 9/22/16 documented, .Wound Location .Sacrum .Wound Type: .Pressure Ulcer .Wound Measurements (LxW) 0.2000 (L) x 0.2000 (W)cm (centimeters) .Depth (D): 0.1000cm .Wound Stage: Stage 3 . The Weekly Wound assessment by the treatment nurse dated 9/22/16 and 9/28/16 documented, .Wound Location .Sacrum .Wound Measurements (LxW) 0.2000 x 0.2000cm .Depth 0.1000cm Present On Admission: False Wound Stage:3 . An IDT Note dated 9/30/16 documented, .IDT/PAR (Patient At Risk) review r/t (related to) FAPU (facility acquired pressure ulcer), Stage III (3) to Sacrum . The Weekly Pressure Wound Tracking report dated 10/4-10/10/16 documented Resident #2 had a stage 3 pressure ulcer to her sacrum. The failure of the facility to revise the care plan to reflect the pressure ulcer status change from a stage 2 to a stage 3. 4. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the weight records revealed on 6/1/16 the resident weighed 110 pounds (lbs) and on 10/6/16 the resident weighed 92.6 lbs. Resident #14 had a 30 day weight loss of 8.7%, and a 90 day weight loss of 12.4%. Observations in the residents room on 10/12/16 at 11:07 AM revealed Resident #14 ate 1/2 boiled egg, drank her supplement, and stated I don't eat, it makes me sick .'' Interview with Licensed Practical Nurse (LPN) #7 on 10/13/16 at 10:32 AM, in the hall by room [ROOM NUMBER], LPN #7 was asked about Resident #14's food intake. LPN #7 stated, (Resident #14) refuses her food and her medication . Interview with LPN #8 on 10/13/16 at 7:20 PM, on the 2nd floor nurses station, LPN #8 was asked if Resident #14 had a care plan for refusing nutrition. LPN #8 stated, They don't have one. LPN #8 was asked should Resident #24 should have a care plan for refusing medication and meals. LPN #8 stated, Yes. The care plan dated 6/14/16 and revised 10/11/16 for Resident #14 revealed the care plan did not reflect Resident #14's refusal of nutrition. 5. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the weight records revealed the following: a. On 4/6/16 the resident weighed 124.3 pounds (lbs) b. On 5/6/16 the resident weighed 122 lbs c. On 6/7/16 the resident weighed 126.4 lbs d. On 7/6/16 the resident weighed 124.6 lbs e. On 8/3/16 the resident weighed 124.2 lbs f. On 9/9/16 the resident weighed 116.0 lbs g. On 10/6/16 the resident weighed 108 lbs Resident #24 had a 30 day weight loss of 6.89%, 90 day weight loss of 12.9% and 180 day weight loss of 13.1%. The Progress Notes Report (Nutritional Note) dated 9/18/16 documented, Est (Estimated) needs cannot be met with current po (by mouth) intake . Observations in Resident #24's room on 10/12/16 at 12:48 PM, revealed Resident #24's lunch tray with Barbeque (BBQ), beans, milk shake, tea, fruit and a cookie. Resident #24 stated she was full after a bite of BBQ. Observations in Resident #24's room on 10/12/16 at 5:54 PM, revealed Resident #24 stated, .not hungry, and do not want to eat or drink . Observations in the Chapel on 10/14/16 at 8:14 PM, revealed a SW entered the Chapel with the care plan for Resident #24 refusing nutrition in her hand and stated, I was informed by MDS to make them and bring them to you. Interview with the LPN #8 on 10/13/16 at 7:20 PM, on the 2nd floor nurses station, LPN #8 was asked if Resident #24 has a care plan for refusing nutrition, LPN #8 stated, .don't have one. LPN #8 was asked should Resident #24 have a care plan for refusing medication and meals. LPN #8 stated, Yes. The care plan did not included interventions to address that Resident #24 was refusing nutrition. 6. Medical record review revealed Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 8/25/16 documented, Problem .8/25/2016 .at risk for developing skin breakdown .8/29/16 .N.O. (new order) L (left) (and) R (right) buttock shearing .9/7/16 .tx (treatment) to sacral wound .As ord (ordered) .9/9/16 requires skilled level II care services D/T (due to) daily wound care for Sacral UTS (unstageable) .Problem .8/25/2016 .has disruption of surface .Left buttock fluid filled blister .Approach .Provide supplemental protein, amino acids .as ordered by the physician to promote wound healing .Treatment as ordered .Problem .9/7/2016 .has Pressure Ulcer .SACRUM .Stage 3 .wound treatment as ordered to sacral . The DAILY SKILLED NURSE'S NOTES documented the following: 8/20/16: .Delusions .Verbal behaviors .Reject evaluation or care . 8/25/16: .Verbal behaviors .Resident refuses to feed self .cussing staff and family out . 8/28/16: .Delusions .Verbal behaviors .CONT TO REFUSE TO ASSIST WITH FEEDING CUSSING STAFF OUT CONFUSION AT TIMES REDIRECTION GIVEN RESIDENT STARTS TO CRY SAYING SHE CALLING THE POLICE . 9/28/16: .Reject evaluation or care . 10/7/16: .Reject evaluation or care .Resident A&O and refuses care, treatments, and meals . The health status notes dated 10/4/16 revealed, .REFUSED LUNCH .REFUSED JUNVA (Juven) AND PROMOD .OFFER OTHER FOODS REFUSED .REFUSED DINNER X3 . The skin/wound notes documented the following: 10/3/16: .refuses aat (at) times to wear the heel protectors .at times refuses to eat . 10/6/16: .increased behaviors and refusal of care . A physician's consult dated 9/13/16 documented, .Acute eval (evaluation) (due to) decline. Not progressing appropriately. Not eating. Not participating in PT .family .has come .will not talk .or interact .would not answer quest (questions) .would not talk .A/P (Assessmemt/Plan) .decline .depression . A behavior note dated 9/15/16 documented, .refused care most of the time . A weekly nurse's note dated 9/29/16 documented, .refused dinner x 4 days .refused to wear collar pain brace . Observations of Resident #64 in her room on 10/4/16 at 9:05 AM and 12:35 PM, revealed Resident #64 refused to eat when staff attempted to assist her with meals. Observation of Resident #64 in her room on 10/12/16 at 8:20 AM, revealed Resident #64 stated, I don't want all that . when staff served her meal to her. Interview with LPN #3 on 10/4/16 at 9:06 AM, at the 3rd floor nurses station, LPN #3 was asked whether resident required eating assistance. LPN #3 stated, Yes. They have offered to help her this morning, and she has refused twice . Interview with LPN #6 on 10/13/16 at 1:27 PM, in the Chapel, LPN #6 was asked whether the behavior of refusal of care and services should be on the care plan. LPN #6 stated, Yes. The care plan was not revised to reflect Resident #64's behaviors of refusal of care and services.",2019-10-01
2115,LAUDERDALE COMMUNITY LIVING CENTER,445354,215 LACKEY LANE,RIPLEY,TN,38063,2017-05-05,328,D,1,0,QMFO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation and interview, the facility failed to suction respiratory secretions to ensure airway patency for 1 of 1 (Resident #61) sampled residents reviewed. The findings included: The facility's SUCTIONING THE UPPER AIRWAY (ORAL PHARYNGEAL SUCTIONING) policy documented, The purpose of this procedure is to clear the upper airway of mucous secretions and prevent the development of respiratory distress .Older clients are more susceptible to aspiration of secretions because of weakened cough and gag reflexes .Access (assess) for the following signs and symptoms of respiratory distress: b. Gurgling .f. Obvious secretions .in mouth . Medical record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] documented Resident #61 was severely cognitively impaired. Resident #61 required extensive assistance for all Activities of Daily Living (ADL). Review of the grievance logs from January-April (YEAR) revealed there were 3 grievances filed for poor care and oxygen tubing on the floor. The facility failed to investigate and could not provide a thorough investigation of these concerns. Observations on 4/29/17 at 4:55 PM, in Resident #61's room revealed, Resident #61 was in a reclined geri-chair, coughing with a gurgling sound. Observations on 4/29/17 at 5:35 PM in Resident #61's room, revealed the resident was coughing and gurgling. Then a large amount of white secretions exploded out of her mouth, running down her chin. Interview with Confidential Interviewee (CI) #2 on 4/27/17 at 4:35 PM, in the conference room, CI #2 was asked if any complaints/grievances had been filed with the DON.I have been to her 8-10 times .the mucus in her throat .I'm afraid she is going to choke to death .But they don't suction her unless I go get them .I get tired of fighting them .",2020-09-01
2866,BELLS NURSING AND REHABILITATION CENTER,445463,213 HERNDON DRIVE,BELLS,TN,38006,2018-04-19,880,D,1,0,609411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview the facility failed to prevent the potential spread of infections by 1 of 1 (Licensed Practical Nurse (LPN) #1) nurses observed during wound care. The findings included: The facility's Handwashing/Hand Hygiene policy documented, .Dry hands with paper towels and then turn off faucets with a clean, dry paper towel . The facility's TREATMENT/WOUND CLEANSING/DRESSING CHANGES policy documented, .Put on gloves and remove dirty bandage and place in double bagged garbage bag remove gloves and place in doubled garbage bag .Perform proper hand hygiene .Put on new gloves and prepare to cleanse wound .Clean wound well .At this time remove your dressing field and throw in double bag garbage along with your gloves .Perform proper hand hygiene . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of wound care in Resident #1's room on 4/12/18 at 8:33 AM revealed LPN #1 gathered her supplies, placed them on the over bed table, closed the privacy curtains, washed her hands, turned off the faucet with the same paper towel with which she dried her hands, applied gloves, positioned the resident on her right side, and loosened the resident's brief. Resident #1 was noted to have a small amount of bowel movement. LPN #1 removed her gloves, assembled her supplies, and applied new gloves without performing hand hygiene. LPN #1 cleaned the resident, removed her gloves, washed her hands and turned the faucet off with the wet paper towel. LPN #1 applied gloves, placed a barrier and a red biohazard bag on the bed, opened the supplies, removed the old dressing, and discarded the dressing in the red biohazard bag. LPN #1 cleansed the wound, removed her gloves, applied new gloves and applied ointment without performing hand hygiene at any time. LPN #1 then removed her gloves, applied new gloves without performing hand hygiene, packed the wound with Calcium Alginate, applied foam dressing, and applied a dry dressing. She then removed her gloves, performed hand hygiene, and turned the faucet off with her bare hands. LPN #1 applied gloves, changed the linens, repositioned the resident in the bed, and removed her gloves without performing hand hygiene. LPN #1 then disposed of the red biohazard bag, performed hand hygiene and turned off the faucet with the wet paper towel. Interview with the Director of Nursing (DON) on 4/12/18 at 9:20 AM in the activity room, the DON was asked if it was acceptable to not perform hand hygiene after removing the old dressing, to turn off the faucet with her bare hands and turn the faucet off with the wet paper towel. The DON stated, No. Interview with the Medical Director (MD) in the activity room on 4/12/18 at 9:36 AM, the MD was asked if he would expect the staff to perform good hand hygiene during dressing changes according to the facility's policies. The MD stated, Yes, ma'am. Interview with LPN #1 on 4/12/18 at 10:08 AM in the activity room, LPN #1 was asked if it was acceptable to not perform hand hygiene after she removed the dirty dressing and to turn off the faucet with her bare hands. LPN # 1 stated, No.",2020-09-01
3174,"COLLIERVILLE NURSING AND REHABILITATION, LLC",445495,490 WEST POPLAR AVENUE,COLLIERVILLE,TN,38017,2019-02-06,692,D,1,1,XLPJ11,"**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 5 (Resident #45) sampled residents reviewed for nutrition received their tube feeding formula at the prescribed rate. The findings include: The Enteral Nutrition undated policy documented, .Adequate nutritional support through enteral feeding will be provided to residents as ordered . Medical record review for Resident #45 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #45 was cognitively in a vegetative state and received nutrition through a PEG feeding tube. A physician's orders [REDACTED].(symbol for increase) [MEDICATION NAME] 1.5 to 60ml (milliliters)/hr (hour) . Observations in Resident #45's room on 1/9/19 at 1:00 PM, revealed the tube feeding was infusing at 55 ml/hr. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Interview with Registered Nurse (RN) #1 on 1/9/19 at 1:20 PM, in the Nurses' Station, RN #1 was asked about the order to increase the feeding and she stated, .was not aware of that order . Interview with the Regional Director of Clinical Services on 2/4/19 at 4:10 PM, in the Conference Room, the Regional Director of Clinical Services confirmed there was no other documentation of Resident #45's tube feeding from 1/1/19-1/9/19. The facility failed to increase the tube feeding for Resident #45 as ordered from 1/1/19-1/9/19.",2020-09-01
1996,GRACELAND REHABILITATION AND NURSING CARE CENTER,445331,1250 FARROW ROAD,MEMPHIS,TN,38116,2020-02-10,656,J,1,0,U67J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to ensure a Comprehensive Care Plan was developed for elopement risk/exit-seeking behaviors for 1 of 4 sampled residents (Resident #1) reviewed for wandering, exit-seeking behaviors, and elopement. The facility failed to ensure the comprehensive Care Plan included interventions to minimize the risk of elopement for a cognitively impaired resident with known exit-seeking behaviors, which resulted in Immediate Jeopardy for Resident #1 when she exited the facility through a window and then a hole in the facility's fence, crossed a major 7 lane highway, and walked to a neighborhood 1.3 miles from the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-656 on 2/5/2020 at 2:45 PM, in the Conference Room. F-656 was cited at a scope and severity of J. A partial extended survey was conducted on 2/7/2020 through 2/9/2020. The Immediate Jeopardy was effective from 11/1/2019 to 2/9/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 2/7/2020 at 3:00 PM. The Removal Plan was validated onsite by the surveyors on 2/9/2020-2/10/2020 through review of policy related to active exit-seeking behavior, assessments, inservice training records, and staff interviews. The findings include: Review of the facility's undated policy titled, Care Planning, showed that the facility should develop an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident needs and is developed for each resident. The comprehensive care plan is designed to identify problem areas, incorporate risk factors associated with identified problems. Areas of concern are triggered during the resident assessment before interventions are added to the care plan, interventions are designed after careful consideration between resident's problem areas and their causes. The care plan is developed within 7 days of completion of the comprehensive assessment. The nurses on the unit are responsible for all episodic care planning. Assessments of residents are ongoing and care plans are revised as information changes. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plan. Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the Elopement Risk Evaluation dated 7/25/2019, showed Resident #1 was at risk for elopement. Review of the admission Minimum Data Set ((MDS) dated [DATE], showed Resident #1 was assessed to be severely impaired cognitively. Review of the Comprehensive Care Plan dated 8/6/2019, showed there was not a Care Plan developed related to Resident #1's assessed risk of elopement. Review of the Nurses' Notes dated 11/1/2019 and 11/14/2019, showed that Resident #1 exited a door on the 700 Hall and was redirected back into the facility by staff. Review of Resident #1's Social Services note dated 1/16/2020 documented, .exit (exited) the building (Resident #1 was found by a police officer 1.3 miles from the facility) .returned safely .according to officer they received a called (call) resident was picked up . Observation in the Activity Room on 2/3/2020 at 10:00 AM, showed Resident #1 was seated in a wheelchair listening to music. A wanderguard was noted to her left ankle. Observation in the resident's room on 2/5/2020 at 8:04 AM, showed Resident #1 was up walking in her room. Observation in the 800 Hall on 2/6/2020 at 4:03 PM, showed Resident #1 was seated in a wheelchair using her feet to move her wheelchair briskly down the hall toward the Nurses' Station. Observation in the Dining Room on 2/8/2020 at 12:40 PM, showed Resident #1 was eating lunch, and self-propelled herself in the wheelchair. During an interview on 2/7/2020 at 2:02 PM, the Director of Nursing (DON) confirmed that Resident #1's Comprehensive Care Plan dated 8/6/2019 should have had interventions in place for Resident #1's elopement risk on admission. The facility failed to ensure a Comprehensive Care Plan was developed to include interventions to minimize the risk of elopement for a cognitively impaired resident with known exit-seeking behaviors, which resulted in IJ for Resident #1 when she exited the facility through a window and then a hole in the facility's fence, crossed a major 7 lane highway, and walked to a neighborhood 1.3 miles from the facility. Refer to F-600, F-610, F-657, and F-689. The surveyors verified the Removal Plan by: 1. Resident #1 was assessed on 1/16/2020 and reassessed on 2/5/2020 to ensure the accuracy of the assessment. The surveyors reviewed the assessments. 2. A Care Plan will be updated with additional interventions related to elopement risks for Resident #1. The surveyors reviewed Resident #1's Care Plan. 3. All residents will have an elopement assessment on admission, quarterly, and as needed. Inservice and education was initiated on 2/5/2020 with all licensed staff regarding the elopement assessment tool. No licensed nurse will be allowed to work until inservice is completed to include new hires. Protocol forms implemented were: -30-minute Elopement/Exit-Seeking Form -Elopement Risk Rounds -High Risk Elopement Location Sign In/Out Sheet -CNA Shift Change Communication Form for Elopement/Exit Seeking/Wanderers -Elopement/Exit-Seeking Report -Elopement/Exit-Seeking Notification Checklist -Elopement/Exit-Seeking Checklist -Elopement/Exit-Seeking Investigation Information -Elopement/Exit-Seeking Investigation Interview Sheet -Elopement Risk Evaluation The surveyors reviewed assessments, inservice records, and interviewed licensed staff on all shifts. 4. All residents with a high risk of elopement were assessed on 2/5/2020 for accuracy. The surveyors reviewed the assessments. 5. All residents will have a care plan that addresses elopement risks with interventions to address residents' needs and will be updated with any incidents that occur and with appropriate interventions. Unit managers/Designees will ensure Care Plans are in place and will be reviewed on the daily clinical report and discussed in clinical meetings daily. Unit Managers/Designees will be educated on the proper protocol to complete a Care Plan and update with appropriate interventions. The surveyors interviewed the administrative staff, staff on all shifts, and Unit Managers. 6. Care Plans for all residents with a high risk of elopement have been audited on 2/5/2020. The surveyors reviewed the Care Plans. Noncompliance of F-656 continued at a scope and severity D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.",2020-09-01
2479,MAPLEWOOD HEALTH CARE CENTER,445412,100 CHERRYWOOD PLACE,JACKSON,TN,38305,2020-02-26,584,D,1,0,1M5011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to ensure a clean and sanitary environment for 4 of [AGE] rooms (room [ROOM NUMBER], #407, #409, and #504), which had the potential to result in infection control issues for the residents residing in these rooms. The findings include: Review of the facility's undated policy titled, Deep Cleaning List, showed, .Clean Equipment. Review of the facility's policy titled, Infection Control-Standard Precautions, dated 8/2017, showed, .Ensure that environmental surfaces.and other frequently touched surfaces are appropriately cleaned. Observations of the residents' rooms on 2/26/2020 beginning at 2:04 PM, showed the following: room [ROOM NUMBER], #407, #409, and #504 had a black substance in the air conditioner unit vents. During an interview conducted on 2/26/2020 at 2:04 PM, in room [ROOM NUMBER], the Administrator confirmed the findings and stated, Looks like mildew. During an interview conducted on 2/26/2020 at 2:06 PM, in room [ROOM NUMBER], the Administrator confirmed the findings and stated, Mildew. During an interview conducted on 2/26/2020 at 2:08 PM, in room [ROOM NUMBER], the Administrator confirmed the findings and stated, Same as the others (Mildew). During an interview conducted on 2/26/2020 at 2:42 PM, in room [ROOM NUMBER], the Administrator confirmed the findings and stated, Looks like mildew and dust.",2020-09-01
2708,AHC MEADOWBROOK,445443,1245 E COLLEGE ST,PULASKI,TN,38478,2019-08-09,689,J,1,0,VK9F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to ensure a safe environment that provided adequate supervision to prevent elopement for 1 of 4 (Resident #2) sampled residents with wandering behaviors and assessed as an elopement risk, which resulted in Immediate Jeopardy (IJ) when Resident #2 exited the facility and was found at the hospital, 0.2 miles from the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility identified 6 cognitively impaired residents with wandering behaviors who were independently mobile via ambulation or wheelchair. The facility reported a total census of 47 residents. The Administrator and the Regional Director of Operations were notified of the Immediate Jeopardy (IJ) on 8/9/19 at 3:33 PM in the Conference Room. F-689 was cited at a scope and severity of J and is Substandard Quality of Care. A partial extended survey was conducted on 8/9/19. The IJ was effective from 7/31/19 through 8/1/19. The IJ was removed on 8/2/19 when the facility implemented a corrective action plan. Corrective actions were validated by the surveyor on 8/8/19 - 8/9/19. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction. The findings include: The facility's Elopements and Wandering Patients policy undated documented, .This facility ensures that residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment, and had poor decision making skills. Resident #2 required cues and supervision and wandering occurred 4-6 days of the assessment period. Resident #2 had an unsteady gait, did not use assistive devices, and was able to stabilize without human assistance. The Care Plan revised 6/18/19 documented, .Assess potential physical causes for wandering (need for toilet, water, food, pain relief) .Redirect (Resident #2's name) behavior/activity when wandering is observed .Problem date 10/24/18 .Wandering Behaviors .PROBLEM Date: 7/31/19 Pt (patient) had an incident of elopement. Visitor opened door for pt (patient) to go out .Ensure the door alarms/locks are armed to reduce risk of (Resident #2's name) leaving secure area An Elopement Risk assessment dated [DATE], 11/28/18, 3/13/19, 6/18/19, and 8/1/19 documented, .cognitive impairment and/or poor decision making skills . The assessments revealed Resident #2 was at risk for elopement. The physician's orders [REDACTED].(3/29/19 start date) Wander Guard .Notes: Wander guard in place .Monitor .Notes: placement of wanderguard . Review of the (Named Hospital) history and physical dated 7/31/19 documented, .pt (patient) (Resident #2) found by hospital security walking around the woods behind the hospital (in the hospital upper parking lot), pt confused, states 'a friend dropped me off and didn't come back' pt denies complaint, follow commands .verbal response: Confused .Patient (Resident #2) is disoriented .ED (Emergency Department) Course: 20:26 (8:26 PM) Patient (Resident #2) arrived in ED .(8:50 PM) (Named Resident #2's contact person) called from contact info (information) regarding pt (Resident #2), (Resident #2's contact person) informed (this caller) that pt (Resident #2) was a resident of (Named Nursing Home) .history of Alzheimer's, [MEDICAL CONDITION], hallucinations, and possible [MEDICAL CONDITION] .CONFUSION DON'T KNOW WHERE SHE (is) .Skin: lesion(s) (none documented) . Review of the Clinical Note dated 7/31/19 at 11:55 PM documented, .pt returned via stretcher with EMS (Emergency Medical Services) .pt's demeanor is calm, cooperative, and joking/playful. Alarm for wanderguard activated as pt entered facility, reset alarm. pt continues to wear wanderguard bracelet to right ankle and is functioning properly. pt ambulating in room/hall with steady gait. when asked why she left, pt states 'I don't know what you're talking about. I went on a picnic and got 2 good looking men . Observations in the common areas of the facility on 8/6/19 at 9:45 AM, 10:40 AM, 12:10 PM and 1:26 PM, 8/7/19 at 9:36 AM, 8/8/19 at 6:58 PM and 7:53 PM, and 8/9/19 at 11:10 AM and 12:26 PM, revealed Resident #2 was ambulating in the halls with her blue bag on her arm, a wanderguard on her right ankle, and she was confused. Resident #2 walked to the front door multiple times but stopped at the front door mat and would look around. Resident #2 never touched the door or activated the alarm. Observations of the area beside the facility on 8/8/19 at 7:47 PM, revealed a slightly sloped embankment with low cut grass. There was a physician's parking lot with street lights and flood lights directed at the parking area. There was a 6 inch curb from the grassy area to the pavement. The hospital parking lot on the lower level had a 6 inch step-up to the curbs and the walkway. The upper parking lot to the hospital (where Resident #2 was located after her elopement from the facility) had a wooded area that was approximately 20 to 30 feet from where Resident #2 was located. Interview with the Administrator on 8/6/19 at 9:30 AM in the Conference Room, the Administrator was asked about Resident #2's elopement and she stated, A visitor (Visitor #1) was taking (Visitor #1's) mother out on the front porch and when another visitor and (Named Resident #2) went through the door. (Visitor #1) deactivated the alarm . Interview with the Maintenance Supervisor on 8/6/19 at 9:40 AM in the Conference Room, the Maintenance Supervisor was asked about Resident #2's elopement incident on 7/31/19. The Maintenance Supervisor stated, .I checked all the doors before and after it (elopement) happened .they were working properly .I checked her wanderguard and it was functioning properly .I checked all the residents with wanderguards and they were working properly . The Maintenance Director stated he checked the doors weekly for wanderguard activation. Interview with Certified Nursing Assistant (CNA) #1 (Resident #2's CNA on the night of the elopement, 7/31/19) on 8/8/19 at 6:59 PM in the Conference Room, CNA #1 was asked when Resident #2 was last seen on 7/31/19. CNA #1 stated, .I seen her walk down to the 200 Hall at 7:30 PM .I received a call at 8:30 PM from the hospital and went to get the charge nurse . Interview with Registered Nurse (RN) #1 (the Charge Nurse on the night of the elopement, 7/31/19) on 8/8/19 at 7:01 PM at Nurse's Station #1, RN #1 was asked when Resident #2 was last seen on 7/31/19. RN #1 stated, .(Resident #2's name) was ambulating in the hall at 7:00 PM . Interview with Visitor #1 on 8/8/19 at 7:10 PM on the Front Porch, Visitor #1 was asked when she last saw Resident #2 on 7/31/19. Visitor #1 stated, .we (Visitor #1 and her mother) were sitting on the front porch when (Resident #2) came out the door with another visitor. It set the alarm off and I went in and cut the alarm off .we sat on the porch awhile and when we started in (Resident #2) stopped and said she (Resident #2) would go this way .I didn't think anything about it because they (residents) use the other door too .I didn't know (Resident #2) didn't go in .it was about 20 till 8:00 (7:40 PM) .she went toward the other door .I hate I had cut the alarm off. I won't ever do that again . Interview with the Hospital Security Officer (that located Resident #2) on 8/8/19 at 7:55 PM outside the (Named Hospital) emergency room (ER) Waiting Room, the Security Officer was asked when he first saw Resident #2 on 7/31/19. The Security Officer stated, .I just happened to get a glimpse of her in the upper parking lot .she wasn't in the woods, she was standing in the middle of the parking lot .she was confused .first saw (Resident #2) at 8:00 (PM) . Interview with the Hospital ER Registered Nurse (RN) (the RN that notified the facility of Resident #2's elopement) on 8/8/19 at 8:04 PM in the ER, the RN was asked how long Resident #2 was in the hospital before the facility was notified. The RN stated, .About 20 minutes . The RN was asked about Resident #2's assessment in the ER. The RN stated, .she wasn't hurt .she was clean .she had a UTI (urinary tract infection) . Telephone interview with the Medical Director on 8/9/19 at 1:10 PM, the Medical Director was asked if he was involved in the Quality Assurance (QA) meeting, and he stated, Yes . The Medical Director was asked if the plan put into place after the elopement was effective, and he stated, Yes . The Medical Director was asked if the visitor had not disarmed the alarm, would Resident #2 have been able to exit the facility. The Medical Director stated, No, I do not think so . The facility failed to ensure a safe environment for Resident #2 when the staff had no knowledge of her location for approximately 1 hour. Resident #2 had been assessed and documented as cognitively impaired with a risk for elopement. Resident #2 eloped from the facility on 7/31/19 and was found approximately 1 hour later on 7/31/19 in the middle of the upper hospital parking lot. The facility's corrective action plan included the following: On 8/1/19 the facility did the following: [NAME] Staff confirmed Resident #2's whereabouts every 15 minutes for 3 days. B. The Maintenance Supervisor checked the functionality of all 5 exit doors with a wanderguard tester, door code boxes and the alarm systems of the doors. C. The Maintenance Supervisor checked the functionality of all wanderguards. D. Signs were posted at the front and back of the front door entrance. The sign on the key pad beside the doors documented, ATTENTION VISITORS!! Please do not let residents outside without notifying the charge nurse. Our residents' safety is our priority. If you see someone outside unsupervised, please notify someone immediately. Please do not take any resident outside other than your family member without permission from the charge nurse. Thank you for helping keep (Named Nursing Home) a safe place to call home. E. The security codes to all 5 entrance/exit doors were changed by the Maintenance Director. F. The facility conducted in-service education on wandering residents, elopement, and systemic changes that were implemented to promote resident safety with 100% of the staff. Staff were required to have the in-service education prior to working their next shift. 1. If staff observed changes in a resident's behavior that included wandering and/or exit seeking behavior, the nurse completed an elopement risk assessment. After completing the risk assessment, if the resident was determined to be at risk of elopement, the resident was to be added to alert charting to be completed by nursing. 2. The CNA is to communicate to nurses any observed changes in a resident's behavior that involved wandering and/or exit seeking. 3. If any entrance/exit door alarm sounds, a staff member is to go to the door and check outside and never assume it was a visitor. 4. Never give anyone the code to the doors. [NAME] The Elopement Prevention Tips were placed at each nurses' station. H. Letters were mailed to all families that only staff are allowed to deactivate the alarm system. All visitors are to have a visitors pass when taking a resident out of the building and return it to the charge nurse when reentering the facility. These letters were included in all new admission packets also. I. A visitor's pass was implemented that requires all visitors to obtain a pass from the charge nurse before going out of the facility with a resident and the pass is to be returned to the charge nurse upon reentering the facility. This pass contains the resident's room number and the location of the resident and the visitor. [NAME] The Director of Nursing (DON) and designee conducted in-services with the all nursing staff on the procedure for elopement risk. If a resident is observed with elopement behaviors the following must be done: 1. Ensure safety of resident/residents 2. Complete Elopement risk assessment 3. Notify the Medical Doctor (MD) and family 4. Notify the DON and Administrator The charge nurse and unit manager will monitor the implementation of interventions, response to interventions, and document accordingly. K. The Nursing Home Administrator, DON, Assistant Director of Nursing (ADON), Director of Social Services, Maintenance Director, and Medical Director conducted a Quality Assurance Meeting to review the circumstances of the incident and implement an immediate action plan for the investigation of the incident. The surveyor verified the facility's corrective action plan on 8/9/19 as follows: [NAME] Review of the Quality Assurance Performance Improvement (QAPI) meeting documented the attendance at the meeting. The agenda sheets and minutes were reviewed and the QAPI team began the monthly review on 8/6/19 to ensure sustainability of the plan of correction. B. Medical record review revealed 100% of residents with wanderguards were assessed on 8/1/19 for proper functioning of their wander guards with 100% found to be functioning properly. C. Review of the Resident Monitoring System log and interview with the Maintenance Supervisor on 8/6/19 at 9:40 AM in the Front Door Area, the Maintenance Supervisor confirmed the 5 exit door alarms were checked weekly for functioning alarm sounding, and had been checked on 7/30/19, 8/1/19, and 8/6/19. Continued interview confirmed the security code was changed immediately after the elopement. D. On 8/9/19 at 2:23 PM the surveyor attempted to exit through the doorway located at the end of the 200 hall by pushing on the door which activated the alarm. The facility staff responded immediately. E. Review of the in-service records on facility policy and systemic changes and the sign in forms beginning 8/1/19 validated the attendance of all staff at the in-services conducted. Interview on 8/9/19 at 10:13 AM in the Conference Room with the DON, the DON confirmed all staff had received the education. The DON confirmed the facility will continue to do elopement risk assessments weekly times 4 weeks, monthly times 3 months and quarterly thereafter. After the assessments are completed they will be submitted to the Administrator and presented at the Quality Assurance Performance Improvement (QAPI) meetings. F. Multiple observations and interviews were conducted with residents, visitors, and employees on both shifts throughout the complaint survey conducted on 8/6/19 - 8/9/19, which confirmed full implementation of the systemic changes to provide supervision and safety for residents with elopement/wandering behaviors. [NAME] Review of the facility's self-reported incidents to the State Agency and review of the Concern/Comment Log revealed the facility had no other incidents or allegations of neglect and/or elopement since the implementation of the corrective action plan.",2020-09-01
516,GRACE HEALTHCARE OF FRANKLIN,445146,1287 WEST MAIN,FRANKLIN,TN,37064,2019-04-24,689,J,1,0,G6YR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to ensure a safe environment that provided adequate supervision to prevent elopement for 1 of 6 (Resident #1) cognitively impaired, vulnerable sampled residents reviewed who had elopement behaviors/risk. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility failed to ensure a safe environment and placed Resident #1 in Immediate Jeopardy (IJ) by failing to adequately supervise Resident #1, a cognitively impaired resident with known wandering behavior, who was missing for approximately 2 hours from the facility before the staff realized she had eloped from the facility. Resident #1 had eloped from the facility and was not located until approximately 4.5 hours later when she was found lying in a creek embankment containing water and suffered from hypothermia (dangerously low body temperature) and hematoma (swelling and bruising) around her right eye. This resulted in an IJ for Resident #1. The facility identified 9 cognitively impaired residents who were independently mobile via ambulation or wheelchair with wandering behaviors. The facility reported a total census of 57 residents. F-689 was cited at a scope and severity of J and is Substandard Quality of Care. The Nursing Home Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 4/23/19 at 12:00 PM in the Family Room. The IJ was effective from 3/18/19 through 3/19/19. The IJ was removed on 3/19/19 when the facility implemented a corrective action plan. Corrective actions were validated by the surveyor on 4/22/19 - 4/24/19. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction for those tags. The findings include: The facility's Wandering, Unsafe Resident policy, undated documented, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement .The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as detailed monitoring plan will be included . Medical record review revealed Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The 5 day Minimum Data Set ((MDS) dated [DATE] revealed, Resident #1 was moderately cognitively impaired, had poor decision making skills, required cues and supervision, wandering occurred 1-3 days of the assessment period, had an unsteady gait and used a walker with ambulation. The Baseline Care Plan dated 3/12/19 documented, .PROBLEM Date: 3/12/19 I am at risk for elopement as evidenced by .Wandering .Other encephalitis (symbol for increased) agitation (symbol for increased) confusion Ambulatory .3-18-19 - Elopement - Resident Sent to ER (emergency room ) c (with) minor injuries . Review of the facility's list of residents at risk for elopement revealed Resident #1 was not included on the list from 3/12/19 - 3/18/19. Medical record review included the following notes that documented Resident #1 displayed impaired cognitive status. A Nurse's Note dated 3/14/19 3:36 AM documented, .Some confusion . A Nurse's Note dated 3/14/19 4:40 PM documented, .Some confusion noted . A Nurse's Note dated 3/14/19 11:53 PM documented, Resident up in room rearranging belongings. Stated she got OOB (out of bed) at 6:00 pm thinking her son was coming to take her to get her mail but he did not come .Up in the hall requesting toilet paper, but some was found to be already in place in her room . A Nurse's Note dated 3/17/19 3:13 PM documented, .increased confusion. When helping resident get dressed this morning resident kept attempting to put her shirt on as her pants. Walked out of her room several times asking for the bathroom .Wandering into residents room and pushing on exit door handles . A Nurse's Note dated 3/18/19 6:10 AM (late entry) documented, Pt (patient) not in her (Resident #1's) room all rooms searched completely .Police notified and given information of incident . A Police Department incident report dated 3/18/19 at 3:01 AM to 4:45 AM documented, (Named Nurse and Certified Nursing Assistant (CNA)) informed officers that (Resident #1) left the facility between 0000-0030 (12:00 AM-12:30 AM) hours .last seen wearing a pink sweatshirt, blue pants, possibly wearing slippers, and suffers from dementia .stated (Resident #1) had been wandering around all-night in the hallway .0331 (3:31 AM) hours EMA (Emergency Management Agency) K9 (Search and Rescue dog) notified .0411 (4:11 AM) hours - K9 began track Based on the United States Weather Service records, the recorded low temperature for the facility area on 3/18/19 was 37 degrees Fahrenheit. Review of the (Named Hospital) history and physical dated 3/18/19 documented, The ER patient (Resident #1) was found to have [MEDICAL CONDITION](elevated heart rate) hypertension (elevated blood pressure) as well as hypothermia patient started on Bair hugger (warming device) .Vital Sign Ranges Last 24 Hours 92.2 F (Fahrenheit) -98.2 F (normal body temperature 98.6 F) .patient has hematoma around the right eye . Observations on 3/21/19 at 2:00 PM behind the facility, revealed the enbankment to be a steep enbankment, with undergrowth of grass and weeds, there was a creek with water in the creek bed. Observations on 4/23/19 at 2:10 PM behind the facility, revealed the enbankment to be a steep enbankment, with undergrowth of grass and weeds, there was a creek with water in the creek bed. There had been a recent rain and the creek was slightly deeper than the observation on 3/21/19. A telephone interview with Certified Nursing Assistant (CNA) #1 on 3/21/19 at 1:30 PM, CNA #1 was asked when was the last time she saw Resident #1. CNA #1 stated, I saw her about 12:15 (AM). Took her to her room, put her to bed and closed the door . Interview with the DON on 3/21/19 at 3:37 PM, in the Family room, the DON stated, She (Resident #1) was found sitting in the creek, water was to her waist while sitting in the creek. Legs were wet. Top was dry. She was disoriented. The Search and Rescue dog with the policeman found her with help of the fire department. Interview with Registered Nurse (RN #1) on 4/22/19 at 5:55 PM, in the Family Room, RN #1 was asked when was the last time she saw Resident #1. RN #1 stated, Can't recall exact time I last saw her. She was going in other rooms and coming in/out hallway .Just thought I'd check in on her. It was 2:00 AM. Checked the room. Asked (named CNA) if she had seen her leave . Interview with CNA #2 on 4/22/19 at 6:47 PM, in the Family Room, CNA #2 was asked when was the last time she saw Resident #1. CNA #2 stated, I saw her going down the hall .about 12:15 AM. I went back to my hall on 300 . CNA #2 was asked if she heard any door alarms sounding that night. CNA #1 stated, No . A telephone interview with CNA #1 on 4/22/19 at 7:20 PM, CNA #1 stated, .I heated up my meal in the breakroom across from the nurses' station. Nobody was particularly watching the room. I went about 1:30 (AM) and helped (named CNA). I had a light going off I went and answered the lights. Went to the bathroom a couple of times. CNA #1 was asked who was monitoring the hall. CNA #1 stated, Not sure. I was in/out rooms. CNA #1 was asked if she heard any door alarms sounding that night. CNA #1 stated, No Interview with the Administrator on 4/23/19 at 9:25 AM, in the Family Room, the Administrator stated, I could see how going into other people's rooms could lead to exiting. Interview with the DON on 4/23/19 at 10:15 AM, in the Family Room, the DON stated, I looked back at the nurses' notes for the day before (day prior to the elopement) During that day, based on the nurses' notes, she was wandering that day and went to an exit door and exhibited those behaviors .Going to exit doors . The DON was asked what her expectations were for monitoring a resident with behaviors of wandering/at risk for elopement. The DON stated, .I would not expect them to be left alone. Be kept in sight. I would expect a visual . The facility failed to ensure a safe environment for Resident #1 when they had no knowledge of her location for approximately 4.5 hours. Resident #1 had been assessed and documented as cognitively impaired with risk for elopement as evidenced by wandering behaviors and eloped from the facility on 3/18/19. She was found 4.5 hours later on 3/18/19 lying in a creek embankment containing water. The facility's corrective action plan included the following: On 3/18/19 the facility did the following: [NAME] A Certified Nursing Assistant (CNA) was stationed by the 200 hall door until all emergency doors and wiring of emergency doors were inspected for proper functioning. B. The Maintenance Director checked the functionality of all 7 exit doors, door code boxes and the alarm systems of the doors. 1. Opened every code box at every exit door and checked the wiring to ensure working properly. 2. Checked every code box battery to ensure they were working properly. Ordered all new batteries as a preventive measure. On 3/19/19 replaced all batteries in the code boxes on all exit doors. C. In the ceiling above the 200 hall exit door, opened the junction box to ensure all wiring was correct, tight, and replaced the discolored wiring. D. The security code to the 200 hall entrance/exit door was changed by the Maintenance Director. E. The Maintenance Director changed the wiring from the 200 hall exit door to the generator due to discoloration of the wires. F. The DON and designee re-assessed all residents in the building to determine any resident at risk for elopement. Results were no new residents identified as an elopement risk or added to the list. [NAME] Conducted in-services with 100% of all staff on wandering residents, elopement, abuse and systemic changes that were implemented to promote resident safety. Staff was required to have the in-service education prior to working their next shift. Changes included: 1. If staff observed changes in a resident's behavior that included wandering and/or exit seeking, the nurse must complete an elopement risk assessment. After completing the risk assessment, if the resident is determined to be at risk of elopement, the resident is to be added to alert charting to be completed by nursing. 2. The CNA is to communicate to nurses any observed changes in a resident's behavior that involved wandering and/or exit seeking. 3. The Elopement Binder was updated to include a current facesheet and picture of each resident at risk of elopement. An Elopement Binder will be kept at the receptionist desk and one at the nurses' station. 4. If any entrance/exit door alarm sounds, a staff member is to go to the door and check outside. Don't assume it was a visitor. H. The Care Plan for Resident #1 was updated to include new interventions for the risk for elopement. I. Completed an elopement scenario drill for each shift. [NAME] DON and designee conducted in-services with nursing staff on procedure process for risk of elopement: 1. If resident is observed with elopement behaviors the following must be done: a. Ensure safety of resident/residents b. Complete Elopement risk assessment c. Notify MD (Doctor of Medicine) and family d. Notify DON and Administrator e. Medical records to update Elopement Binder f. Begin Alert charting. K. The Nursing Home Administrator, DON, Assistant Director of Nursing (ADON), Director of Social Services, Maintenance Director, Regional Director Operational Support and Regional Director Clinical Services Support conducted an ad hoc Quality Assurance Meeting to review the circumstances of the incident and implement an immediate action plan for the investigation of the incident. The surveyors verified the facility's corrective action plan on 4/22/19-4/24/19 as follows: [NAME] Review of the Quality Assurance Performance Improvement meeting, attendance, agenda sheets and minutes confirmed the facility conducted an ad hoc Quality Assurance meeting on 3/18/19, and began review monthly on 4/19/19 to ensure sustainability of the plan of correction. B. Medical record reviews revealed 100% of residents were re-assessed on 3/18/19 using the Nursing Risk Assessment for Elopement Risk with 100% completion. C. Observation of the Resident Monitoring System log and interview with the Maintenance Director on 4/22/19 at 10:50 AM, in the Family Room, confirmed the 7 exit door alarms were checked weekly for functioning alarm sounding. Continued interview confirmed the battery function of the security code boxes was checked monthly. D. Review of the list of residents at risk of elopement confirmed the list was updated and the Elopement Binders were updated to include all residents currently at risk of elopement. E. On 4/23/19 at 2:05 PM, the surveyor attempted to exit through the doorway located at the end of the 200 hall by pushing on the door, setting off the alarm. The facility staff responded immediately. F. Comparison of facility in-service records and sign in/out sheets, for policy reviews and changes beginning 3/18/19 were validated. Interview with the DON on 4/23/19 at 10:15 AM, in the Family Room, confirmed staff education was 100% complete. Continued interview revealed the facility had conducted elopement scenarios with facility staff on 3/18/19 and 3/19/19 and will continue at random. [NAME] Multiple observations and interviews were conducted by the surveyor with residents and employees on both shifts throughout the complaint survey conducted on 3/21/19 - 4/24/19, which confirmed full implementation of the systemic changes to enhance resident/staff safety and the reporting. H. Review of the facility's self-reported incidents to the State Agency and review of the Concern/Comment Log revealed the facility had no other incidents of allegations of neglect and/or elopement since the implementation of the corrective action plan.",2020-09-01
1081,SPRING GATE REHAB & HEALTHCARE CENTER,445220,3909 COVINGTON PIKE,MEMPHIS,TN,38135,2019-10-03,689,D,1,1,VBXZ11,"**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 an environment was free of accident hazards for 2 of 5 (Resident #6 and #149) sampled residents reviewed for falls. The findings included: 1. The facility's Mechanical Lift policy revised 8/2016 revealed, The purpose of this procedure is to help lift residents using a manual lifting device .Two (2) nursing assistants will be required to perform any mechanical lift procedure . 2. Medical record review revealed Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. The care plan updated on 6/13/19 documented Resident #6 was to be transferred via mechanical lift with 2 or more staff assist. The quarterly Minimum (MDS) data set [DATE] documented Resident #6 was assessed with [REDACTED]. An Incident Report dated 9/6/19 documented, Resident was being transferred from w/c (wheelchair) c (with) Hoyer lift (type of mechanical lift) X 1 CNA (by 1 Certified Nursing Assistant), lift tilted over . resident fell on floor .0 (no) visible injuries . Review of the emergency room record dated 9/6/19 revealed, .Fall .No fracture .discharged to home .no further workup or admission to hospital is needed . Observations in the Dining Room on 9/23/19 at 11:15 AM, revealed Resident #6 was up in a wheelchair eating the noon meal. There were no visible injuries noted. Observations in the Dining Room on 9/25/19 at 11:30 AM, revealed Resident #6 was seated in her wheelchair, participating in the activity. Observations in Resident #6's room on 10/1/19 at 4:05 PM, revealed Resident #6 lying in bed, appeared clean and well groomed. Interview with Licensed Practical Nurse (LPN) #1 on 9/23/19 at 1:00 PM, in the Conference Room LPN #1 was asked about Resident #6's fall. Licensed Practical Nurse (LPN) #1 stated, .The CNA was transferring (Resident #6) by herself and not supposed to, we transfer with 2 people for lifts . Interview with the Director of Nursing (DON) on 9/23/19 at 3:30 PM, in the Conference Room, the DON was asked about Resident #6's fall, the DON stated, .The CNA was new here, had been trained and her competency checked. We terminated her . Telephone interview with CNA #1 on 9/24/19 at 4:33 PM, CNA #1 was asked about Resident #6's fall, CNA #1 stated, (Named Resident #6) had been up and was ready to go to bed, really past ready .Yes, I am aware to use 2 people with lifts . The facility failed to ensure 2 person mechanical lift transfer was conducted for Resident #6. 3. Medical record review revealed Resident #149 was admitted on [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] documented Resident #149 with a BIMS of 15 out of 15 indicating no cognitive deficit and was nonambulatory. The care plan updated on 8/28/19 documented Resident #149 .requires air redistribution mattress . An Incident Report dated 9/20/19 documented, .unobserved fall .air mattress overlay slid off of mattress, mattress overlay not secured properly . An emergency room record dated 9/20/19 documented, .fell out of bed .abrasion above right eye .denies pain .symptoms is pain and swelling .degree at present is minimal . Observations in Resident #149's room on 9/23/19 at 11:20 AM, revealed Resident #149 lying in a bariatric bed with bolsters and half upper side rails up. When asked about his fall, Resident #149 reported he had been on a regular mattress with an air overlay that had vibrated slowly over and just slid off and he slipped off the side of the bed. Observations in Resident #149's room on 9/30/19 at 9:10 AM, revealed Resident #149 lying in a bariatric bed on an air mattress, watching television. Interview with the DON on 9/23/19 at 4:00 PM, in the Conference Room, the DON was asked how the air mattress slid off the bed. The DON stated, Housekeeping had changed out his mattress and did not properly reattach it. It slid partially off the bed causing (Named Resident #149) to slide off . Interview with LPN #2 on 9/30/19 at 12:30 PM, in the DON office LPN #2 was asked about what caused Resident #149 to fall off the bed, LPN #2 stated, .the sheet part was supposed to be fastened together under the bed .it wasn't. It slid partially off and he fell , no real injury . The facility failed to ensure Resident #149 's air mattress was attached properly and he was free of an accident hazard.",2020-09-01
2956,DICKSON HEALTH AND REHAB,445477,901 N CHARLOTTE,DICKSON,TN,37055,2019-08-29,656,D,1,1,K4RM11,"**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 comprehensive care plan interventions were followed for 2 of 4 (Residents #38 and #44) sampled residents reviewed for wandering, exit seeking behaviors, and elopement. The findings include: 1. The facility's Using the Care Plan policy dated 9/2012 documented, The care plan shall be used in developing the resident's daily routines and will be available to staff personnel who have responsibility for providing care or services to the resident . The facility's Wandering Unsafe Resident policy, revised (MONTH) (YEAR) documented, .The resident's care plan will indicate the resident is at risk for elopement or other safety issues. The facility's Elopement policy dated 11/2017 documented, .For residents requiring increased monitoring of wandering, the Licensed Nurse will initiate 'Elopement/Wandering supervision for a specific period of time identified in the care plan .such actions are .Attempted elopement .'Moderate or High Risk' scoring on assessment .Wandering not conducive to the safety of the resident . 2. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 3 which indicated Resident #38 was severely cognitively impaired and had adequate vision with corrective lenses. The MDS documented Resident #38 had delusional behaviors. The physician orders [REDACTED].Wanderguard r/t (related to) elopement risk . The Care Plan for Resident #38 dated 8/15/19 documented, .(Named Resident #38) is an elopement risk/wanderer AEB (as evidenced by) Impaired safety awareness .Goal .(Named Resident #38) will have no further attempts to leave the facility without staff or family .Interventions .Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book .Document wandering behavior .Increased monitoring in afternoon/evening when (Named Resident #38) begins to sundown and begins to exit seek (8/20/19) .Wanderguard applied and placement checked per protocol . The facility was unable to provide a protocol for wanderguards. Review of Resident #38's Activity of Daily Living (ADL) task list for 8/2019 revealed there was no documentation of wanderguard functioning tests monitored on the day shift on 8/18/19, 8/24/19, 8/25/19, or 8/26/19. Review of the facility's investigation dated 8/20/19 revealed on 8/20/19, Resident #38 eloped from the facility in his wheelchair, through an unlocked exit door on the East hallway, and was found by a staff member on a heavily traveled city street beside the facility at approximately 3:30 PM. The facility's failure to ensure Resident #38 remained in a safe area on the premises, resulted in IJ for Resident #38. Observations in the East Hall on 8/26/19 at 2:36 PM, revealed Resident #38 was self-propelling in a wheelchair and had a wanderguard on his right ankle. Observations in the Dining Room on 8/27/19 at 11:38 AM, revealed Resident #38 slowly rolled his wheelchair backward and forward using his feet and had a wanderguard on his right ankle. Observations in the hallway by the Rehabilitation (Rehab) Department on 8/29/19 at 9:05 AM, revealed Resident #38 attempted to reach the East Hall exit door on the parking lot side of the hallway. Staff were between the door and Resident #38, and were redirecting Resident #38. 3. Medical record review revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Monitor placement and function of wanderguard two times a day . The Care Plan revised 7/7/19 documented, (Named Resident #44) is an elopement risk/wanderer .wanders aimlessly .Interventions .Placement of wanderguard per protocol. Monitor for placement and in working order. Date Initiated: 10/18/2017 Medical record review of Resident #44's (MONTH) and (MONTH) 2019 ADL task list revealed there was no documentation of monitoring wanderguard equipment checks for the day shift on 7/7/19, 8/11/19, 8/12/19, or 8/25/19, and no documentation for either shift on 8/13/19 through 8/24/19. Medical record review of the quarterly MDS for Resident #44 dated 7/11/19 revealed a BIMS of 1 which indicated severe cognitive impairment. Observations in the Dining Room on 8/26/19 at 9:30 PM, revealed Resident #44 walking around in the dining room. Interview with the DON on 8/27/19 at 4:46 PM, in the DON office, the DON was asked how she would know the wanderguards were being checked. The DON stated, We don't. The DON was asked what would check the wanderguard per protocol mean. The DON stated, We monitor them every shift that's what we do. That is just what we have done. We could not find a wanderguard protocol itself . Interview with the DON on 8/27/19 at 6:42 PM, in the ADON Office, the DON confirmed the wanderguard checks were incomplete and confirmed they should have been checked on all shifts. Interview with the DON and the Administrator on 8/27/19 at 7:05 PM, in the ADON Office, the DON and Administrator were asked if there was a protocol for wanderguards. The Administrator stated, We were told by corporate there is not one . Observations in the North hallway on 8/28/19 at 8:49 AM, revealed Resident #44 walking up and down the hallway. Interview with the DON on 8/29/19 at 12:04 PM, in the ADON Office, the DON was asked why the wanderguards were not being checked. The DON stated, .we did not realize it (the wanderguard checks) had dropped off (were not documented) until we started looking for stuff for you all (the survey team) on the 25th of (MONTH) (8/25/19) .they should have done a paper charting when the task was dropped off .",2020-09-01
3745,"COLLIERVILLE NURSING AND REHABILITATION, LLC",445495,490 WEST POPLAR AVENUE,COLLIERVILLE,TN,38017,2017-03-02,441,E,1,0,4B1111,"**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 3 (Certified Nursing Assistant (CNA) #4, Respiratory Therapist (RT) #1, and Licensed Practical Nurse (LPN) #2) staff failed to perform effective hand hygiene during resident care. The findings included: 1. The facility's Standard Precaution: Hand Hygiene policy documented, .Assume every person is potentially affected or colonized with organisms that could be transmitted in the facility and apply the following infection control practices during the deliver (delivery) of health care .Hands shall be washed with soap and water whenever visibly soiled with blood or body fluids, before eating, and after using the restroom .If hands are not visibly soiled, alcohol-based hand rubs are preferred for hand hygiene .After removing gloves .[NAME] Before having direct contacts with residents .B. After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings .D. If hands will be moving from a contaminated-body site to a clean-body site during patient care . 2. Medical record review revealed Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, indicating no cognitive impairment, and that Resident #4 was totally dependent on staff for bathing. Observations in Resident #4's bathroom on 2/27/17 at 9:55 AM, revealed Resident #4 was seated on the toilet, dressed in a hospital-type gown. CNA #4 assisted Resident #4 to wash her face using a wet washcloth. CNA #4 donned gloves, removed the wet brief from Resident #4, threw it in trash can, removed Resident #4's gown and threw it on the floor. CNA #4 applied shampoo-body wash to the wash cloth, washed Resident #4's back, dried with a towel, then used the washcloth to wash Resident #4's neck, chest, abdomen, and axillae. CNA #4 rinsed the washcloth under running water in the sink, rinsed the soap off Resident #4 and dried her with a towel. CNA #4 then applied baby oil gel to Resident #4's trunk, and baby powder to the axillae. CNA #4 dressed Resident #4 with a blouse, then got the washcloth out of the sink, applied more shampoo-body wash, and washed the right leg, rinsed and dried it, applied baby oil gel, then washed the left leg, rinsed, dried, and applied baby oil gel. CNA #4 then put her foot on the dirty gown on the floor, and used the gown to mop up water droplets off the floor with her foot. CNA #4 put Resident #4's socks, pants, slippers, and a clean brief on her legs, and provided pericare, front to back, and then threw the washcloth on the floor. CNA #4 used the end of the towel to wipe off her gloves, and gave the end of the towel to Resident #4 to dry her hands, dried Resident #4's peri area with the towel, then threw the towel on the floor. CNA #4 then removed the gloves to reveal another pair of gloves on underneath them. CNA #4 used gloved hands to apply oil gel to Resident #4's face. CNA #4 did not perform hand hygiene first. CNA #4 removed those gloves, and picked up the soiled towel, gown, and washcloth, and placed them in a plastic bag using her bare hands. Interview with the Director of Nursing (DON) on 3/2/17 at 5:05 PM, in the Theater Room, the DON was asked whether it was acceptable for staff to double glove, and remove one pair of the gloves, then continue on with patient care without performing hand hygiene during patient care. The DON stated, They should wash their hands. 3. The facility's TRACHEOSTOMY CARE PR[NAME]EDURE documented, .It is important to keep the stoma and the trach tube clean .trach care should be done at least twice a day and as needed .This includes cleaning the inner cannula, around the trach tube and the stoma .using clean technique .trach tube should be changed once a month .This is always done using a sterile technique .Good hand washing technique is vital to prevent infections .must always use gloves when dealing with trach tubes .dressing should be changed when doing trach care or as needed .dressings should not be moist or soiled .ties should be changed daily with trach care or as needed .Infection Control .It is important to use sterile technique to minimize infections .Utilize standard precautions . Medical record review for Resident #114 revealed was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A significant change MDS dated [DATE] documented a BIMS score of 11, indicating moderate cognitive impairment, that Resident #114 required extensive to total staff assistance for all Activities of Daily Living (ADLs), and received tracheostomy care while a resident at the facility. Observations in Resident #114's room on 2/24/17 at 8:44 AM, revealed RT #1 performed tracheostomy (trach) care for Resident #114. RT #1 donned clean gloves, opened all supplies, and applied sterile gloves over the clean gloves. RT #1 removed Resident #114's trach dressing, cleaned around the trach site with peroxide solution, removed the sterile gloves, and donned a new pair of sterile gloves over the same pair of clean gloves without performing hand hygiene. RT #1 suctioned Resident #114, and removed the suction catheter, discarding it inside the sterile gloves. RT #1 still had on the same pair of gloves she first applied. RT #1 removed the trach collar and replaced it with a new one. Using the same pair of gloves, RT #1 suctioned secretions, used the same gloved hands to reach inside a bag hanging on the wall over the bed, removed a pair of sterile gloves, applied the new pair of sterile gloves without performing hand hygiene, opened a sterile suction catheter, and suctioned Resident #114 again. Hand hygiene was not performed during the trach care. Interview with the DON on 3/2/17 at 5:05 PM, in the Theater Room, the DON was asked what she expected staff to do during trach care after cleaning the trach, and before applying clean dressings. The DON stated, They should wash their hands. 4. The facility's Dressing, Dry/Clean Competency policy documented, .Wash and dry hands thoroughly .Put on clean gloves .Loosen tape and remove soiled dressing .Pull gloves over the dressing and discard into biohazard or plastic bag .Wash and dry hands thoroughly .Set up a clean barrier field for supplies .Put on clean gloves .Assess the wound .Apply the ordered dressing .Discard disposable items .Remove gloves and discard .Wash and dry hands thoroughly .Ensure resident is comfortable .Place call light within easy reach of the resident .Wash and dry hands thoroughly . Medical record review revealed Resident #153 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] documented a BIMS score of 15, indicating no cognitive impairment, that Resident #153 was totally dependent on staff for ADLs, and had 1 stage 4 pressure ulcer that was present on admission to the facility. Observations in Resident #153's room on 2/28/17 at 10:30 AM, revealed LPN #2 performed wound care to the left ischial stage 4 pressure ulcer. LPN #2 donned gloves, removed the wound dressing, revealing a large open shallow wound. LPN #2 sprayed the wound with wound cleanser and wiped the wound with gauze, resulting in small amount bright red bleeding. LPN #2 then applied calcium alginate, then a 4x4 gauze pad and border gauze. LPN #2 did not remove gloves and perform hand hygiene after cleansing the wound or before applying the clean treatment and dressings. Interview with the DON on 3/2/17 at 5:05 PM, in the Theater Room, the DON was asked what she expected staff to do during wound care after cleaning the wound, and before applying clean dressings. The DON stated, They are supposed to wash their hands. 5. The facility's Standard Precaution: Hand Hygiene policy documented, POLICY Assume every person is potentially infected or colonized with organisms that could be transmitted in the facility and apply the following infection control practices during the deliver of health care. GUIDELINES .4. Hands should be washed with soap and water whenever visibly soiled with blood or body fluids, before eating, and after using the restroom. 5. If hands are not visibly soiled, alcohol-based hand rubs are preferred for hand hygiene: [NAME] Before having direct contacts with residents. B. After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings .D. If hands will be moving from a contaminated-body site to a clean-body site during patient care . Observations in front of Resident #33's room on 3/1/17 beginning at 2:15 PM, revealed LPN #2 prepared supplies at the cart, placed clean gloves from the cart into her pocket, donned an isolation gown, donned gloves from her pocket, gathered supplies in the bag, knocked and entered Resident #33's room. LPN #2 cleaned the overbed table with a bleach wipe, placed a barrier on the table, and placed supplies on the table. LPN #2 removed her gloves, washed her hands, obtained gloves from her pocket, and donned the gloves, as she was finishing setting up the supplies, she removed her gloves, washed her hands, went to the treatment cart in the 300 hall and obtained the Santyl, donned an isolation gown, entered Resident #33's room, donned gloves from her pocket, cleaned the scissors with a bleach wipe, removed her gloves, and washed her hands. LPN #2 obtained gloves from her pocket, donned the gloves, removed the dressing to the right posterior shoulder and the right upper back. LPN #2 removed her gloves, and washed her hands. LPN #2 obtained gloves from her pocket, cleaned the right posterior wound with wound cleanser and Kerlix, did not remove gloves or wash hands, and applied Santyl to the wound. LPN #2 removed her gloves, washed her hands, obtained gloves from her pocket, donned the gloves, and packed the wound with Kerlix and covered with a dressing. LPN #2 removed her gloves, washed her hands, obtained gloves from her pocket, and donned the gloves. LPN #2 cleaned the wound to the right upper back with wound cleanser and Kerlix, did not change her gloves or wash her hands, and applied Santyl to the wound, then packed the wound with Kerlix. LPN #2 removed her gloves, washed her hands, obtained gloves from the table, and covered the wound with a dry dressing. LPN #2 obtained gloves from her pocket as she was performing these dressing changes and did not change her gloves or wash her hands after cleaning the wound (which was dirty), and prior to applying the Santyl/dressing to these wounds. Interview with the DON on 3/1/17 at 4:00 PM, in the DON office, she was asked if gloves should be placed in the pocket to be used with wound care. She stated, No. She was asked what should be done after cleaning a wound, and prior to applying ointments/dressings to a wound. She stated, Should remove their gloves, and wash hands .",2020-03-01
2667,GALLAWAY HEALTH AND REHAB,445440,435 OLD BROWNSVILLE RD,GALLAWAY,TN,38036,2019-06-27,880,E,1,1,GTCJ11,"**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 3 of 3 (Wound Care Nurse, Certified Nursing Assistant (CNA) #5, Licensed Practical Nurse (LPN) #1) staff members failed to perform proper hand hygiene during 3 of 3 (Resident #7, #21, and #41) observations of provision of care and dirty linens were left on the bathroom floor in 1 of 3 (100 Hall Central Bath) shower rooms and 1 of 42 (room [ROOM NUMBER]) resident room bathrooms. The findings include: 1. The facility's Handwashing/Hand Hygiene policy with a revision date of (MONTH) 2010 documented, .This facility considers hand hygiene the primary means to prevent the spread of infections .Employees must wash their hands .Before and after direct contact with residents .After removing gloves .The use of gloves does not replace handwashing/hand hygiene . 2. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation in Resident #7's room on 6/20/19 at 11:05 AM revealed the Wound Care Nurse performing a dressing change on Resident #7 with the assistance of CNA #5. The Wound Care Nurse removed the dressing from the Stage 3 (full thickness skin loss) pressure ulcer on the left gluteal fold, cleaned the open wound with wound cleanser, patted the wound dry, applied skin prep and [MEDICATION NAME] Skin Protectant around the wound using the same gloved hands. The Wound Care Nurse then removed her gloves and donned clean gloves without performing hand hygiene, and applied a clean dressing over the wound. The Wound Care Nurse did not perform hand hygiene and change gloves between cleaning the wound and applying a clean treatment to the wound. The Wound Care Nurse did not perform hand hygiene after removal of her gloves and before donning clean gloves. Continued observation revealed CNA #5 pushed the edge of Resident #7's brief down, and revealed a small amount of feces oozing from the brief and onto CNA #5's glove. CNA #5 then pressed down the edges of the clean dressing with the same gloved hand without changing the soiled glove. The Wound Care Nurse then removed a dressing from the Stage 3 pressure ulcer to the right hip, cleaned the wound with wound cleanser, patted the wound dry, applied skin prep and [MEDICATION NAME] Skin Protectant around the wound edges using the same gloves. The Wound Care Nurse did not perform hand hygiene and change gloves between cleaning the wound and applying a clean treatment to the wound. 3. Medical record review revealed Resident #41 was admitted on [DATE] with [DIAGNOSES REDACTED]. Observation in Resident's #41's room on 6/20/19 at 1:00 PM revealed the Wound Care Nurse performing a dressing change on Resident #41. The Wound Care Nurse cleaned the sacral wound, removed her gloves, and donned new gloves without performing hand hygiene. The Wound Care Nurse cleaned the left hip wound, washed her hands, donned a new pair of gloves, and placed Alginate into the wound bed using a cotton swab. The Wound Care Nurse then covered the left hip with a clean dressing and removed her gloves. The Wound Care Nurse did not perform hand hygiene. The Wound Care Nurse covered Resident #41 with a blanket, picked up the bed remote, and raised the head of the bed without performing hand hygiene. The Wound Care Nurse used her bare hands to partially remove Resident #41's left sock, went to the medication cart, picked up a hand held mirror, looked at the bottom of Resident #41's heel, and then placed a new glove on her right hand, without performing hand hygiene. The Wound Care Nurse picked up the wound barrier and placed it into the biohazard bag, and removed her glove and donned clean gloves without performing hand hygiene after removal of the gloves. The Wound Care Nurse then removed Resident's cover again, turned Resident #41 to her left side, removed the right hip dressing and applied a new cover dressing over the right hip wound. The Wound Care Nurse removed her gloves and covered the resident with a blanket using her bare hands without performing hand hygiene. The Wound Care Nurse failed to wash her hands between glove changes, between dirty and clean dressings, and before direct contact with the resident. 4. Medical record review revealed Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #21's room on 6/25/19 at 2:04 PM revealed Licensed Practical Nurse (LPN) #1 cleaned Resident #21's buttock area with disposable wipes, changed gloves without performing hand hygiene, and then applied [MEDICATION NAME] Skin Protectant cream to the coccyx/sacrum/buttocks areas. LPN #1 then cleaned the scrotum and groin area with disposable wipes and applied [MEDICATION NAME] Skin Protectant cream to these areas using the same gloved hands. LPN #1 assisted Resident #21 to reposition himself in bed, repositioned the 3 pillows behind his head, and used his bed remote to raise his head of bed, still wearing the same gloves. LPN #1 then removed her gloves and performed hand hygiene at the sink in Resident #21's room. LPN #1 turned off the faucet with the same paper towel she used to dry her hands. Interview with the Director of Nursing (DON) on 6/27/19 at 11:34 AM in the conference room, revealed the DON was asked if a resident had a soiled brief on, should the staff change the brief before performing wound care. The DON stated, Yes ma'am. The DON was asked when the nurse should perform hand hygiene during wound care. The DON stated, Before beginning, before gloves, when changing gloves in between, and at the end of wound care. The DON was asked when staff should perform hand hygiene during perineal care. The DON stated, Before beginning, before putting gloves on, after removal of soiled items. They should wash hands and put on new gloves and wash again after they take them off. 5. Observations in room [ROOM NUMBER]'s bathroom on 6/24/19 at 9:41 AM revealed a dirty, crumpled towel and washcloth on the floor beside the toilet. Observations in the 100 Hall Shower Room on 6/25/19 at 8:06 AM revealed dirty, wet towels on the floor. Interview with CNA #6 on 6/24/19 at 9:42 AM in room [ROOM NUMBER]'s bathroom, revealed CNA #6 was asked if the dirty towel and washcloth should be on the bathroom floor. CNA #6 stated, No ma'am, they shouldn't .",2020-09-01
1640,COUNTRYSIDE HEALTHCARE AND REHABILITATION,445280,3051 BUFFALO ROAD,LAWRENCEBURG,TN,38464,2017-07-20,315,E,1,0,4V9N11,"**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 were followed to prevent the potential spread of infection when 1 of 1 (Certified Nursing Assistant (CNA) #1) staff members failed to use appropriate hand hygiene and appropriate technique for performing incontinence care and urinary catheter care for 2 of 2 (Resident #1 and #6) sampled residents observed for incontinence care. The findings included: 1. The facility's Incontinence Care policy documented, .STEPS OF PR[NAME]EDURE .1. Lower head and foot of bed .2. Cleanse hands .5. Put on gloves .6. Wash/use cleansing agent to soiled skin areas washing front to back, rinse and dry very well, especially between skin folds .7. Turn resident on side and cleanse buttock area, wiping toward back . 2. The facility's Handwashing/Hand Hygiene policy documented, .Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-microbial soap and water .Before and after direct contact with residents .After removing gloves .After handling items potentially contaminated with blood, body fluids, or secretions .The use of gloves does not replace handwashing/hand hygiene . 3. Medical record review revealed Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum (MDS) data set [DATE] documented a Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment, was totally dependent on staff for toileting and personal hygiene, and was always incontinent of bowel and bladder. The care plan dated 4/27/17 documented altered thought process, forgetful most of the time, and unable to let staff know when wet or dry. Interventions included staff was to make rounds every 2 hours and as needed (PRN) to check for incontinence and check/change PRN. Observations in Resident #1's room on 7/18/17 at 12:25 PM, revealed CNA #1 performed incontinence care on Resident #1. CNA #1 did not wash hands before or during the procedure. CNA #1 cleaned Resident #1's perineal area with a washcloth and peri-spray, then put the soiled washcloth on the floor. CNA #1 did not perform hand hygiene. CNA #1 used the same soiled gloves to put a clean brief on Resident #1 and pull up the resident's pants. 4. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment, was totally dependent on staff for toileting and personal hygiene, and had a urinary catheter. The Care Plan dated 4/27/17 documented Resident #6 had a Foley catheter, and interventions included catheter care was to be performed every shift. The physician's orders [REDACTED].FOLEY CARE EVERY SHIFT . Observations in Resident #6's room on 7/18/17 at 11:37 AM, revealed CNA #1 performed incontinence care for Resident #6, after an episode of bowel incontinence. CNA #1 used wipes to clean the perineal/buttock area, then used the same gloved hands to clean around urinary meatus and catheter. CNA #1 used the same soiled gloves to apply barrier cream to Resident #6's buttocks. Interview with the Director of Nursing (DON) on 7/18/17 at 5:37 PM, in the conference room, the DON was asked what she expected staff to do after cleaning a resident during incontinence care, and before applying cream to skin or before dressing the resident in clean clothing or briefs. The DON stated, Change gloves, use hand sanitizer. The DON was asked whether it was acceptable for staff to use the same gloves to clean around the urinary catheter after cleaning perineal area after bowel incontinence. The DON stated, No .between front and back always change gloves.",2020-09-01
1997,GRACELAND REHABILITATION AND NURSING CARE CENTER,445331,1250 FARROW ROAD,MEMPHIS,TN,38116,2020-02-10,657,J,1,0,U67J11,"**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 Care Plan was revised for 1 of 4 sampled residents (Resident #1) reviewed for wandering, exit-seeking behaviors, and elopement. The facility failed to ensure the Care Plan was revised to include interventions to minimize the risk of elopement for a cognitively impaired resident with known exit-seeking behaviors, which resulted in Immediate Jeopardy for Resident #1 when she exited the facility through a window and then a hole in the facility's fence, crossed a major 7 lane highway, and walked to a neighborhood 1.3 miles from the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-657 on 2/5/2020 at 2:45 PM, in the Conference Room. F-657 was cited at a scope and severity of J. A partial extended survey was conducted on 2/7/2020 through 2/9/2020. The Immediate Jeopardy was effective from 11/1/2019 to 2/9/2020. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 2/7/2020 at 3:00 PM. The Removal Plan was validated onsite by the surveyors on 2/9/2020-2/10/2020 through review of policy related to active exit-seeking behavior, assessments, inservice training records, and staff interviews. The findings include: Review of the facility's undated policy titled, Care Planning, showed that the facility should develop an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident needs and is developed for each resident. The comprehensive care plan is designed to identify problem areas, incorporate risk factors associated with identified problems. Areas of concern are triggered during the resident assessment before interventions are added to the care plan, interventions are designed after careful consideration between resident's problem areas and their causes. The care plan is developed within 7 days of completion of the comprehensive assessment. The nurses on the unit are responsible for all episodic care planning. Assessments of residents are ongoing and care plans are revised as information changes. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plan. Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the Elopement Risk Evaluation dated 7/25/2019, showed Resident #1 was at risk for elopement. Review of the admission Minimum Data Set ((MDS) dated [DATE], showed Resident #1 was assessed to be severely impaired cognitively. Review of the Nurses' Notes dated 11/1/2019, showed that Resident #1 exited a door on the 700 Hall and was redirected back into the facility by staff. The Care Plan revised 11/1/2019 showed that Resident #1 was at risk of elopement and interventions of wanderguard placement and encourage participation and interactions that decrease anxiety and exit-seeking. Review of the Nurses' Notes dated 11/14/2019, showed that Resident #1 exited a door on the 700 Hall and was redirected back into the facility by staff. Review of the medical record showed Resident #1 was admitted to a psychiatric hospital from 11/14/2019 to 12/10/2019 related to yelling, screaming, and exit-seeking behavior. Review of the Comprehensive Care Plan revised 11/1/2019, showed that the Care Plan was not revised with new interventions for the exit-seeking behavior that occurred on 11/14/2019. Review of Resident #1's Social Services note dated 1/16/2020 documented, .exit (exited) the building .returned safely .according to officer they received a called (call) resident was picked up . Review of the Comprehensive Care Plan revised 1/23/2020, showed interventions for the elopement included: the fence was replaced, frequent checks of the resident's presence in the facility, and windows to be checked. The Care Plan did not show how often frequent checks should be done. Observation in the Activity Room on 2/3/2020 at 10:00 AM, showed Resident #1 was seated in a wheelchair listening to music. A wanderguard was noted to her left ankle. Observation in the resident's room on 2/5/2020 at 8:04 AM, showed Resident #1 was up walking in her room. Observation in the 800 Hall on 2/6/2020 at 4:03 PM, showed Resident #1 was seated in a wheelchair using her feet to move her wheelchair briskly down the hall toward the Nurses' Station. Observation in the Dining Room on 2/8/2020 at 12:40 PM, showed Resident #1 was eating lunch, and self-propelled herself in the wheelchair. During an interview on 2/7/2020 at 2:02 PM, the Director of Nursing (DON) confirmed that Resident #1's Care Plan should have been revised after the elopement attempt on 11/14/2019. The facility failed to ensure the Care Plan was revised to include interventions to minimize the risk of elopement for a cognitively impaired resident with known exit-seeking behaviors, which resulted in IJ for Resident #1 when she exited the facility through a window and then a hole in the facility's fence, crossed a major 7 lane highway, and walked to a neighborhood 1.3 miles from the facility. Refer to F-600, F-610, F-656, and F-689. The surveyors verified the Removal Plan by: 1. Resident #1's Care Plan has been updated with appropriate interventions. The surveyors reviewed Resident #1's Care Plan. 2. All residents will have a Care Plan initiated upon admission and when any episodes of exit-seeking/elopement are noted with appropriate interventions addressing the resident's needs. The surveyors interviewed staff on all shifts related to their responsibilities for care planning. 3. Residents with elopement/exit-seeking risks will be addressed in clinical meeting. Elopement risks will be added to the clinical report sheet. All residents with elopement risks will be audited during clinical meetings for appropriateness of interventions and submitted to the Quality Assurance Performance Committee. Clinical meetings are held Monday-Friday of each week. On 2/7/2020, Unit Managers/Designees have been in serviced on revising the Care Plan of elopement/exit-seeking risk residents with appropriate interventions. The surveyors reviewed the inservice sign in sheets, audit forms, interviewed staff on each shift, and interviewed the Unit Managers. Noncompliance of F-657 continued at a scope and severity D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a Plan of Correction.",2020-09-01
1080,SPRING GATE REHAB & HEALTHCARE CENTER,445220,3909 COVINGTON PIKE,MEMPHIS,TN,38135,2019-10-03,656,D,1,1,VBXZ11,"**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 comprehensive care plan intervention of 2 person transfers via mechanical lift were implemented for 1 of 38 (Resident #6) sampled residents reviewed. The findings included: The facility's Care Plans-Comprehensive policy revised on 1/28/11 documented, .Our facility's Care Planning/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 .Identify the professional services that are responsible for each element of care; Aid in preventing or reducing declines in the resident's functional status and/or functional levels . Medical record review revealed Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. The care plan updated on 6/13/19 documented Resident #6 was to be transferred via mechanical lift with 2 or more staff assist. The quarterly Minimum (MDS) data set [DATE] documented Resident #6 was assessed requiring extensive assistance of 2 persons with transfers. An Incident Report dated 9/6/19 documented, Resident was being transferred from w/c (wheelchair) c (with) Hoyer lift (type of mechanical lift) X 1 CNA (by 1 Certified Nursing Assistant), lift tilted over .resident fell on floor .0 (no) visible injuries . Observations in the Dining Room on 9/23/19 at 11:15 AM, revealed Resident #6 was up in a wheelchair eating the noon meal. There were no visible injuries noted. Observations in the Dining Room on 9/25/19 at 11:30 AM, revealed Resident #6 was seated in her wheelchair, participating in the activity. Observations in Resident #6's room on 10/1/19 at 4:05 PM, revealed Resident #6 lying in bed, appeared clean and well groomed. Interview with Licensed Practical Nurse (LPN) #1 on 9/23/19 at 1:00 PM, in the Conference Room LPN #1 was asked about Resident #6's fall. Licensed Practical Nurse (LPN) #1 stated, .The CNA was transferring (Resident #6) by herself and not supposed to, we transfer with 2 people for lifts . Interview with the Director of Nursing (DON) on 9/23/19 at 3:30 PM, in the Conference Room, the DON was asked about Resident #6's fall, the DON stated, .The CNA was new here, had been trained and her competency checked. We terminated her . Telephone interview with CNA #1 on 9/24/19 at 4:33 PM, CNA #1 was asked about Resident #6's fall, CNA #1 stated, (Named Resident #6) had been up and was ready to go to bed, really past ready Yes, I am aware to use 2 people with lifts . The facility failed to ensure that a mechanical lift transfer was conducted by 2 persons per the resident care plan.",2020-09-01
2663,GALLAWAY HEALTH AND REHAB,445440,435 OLD BROWNSVILLE RD,GALLAWAY,TN,38036,2019-06-27,689,D,1,1,GTCJ11,"**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 safety of a resident during transfer for 1 of 6 (Resident #35) sampled residents reviewed for accidents. The findings include: 1. The facility's Lifting Machine, Using a Portable policy with a revision date of (MONTH) 2010 documented, .Preparation .Review the resident's care plan to assess for any special needs of the resident .General Guidelines .The portable lift can be used by one nursing assistant if the resident can participate in the lifting procedures. If not, two (2) nursing assistants will be required to perform the procedure .Documentation .The following information should be recorded in the resident's medical record .Any problems .related to the procedure .Report other information in accordance with facility policy and professional standards of practice . The facility's Fall and Fall Risk, Managing policy with a revision date of (MONTH) (YEAR) documented, .Fall Definition .Unintentionally coming to rest on the ground, floor, or other lower level . 2. Medical record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had severe cognition impairment, walking did not occur, required extensive assistance using 2-plus persons for transfers, had functional limitation in range of motion to bilateral lower extremities, moving from seated to standing position did not occur, and was not steady with surface-to-surface transfers. The care plan dated 10/12/18, and last reviewed 6/20/19, documented, .at risk for falls .d/t (due to) impaired mental (status), medications, and physical status Interventions .Provide a mechanical lift for all transfers with the support of 2 staff members. Date Initiated: 06/13/2019 .TRANSFER: Requires staff participation .requires extensive weight bearing assist for all transfers . The interventions that were in place on the care plan prior to the fall on 6/12/19 did not document 1 or 2 persons to assist with transfers. The Progress Notes documented, .6/12/2019 .Nursing Note .Reported by staff that residents (resident's) legs gave out while being transferred using standup lift on the previous shift .swelling to upper left chest region with bruising to the left axilla . The hospital emergency room history and physical dated 6/12/19 documented, .presents with .LEFT ARM, SHOULDER AND LEFT CHEST PAIN, SWELLING AND BRUISING .Musculoskeletal: Proximal upper extremity: Left, anterior, shoulder, arm, tenderness, swelling, [DIAGNOSES REDACTED], ecchymosis .CT (Computed [NAME]ography) Chest W/ (with) Contrast .10 cm (centimeter) hyperdense lesion along the left pectoralis musculature, with surrounding [MEDICAL CONDITION], most compatible with hematoma . The resident required no aggressive treatment and returned to the facility on [DATE]. The Progress Notes documented, .6/23/2019 .Nursing Note .chest on left side remains swollen and fluid filled . Observations in Resident #35's room on 6/27/19 at 4:15 PM revealed bruising to Resident #35's chest area and the rib cage, and slight swelling to the left shoulder and axilla area. Interview with Certified Nursing Assistant (CNA) #3 on 6/26/19 at 2:00 PM in the Conference Room, revealed CNA #3 was asked how many staff members should be used when transferring a resident with the stand-up lift. CNA #3 stated, Always a 2-person. They always tell us to never use the lift alone. Interview with CNA #4 on 6/26/19 at 2:59 PM, in the Conference Room, revealed CNA #4 was asked what happened while she was transferring Resident #35 using a stand-up lift. CNA #4 stated, I used the stand-up lift to transfer him from the chair to the bed. He did not stand up completely .I put the stand up lift in front of him, hooked him up, and he held on .I raised the lift up, and when he came up in the air, his feet wasn't on the bottom of the lift .a pad goes around him and it hooks about his waist. The other part of the pad hooks around the lift. Part of the pad goes up under his arms .I yelled out in the hall for help, and (Named CNA #2) came to help .he (Resident #35) was hooked on the lift and sitting on the side of the bed I lowered the lift and unhooked him and he was on the side of the bed he never complained pain CNA #4 was asked if she reported the incident to anyone. CNA #4 stated, No . Interview with CNA #2 on 6/26/19 at 3:13 PM in the Conference Room, revealed CNA #2 was asked about the incident with Resident #35 and the use of the lift. CNA #2 stated, When (CNA #4) called for me to come in there and help her, he was like down on the floor already, his legs were on the floor . CNA #2 was asked if Resident #35 could stand. CNA #2 stated, No. I been working with him a long time and I never use the stand up lift. We just transfer him .2-person transfer. CNA #2 was asked if anyone else was in the room helping CNA #4 with him when she attempted to use the stand up lift. CNA #2 stated, No, ma'am, just her. Interview with CNA #2 on 6/26/19 at 3:23 PM across from the 100 Hall Nurses' Station, revealed CNA #2 pointed to the stand-up lift base, and stated, He was like down on the base of the lift .his knees. His arms were like coming through the pad. He was still trying to hold on .We were just trying to keep him from falling and get him on the bed .If they ain't weight bearing, we are not supposed to use it. If they don't have the strength in his legs, it's not safe . Interview with Licensed Practical Nurse (LPN) #2 on 6/27/19 at 3:55 PM in the Conference Room, revealed LPN #2 was asked what happened during the incident with the lift with Resident #35. LPN #2 stated, I think they were transferring him from chair to bed . LPN #2 was asked how many staff members should be used to transfer a resident using the lift. LPN #2 stated, 2 persons with all lifts. LPN #2 was asked if only 1 CNA should transfer a resident using the lift alone. LPN #2 stated, No ma'am.",2020-09-01
3725,HUMBOLDT NURSING AND REHABILITATION CENTER,445441,3515 CHERE CAROL RD,HUMBOLDT,TN,38343,2017-03-29,282,D,1,0,ZWOY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to follow resident care plan interventions related to wound assessments for 1 of 16 (Resident #9) sampled residents reviewed of the 30 residents included in the stage 2 review. The findings included: Closed medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 3/1/17 documented, .Wound documentation: Measure wounds weekly. Record L (length) x (by) W (width) x D (depth), appearance, amount and odor of any drainage . Review of the Wound Assessment Report(s) revealed the following: a. There was a wound assessment done on 9/13/16 which documented Resident #9 had a pressure ulcer to the sacrum, an onset date of 8/13/16 and it was present on admission. The pressure ulcer was an unstageable wound due to slough/eschar the measurements were 7 centimeters (cm) long x 5 cm wide and 0 cm deep. b. There was a wound assessment done on 10/20/16 which documented Resident #9 had a pressure ulcer to the sacrum, an onset date of 8/13/16 and it was present on admission. The pressure ulcer was a stage 4 and the measurements were 6 cm long x 4 cm wide and 3.5 cm deep. Review of the medical record revealed Resident #9 was hospitalized from [DATE] to 10/7/16, and 10/12/16 to 10/19/16. The Departmental Notes dated 10/7/16 documented, .Admission Assessment, Re-admission .Resident has a pressure ulcer on sacrum .Wounds referred to wound care . There was no assessment of this pressure ulcer. There was no wound assessment present from 10/7/16 (the day the resident returned from the hospital) to 10/12/16 (the day the resident was admitted to the hospital). Interview with the Treatment nurse on 3/29/17 at 12:47 PM, in the Director of Nursing (DON) office, the Treatment nurse was asked if there was a wound assessment performed on the resident after he returned from the hospital on [DATE]. The Treatment nurse stated, .not that I can find in here (medical record) . At 1:21 PM, the Treatment nurse stated, The admission nurse did chart that he had a pressure ulcer on his sacrum (on the Admission Assessment, Re-admission Departmental Notes) .",2020-03-01
1309,DIVERSICARE OF MARTIN,445249,158 MT PELIA RD,MARTIN,TN,38237,2018-05-31,604,E,1,1,Q6Y111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to follow the policy related to physical restraints for 2 of 3 (Resident #35 and 80) sampled residents reviewed for physical restraints. The findings included: 1. The facility's Physical Restraint Guideline policy dated (MONTH) (YEAR) documented, .For each patient/resident to maintain his or her highest practical health or well-being in an environment that prohibits the use of restraints for discipline or convenience, and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints .Upon determination .a patient/resident presents with medical symptoms that may require a restraint, they are evaluated using the applicable Pre-Restraint evaluation .If it is determined a restraint is needed the least restrictive device will be considered .A physicians order is required for any physical restraint, which will include the medical symptom(s) that warrant the restraint along with observation and release time parameters .Signed consent is obtained by the patient/resident representative after a review of the risks and benefits of using a restraint .The IDT (Interdisciplinary Team) care plan needs to address: When the restraint is to be used, plans for alternative measures, periodic and routine evaluation for reduction of the device and continued need .When a patient/resident is determined to need a restraint, the Physical Restraint Elimination evaluation .will be completed at least on a quarterly basis or with a significant change in the patients/residents condition. This evaluation will assist in determining continued need or possible reduction/elimination . 2. Medical record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan documented, .requires staff assistance with ADL's (activities of daily living) .Approaches .3/13/18 Low air loss mattress .Full side rails x (times) 2 d/t (due to) low air loss mattress . Review of the signed physician's orders [REDACTED]. There was no documentation a consent for siderails was obtained until 5/30/18. Observations in Resident #35's room on 5/29/18 at 9:26 AM, 11:33 AM, 12:35 PM, 1:08 PM, 3:00 PM, and 4:42 PM; and on 5/30/18 at 7:25 AM, 11:10 AM, 3:25 PM, and 5:54 PM, revealed Resident #35 lying in bed with bilateral full siderails raised. Interview with the Director of Nursing (DON) on 5/31/18 at 1:26 PM, in the conference room, the DON was asked when he expected the consent for siderails to be obtained. The DON stated, Prior to use. The DON was asked if it was acceptable that the siderail assessment and consent were not completed prior to use of bilateral full siderails for Resident #35. The DON stated, No. 3. Medical record review revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #80 had severe cognitive impairment per staff assessment, required extensive to total staff assistance for all ADLs, and a trunk restraint was used. The care plan last reviewed and updated 5/10/18 documented, .at risk for injury due to need for trunk restraint .Approaches .Self Release Alarm Seatbelt while up in wheelchair check every 30 minutes . The signed physician's orders [REDACTED].SELF RELEASE ALARM SEATBELT WHILE UP IN WHEELCHAIR CHECK EVERY 30 MINUTES AND RELEASE EVERY 2 HOURS . The last completed RESTRAINT ELIMINATION REVIEW was dated 1/23/17. The Interdisciplinary Therapy Data Collection Form dated 4/24/18 documented, .No significant (changes) in positioning/seatbelt . The Interdisciplinary Therapy Data Collection Form dated 5/14/18 documented, .NSG (Nursing) referral to assess safety of removing self-release alarm seatbelt . Interview with the DON on 5/31/18 at 6:35 PM, in the conference room, the DON was asked if it was acceptable that the restraint elimination assessments were not completed quarterly per the facility policy. The DON stated, Only thing I can find is we missed one by a month . Interview with Certified Nursing Assistant (CNA) #2 on 5/31/18 at 6:30 PM, on the 300 hall, CNA #2 was asked how often she checked Resident #80's seatbelt. CNA #2 stated, Every hour and a half or 2 hours .I just check to see if it's too tight or not hurting her .",2020-09-01
3016,THE VILLAGE AT GERMANTOWN,445482,7930 WALKING HORSE CIRCLE,GERMANTOWN,TN,38138,2018-01-11,689,D,1,0,XXVY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to follow their policy for falls by notifying the resident's representative and failed to perform post fall risk assessments to ensure residents were free from accident hazards for 1 (Resident #1) of 3 sampled residents. The findings included: 1. Review of the facility's FALLS RISK ASSESSMENT SYSTEM GUIDELINES policy documented, .Following a resident's fall, the licensed nurse will assess the resident for injuries and necessary treatment. The physician and resident's representative will be notified .A Post-Fall Assessment will be completed by the Charge Nurse within 48 hours of the fall . 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented Resident #1 was cognitively intact and required limited supervision and assistance with activities of daily living. The care plan dated 7/25/17 documented, .Risk for falls due to impaired mobility .Perform a falls risk assessment upon admission and prn (as needed) with significant changes in resident condition. Fall Risk assessment dated [DATE] (admission assessment) documented, .Total Score/Value 5 . A score of 10 or greater, the resident should be considered at HIGH RISK for potential falls. [NAME] Incident Report dated 8/12/17 documented, .CNA (Certified Nursing Assistant) entered the room she was in the bathroom on the floor .Neuro checks have been started .Family notified . B. Incident Report dated 8/16/17 documented, .At 6am this nurse was at the nursing station charting before heard Boom! I looked up observed Resident sitting on the floor beside the table at the dinning (dining) .assessment conducted .NP (Nurse Practitioner) and family notified . C. Incident Report dated 9/2/17 documented, .Called to public restroom .reported res (resident) had fallen in the bathroom .Neuro checks initiated . D. Incident report dated 9/9/17 documented, .resident was observed at sitting position on the floor beside bed .neuro checks initiated .family and NP notified . E. Incident report dated 9/10/17 documented, .resident noted per staff to be on ground outside dining room patio area .assessment for injury and neuro checks begun . 3. Telephone interview with Registered Nurse (RN) #1 on 1/5/18 at 3:45 PM, RN #1 was asked if it was appropriate for residents to be in the courtyard unattended. RN #1 stated, .if they have dementia or are a fall risk, they are supposed to have someone with them .I don't know who let her out . Fall Risk Assessments were requested but not provided for the falls on 8/2/17, 8/16/17, 9/2/17, 9/9/17, and 9/10/17. The responsible party was not notified after Resident #1's fall on 9/10/17. Interview with the Director of Nursing (DON) on 1/5/18 at 3:08 PM, in the Family Dining Room, the DON stated, .assessments should be performed prior to moving a resident after an unwitnessed fall and the physician, DON or Administrator, and the family should be notified . The DON was asked if residents should be in the courtyard unattended. The DON stated, .staff should be with them . The DON was asked who monitors the doors. The DON stated, .the doors are not locked . The DON was asked if the physician and responsible party should have been called. The DON stated, We have to notify the physician or nurse practitioner. The DON was shown the incident report and asked if the physician or family was notified. The DON stated, .it's not listed (documented) . The DON was asked if a new Fall Risk Assessment should have been completed after each fall. The DON stated, .it is our policy . Interview with the Dietary Manager (DM) on 1/5/18 at 3:20 PM, the DM stated, .the resident had asked to go out several times so the CNA took her out .the CNA was answering call lights and would go check on the resident . Telephone interview with CNA #1 on 1/11/18 at 9:12 AM, CNA #1 stated, .I was not the resident's CNA .there was an agency CNA taking care of her .I just found the resident outside .the resident's CNA was sitting in the dining room area on her personal phone .",2020-09-01
3180,"COLLIERVILLE NURSING AND REHABILITATION, LLC",445495,490 WEST POPLAR AVENUE,COLLIERVILLE,TN,38017,2018-03-21,689,D,1,1,RZTK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to follow their policy for neurological (Neuro) checks on 1 of 3 (Resident #11) sampled residents reviewed for falls. The findings included: 1. The facility's Falls policy documented, .If a fall occurs the following actions will be taken .Neuro Checks will be completed on residents that experience an unwitnessed fall . 2. The facility's Neurological Check Monitoring policy documented, .Protocol: Neurological checks (Neuro checks) will be completed .upon any unwitnessed fall .Every 15 minutes times four checks, Every 30 minutes times four checks, Every one hour times four checks, Every four hours times Four checks, Every 8 hours until 72 hours are completed . 3. Medical record review revealed Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The RT (Respiratory Therapy) Progress Notes dated 12/29/17 from 4:45 PM to 5:00 PM documented, Found pt (patient) on the floor. Nurse, CNA (Certified Nursing Assistant) assisted in placing pt back in bed .2130 (9:30 PM) .EMT (Emergency Medical Technician) have arrived to take pt for evaluation at (Named Hospital) . The incident report dated 12/29/17 documented, .Un-witnessed .LPN (Licensed Practical Nurse) believe res. (Resident) could have slid .No witnesses found .Level of Consciousness: Lethargic (Drowsy) . The hospital Computed [NAME]ography (CT) findings dated 12/31/17 at 3:20 AM, documented, .COMPARISON (MONTH) 30, (YEAR) .FINDINGS .No evidence of acute infarct, hemorrhage .is identified .small foci of hemorrhage seen within the right frontoparietal region are unchanged from prior exam .IMPRESSION .Stable exam .No new areas of hemorrhage identified . The hospital discharge summary dated 1/3/18 documented, .DISCHARGE Diagnoses: [REDACTED].[MEDICAL CONDITION] disorder .HOSPITAL COURSE .Patient had a CT scan, which showed some right frontoparietal [MEDICAL CONDITION] .there was no significant change in his neurologic status . Observations on 2/26/18 at 9:10 AM, 11:30 AM, 2/27/18 at 11:26 AM, and 2/28/18 at 2:10 PM, revealed Resident #11 was clean, well groomed, with no odors. Resident #11 was lying on an air mattress in a low bed with fall mats on both sides of the bed. Resident #11 would open his eyes to noise and voices but was unable to speak. Interview with Resident #4 (Resident #11's previous roommate who was in the room at the time of the fall) on 2/26/18 at 12:05 PM, in Resident #4's room, he was asked if he had any knowledge of Resident #11's fall when they were roommates. He stated, I heard him fall out of the bed, they (staff) came in a while later and found him .I heard the noise but I didn't know he fell or I would have used my call light .Nobody was in the room when it happened . Interview with Assistant Director of Nursing (ADON) #2 on 2/27/18 at 1:30 PM, at the 3rd floor nursing desk, ADON #2 was asked where would written neuro checks be found. ADON #2 stated, In the computer. She was asked about handwritten pages. ADON #2 stated, They wouldn't hand write them, they are in the computer. Interview with the Certified Respiratory Therapist (CRT) #1 on 2/27/18 at 2:27 PM, in the conference room, she was asked about Resident #11's fall. CRT #1 stated, I was in the room with the other patient .I was in the room long enough to suction him .The other patient was on the door side and the curtain was pulled .then I went over and that's when I saw him (Resident #11) on the floor. He was still connected to the ventilator and the pulse ox (oximeter). He was between the vent (ventilator) and the bed. His head (right side) was laying on the ventilator base .I called for the nurse and the aide also came in .we all got him back in bed. Interview with Certified Nursing Assistant (CNA) #2 on 2/27/18 at 2:40 PM, in the conference room, she was asked about Resident #11's fall. CNA #2 stated, I was the CNA that assisted (Named CRT) and (Named LPN). We put him back to bed .I don't remember him (the nurse) looking into his eyes or using a flashlight . Interview with the Director of Nursing (DON) on 3/1/18 at 1:50 PM, in the DON office, the DON was asked for the neuro checks for Resident #11. The DON stated, I don't see an eval (neuro evaluation) done. I don't see any documentation of neuro checks. The DON was asked should there have been neuro checks done on Resident #11 from the time of the fall until he was transferred to the hospital (approximately 5 hours). The DON stated, Yes, unless they did them on paper. She was asked according to the policy, should neuro checks be done. The DON stated, I have this thing out on the floor how often to do it. We don't have a policy about neuro checks. The DON was asked if neuro checks should have been done on Resident #11. The DON stated, Um hum. Interview with LPN #1 on 3/1/18 at 2:45 PM, in the conference room, she was was asked if she did neuro checks on Resident #11 after the unwitnessed fall on 12/29/17. LPN #1 stated, I did (neuro checks) on paper. I guess it got lost. I put it at the nurse's desk . The facility was unable to provide evidence that neuro checks were done on Resident #11 after the unwitnessed fall during the 5 hours prior to being sent out to the hospital.",2020-09-01
2790,AMERICAN HEALTH COMMUNITIES OF CLARKSVILLE,445455,900 PROFESSIONAL PARK DRIVE,CLARKSVILLE,TN,37040,2020-02-21,684,D,1,0,65M111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to follow treatment orders for a medicated cream for 1 of 3 sampled residents (Resident #1) reviewed with skin conditions. The findings include: Review of the medical record, showed Resident #1 had a [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Review of the (MONTH) 2020 Treatment Administration Record (TAR), showed that Resident #1 did not get the [MEDICATION NAME]-[MEDICATION NAME] cream twice a day on the following days: 2/13/2020, 2/14/2020, 2/15/2020, 2/16/2020, 2/17/2020, 2/18/2020, 2/19/2020, and 2/20/2020. Observation in the resident's room on 2/20/2020 at 10:50 AM, showed Resident #1 had a moderate red rash under her left and right upper arms and a small red rash to the bilateral sides of her rib cage. During an interview on 2/20/20 at 1:48 PM, Registered Nurse (RN) #1 confirmed that he did not apply the cream as prescribed. During an interview on 2/20/2020 at 4:03 PM, the Director of Nursing (DON) confirmed that Resident #1 did not receive her cream as prescribed.",2020-09-01
1637,COUNTRYSIDE HEALTHCARE AND REHABILITATION,445280,3051 BUFFALO ROAD,LAWRENCEBURG,TN,38464,2017-07-20,279,D,1,0,4V9N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to initiate a care plan for an indwelling urinary catheter for 1 of 10 (Residents #7) sampled residents reviewed. The findings included: 1. The facility's Care Plans-Comprehensive policy documented, .Our facility's Care Planning/Interdisciplinary Team .develops and maintains a comprehensive care plan for each resident .The Care Planning/Interdisciplinary team is responsible for the periodic review and updating of care plans . 2. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating no cognitive impairment, required limited to extensive staff assistance for activities of daily living, and had a urinary catheter. Review of the physician's orders [REDACTED]. Review of the initial care plan dated 6/1/17 revealed no documentation of the urinary catheter. Observations at the East Wing Nurses' Station on 7/18/17 at 10:26 AM, revealed Resident #7 ambulating with a walker. The urinary catheter tubing was visible, and the drainage bag was contained in a dignity bag hanging on the walker. Interview with the Director of Nursing (DON) on 7/18/17 at 5:06 PM, in the conference room, the DON was asked whether use of an indwelling catheter should be documented on the care plan. The DON stated, Yes. The DON was asked whether Resident #7's care plan addressed his Foley catheter. The DON reviewed the care plan, and stated, No .",2020-09-01
3002,THE WATERS OF SPRINGFIELD LLC,445480,704 5TH AVENUE EAST,SPRINGFIELD,TN,37172,2019-12-05,677,D,1,1,LTVO11,"**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 assistance with dressing and bathing for 2 of 3 (Resident #5 and #30) sampled residents reviewed for Activities of Daily Living (ADLs). The findings include: 1. The facility's undated Activities of Daily Living policy documented, .Residents are given routine daily care and HS (Hours of Sleep) care .to promote hygiene, provide comfort .ADL care of the resident includes .Assisting the resident in personal care such as bathing, showering, dressing . 2. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had severe cognitive impairment, required limited staff assistance for dressing and toilet use, and required extensive staff assistance for bathing and personal hygiene. The care plan revised 11/29/19, documented, .Self-care Deficit .requires assistance with ADL .Interventions .requires extensive assistance with dressing .Hygiene .requires extensive assistance .Toileting .requires extensive assistance . Resident #5's shower sheets were reviewed for September, October, November, and (MONTH) 2019. The shower sheets revealed Resident #5 did not receive a shower: 9/12/19 and 9/19/19, 9/23/19 and 10/10/17, 10/10/19 and 10/17/19, 10/17/19 and 10/24/19, and 10/24/19 and 11/21/19. No showers were documented after 11/21/19. The only documentation that Resident #5 had been offered and refused showers from (MONTH) through (MONTH) 2019 on the shower refusal sheets were dated 11/4/19, 11/7/19, and 11/18/19. Review of the ADL Reports for September, October, November, and (MONTH) 2019, revealed no bathing documentation. Interview with Certified Nursing Assistant (CNA) #1 on 12/4/19 at 2:31 PM at the Back Hall Nurse's Desk, CNA #1 was asked how often Resident #5 received showers. CNA #1 stated, .She is supposed to get it twice a week . The facility was unable to provide documentation that Resident #5 was offered or received showers at least twice weekly. Observation in the Dining Room on 12/2/19 at 2:33 PM revealed Resident #5 seated in a wheelchair, dressed in a tan v-neck top, black pants, and white socks, and a gray sweater was draped across the back of her wheelchair. Observation in Resident #5's room on 12/3/19 at 7:51 AM revealed Resident #5 seated on the edge of the bed, and still dressed in the same clothes as the previous day, a tan v-neck top, black pants, and white socks. The gray sweater was draped across the back of the wheelchair at the bedside. Observation in Resident #5's room on 12/03/19 at 10:01 AM, revealed Resident #5 lying in bed and still dressed in the tan v-neck blouse. Observation in Resident #5's room on 12/03/19 at 2:23 PM revealed Resident #5 seated in the wheelchair dressed in a red blouse, blue denim-type pants, black socks and slippers. Observation in the Back Hall Dining Room on 12/3/19 at 4:40 PM revealed Resident #5 seated in the wheelchair, still dressed in the red blouse, blue denim-type pants, black socks and slippers. Observation in Resident #5's room on 12/4/19 at 7:43 AM revealed Resident #5 lying on the bed, still dressed in the same clothing as the previous day, the red blouse, blue denim-type pants, and black socks and slippers. Observation in Resident #5's room on 12/4/19 at 2:25 PM revealed Resident #5 seated in the wheelchair, still dressed in the red blouse, blue denim-type pants, black socks and slippers. Observation in the Back Hall Dining Room on 12/4/19 at 4:47 PM revealed Resident #5 seated in the wheelchair, still dressed in the red blouse, blue denim-type pants, black socks and slippers. Interview with the Director of Nursing (DON) on 12/4/19 at 5:38 PM in the DON office, the DON was asked how often residents should be showered. The DON stated, Twice a week, and more often if they want to be. The DON was asked how often the residents' clothing should be changed. The DON stated, Daily, and more often if they want to be, or if it needs to be. The DON was asked if residents should sleep in their day clothes. The DON stated, No, unless they are alert and oriented and they absolutely want to . The DON was asked if staff should document if a resident refused care or showers. The DON stated, Yes .they should also notify the nurse so the nurse can make a note, and then we also fill out refusal sheets. 3. Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] documented Resident #30 required physical help with the assistance of 1 person for bathing. Interview with Licensed Practical Nurse (LPN) #3 on 12/3/19 at 3:20 PM at the Front Hall Nurses' Station, LPN #3 was asked about the resident's bathing schedule. LPN #3 stated, She gets a shower on night shift on Tuesday and Friday . TheBathing Choice Provided form documented Resident #30 did not receive a shower: 11/16/19 and 11/23/19 and 11/24/19 and 12/1/19. Interview with the DON on 12/04/19 at 2:00 PM in the DON Office, the DON was asked if Resident #30 should receive showers twice a week. The DON stated, .Yes . The facility was unable to provide documentation that Resident #30 received or was offered showers at least twice weekly.",2020-09-01
2669,GALLAWAY HEALTH AND REHAB,445440,435 OLD BROWNSVILLE RD,GALLAWAY,TN,38036,2017-06-29,314,E,1,0,92J611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services for the treatment of [REDACTED].#1, 9, 10 and 12) sampled residents reviewed of the 5 residents reported by the facility as having pressure ulcers. The findings included: 1. The facility's Wound Care Guidelines policy documented, .The purpose of this procedure is to provide guidelines for the care of wounds .Verify that there is a physician's order for treatment . The facility's Pressure Ulcers/Skin Breakdown - Clinical Guidelines policy documented, .The nursing staff will complete an evaluation of the skin weekly .Based upon need and the result of the evaluations the staff will implement interventions for the prevention and care of skin issues . 2. Interview with the Wound Care Nurse on 6/25/17 at 9:05 AM in Resident #1's room, the Wound Care Nurse was asked about frequent wound care orders and stated, .we get new wound care orders routinely every 14 days . The Wound Care Nurse was asked why Resident #1 developed wounds and stated, we would position her and she would roll herself back on her back .noncompliant . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Weekly Pressure Wounds log revealed on 10/18/16 Resident #1 was found to have a left buttocks wound that measured 0.8 centimeters (cm) x 1.3 cm. x 0.1cm. Review of the Physician's orders dated 4/5/17 revealed .CLEANSE LEFT BUTT[NAME]K WOUND WITH WOUND CLEANSER. PAT DRY. LIGHTLY FILL WOUND BED WITH CALCIUM ALGINATE AND COVER WITH A DRY PROTECTIVE DRESSING Q (every) DAY X (times) 14 DAYS . Review of the Physician's orders dated 4/20/17 .Cleanse Left hip wound with wound cleanser, pat dry, Apply [MEDICATION NAME] Cream and Calcium Alginate to wound bed and cover with a dry protective dressing q (every) day x 4 days one time a day . Review of the Treatment Administration Record (TAR) dated (MONTH) (YEAR) revealed no documentation of treatments on 4/3/17, 4/13/17, 4/17/17, and 4/21/17. Review of the Physician's order dated 5/16/17 revealed .CLEANSE LEFT BUTT[NAME]K WOUND WITH WOUND CLEANSER, PAT DRY. LIGHTLY FILL WOUND WITH CALCIUM ALGINATE AND COVER WITH A DRY PROTECTIVE DRESSING Q DAY X 14 DAYS one time a day .weekly skin assessment one time a day every Fri (Friday) for assessment . Review of the TAR dated (MONTH) (YEAR) revealed no documentation of treatments on 5/1/17, 5/2/17, 5/3/17, 5/4/17, 5/5/17, 5/6/17, 5/7/17, 5/8/17, 5/9/17, 5/10/17, 5/11/17, 5/12/17, 5/13/17, 5/14/17, 5/15/17, 5/27/17, and 5/28/17. Review of the TAR dated (MONTH) (YEAR) revealed no skin assessment on 5/19/17. Review of the Physician's order dated 6/2/17 revealed .CLEANSE LEFT BUTT[NAME]K WOUND WITH WOUND CLEANSER. PAT DAY. APPLY CALCIUM ALGINATE TO WOUND BED AND COVER WITH A DRY PROTECTIVE DRESSING Q DAY X 14 DAYS, One time a day . Review of the TAR dated (MONTH) (YEAR) revealed no documentation of treatments on 6/12/17, 6/18/17, and 6/24/17. Observations of Resident #1's wound on 6/27/17 at 9:05 AM, revealed the wound had improved and measured 0.3 cm x 0.3 cm x 0.3 cm. on the left buttock. 3. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Medical record revealed Resident #9 was admitted to Hospice care on 7/29/16 due to declining condition. Review of the Weekly Pressure Wounds log revealed Resident #9 was found to have a coccyx wound that measured 1.3 cm. x 0.4 cm. x 0.4 cm. on 10/18/16. Review of the Physician's orders dated 4/7/17 revealed .[MEDICATION NAME] Cream 1% (Silver [MEDICATION NAME]) Apply to Coccyx topically one time a day . Review of the Physician's orders dated 4/20/17 revealed .Cleanse Coccyx wound with wound cleanser. Pat dry. Apply Calcium Alginate to wound bed and cover with a dry protective dressing q day x 14 days one time a day . Review of the TAR dated (MONTH) (YEAR) revealed no documentation of treatments on 4/11/17, 4/17/17, and 4/21/17. Review of the Physician's order dated 5/1/17-5/31/17 revealed .Weekly skin Assessment every evening shift every Thu (Thursday) for Documentation .Consult wound care physician to eval (evaluate) and treat as indicated as needed . Review of the Physician's orders dated 5/3/17 revealed .Cleanse Coccyx wound with cleanser. Pat dry. Apply Calcium Alginate to wound bed and cover with a dry protective dressing q day x14 days one time a day . Review of the Physician's orders dated 5/16/17 revealed .CLEANSE C[NAME]CYX WOUND WITH WOUND CLEANSER. PAT DRY. LIGHTLY FILL WOUND BED WITH CALCIUM ALGINATE AND COVER WITH A DRY PROTECTIVE DRESSING Q DAY X14 DAYS one time a day . Review of the TAR dated (MONTH) (YEAR) revealed no documentation of treatments on 5/4/17, 5/13/17, 5/17/17, and 5/28/17. Review of the Physician's order dated 6/2/17 revealed .CLEANSE C[NAME]CYX WOUND WITH WOUND WITH WOUND CLEANSER, PAT DRY, APPLY CALCIUM ALGINATE AND COVER WITH A DRY PROTECTIVE DRESSING Q DAY X 14 DAYS one time a day . Review of the Physician's orders dated 6/17/16 revealed .CLEANSE C[NAME]CYX WOUND WITH WOUND CLEANSER. PAT DRY. APPLY CALCIUM ALGINATE AND COVER WITH A DRY PROTECTIVE DRESSING Q DAY X 14 DAYS one time a day . Review of the TAR dated (MONTH) (YEAR) revealed no documentation of treatments on 6/3/17, 6/4/17, 6/9/17, and 6/10/17. Wound care observations of Resident #9 on 6/28/17 at 11:49 AM, revealed a coccyx wound measuring 1.0 cm x 0.5 cm x 0.1 cm. 4. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. The admission record revealed the stage 4 sacral pressure wound measured 4.2 cm. x 1.8 cm. x 0.5 cm. The record revealed Resident #10 developed a left posterior thigh pressure wound on 3/27/17 that measured 7.4 cm. x 6.0 cm. x 1.0 cm. A nurses note dated 5/3/17 revealed the resident still noncompliant with rest periods .refuses to lay down and remains up in wheelchair longer that what MD (Medical Doctor) recommended. Another nurses note dated 6/5/17 revealed the resident refused to take supplements to help with wound healing . Review of the Physician's order dated 4/5/17 revealed .CLEANSE SACRAL WOUND WITH WOUND CLEANSER. PAT DRY. LIGHTLY FILL WOUND BED WITH CALCIUM ALGINATE AND COVER WITH A DRY PROTECTIVE DRESSING Q DAY X14 DAYS one time a day . Review of the Physician's order dated 4/20/17 revealed .CLEANSE SACRAL WOUND WITH WOUND CLEANSER. PAT DRY. LIGHTLY FILL WOUND BED WITH CALCIUM ALGINATE AND COVER WITH A DRY PROTECTIVE DRESSING Q DAY X14 DAYS one time a day . Review of the Physician's order dated 4/6/17 revealed .CLEANSE LEFT POSTERIOR THIGH SHEAR WOUND WITH WOUND CLEANSER. PAT DRY. APPLY SKIN PREP TO PERI-WOUND AREA AND COVER WITH A [MEDICATION NAME] DRESSING Q 3 DAYS X 14 DAYS one time a day every Sun(Sunday), Wed (Wednesday), Fri (Friday) . Review of the Physician's order dated 4/25/17 revealed .Cleanse Unstageable Left Posterior Thigh wound with wound cleanser. Pat dry. Apply Santyl Ointment and cover with xeroform gauze and a dry protective dressing q day x 14 days one time a day . Review of the TAR dated (MONTH) (YEAR) revealed no documentation of treatments on the sacral wound on 4/6/17, 4/10/17, 4/12/17, 4/20/17, and 4/28/17. Review of the TAR dated (MONTH) (YEAR) revealed no documentation of treatments on left posterior thigh wound on 4/10/17, 4/12/17, 4/20/17, and 4/28/17. Review of the Physician's order dated 5/6/17 revealed .weekly skin assessment every evening shift every Sat (Saturday) for assessment . Review of the Physician's order dated 5/9/17 revealed .CLEANSE SACRAL WOUND WITH WOUND CLEANSER PAT DRY. FILL WOUND WITH CALCIUM ALGINATE AND COVER WITH A DRY PROTECTIVE DRESSING Q DAY X 14 DAYS one time a day . Review of the Physician's order dated 5/12/17 revealed .Silver [MEDICATION NAME] Cream 1 % Apply to sacrum topically one time a day .Apply to sacral wound topically one time a day . Review of the Physician's order dated 5/23/17 revealed .[MEDICATION NAME] Cream 1 % (Silver [MEDICATION NAME]) Apply to LT (left) Posterior thigh topically one time a day . Review of the Physician's order dated 5/25/17 revealed .CLEANSE LEFT POSTERIOR THIGH WOUND WITH WOUND CLEANSER. PAT DRY APPLY SANTYL OINTMENT AND COVER WITH A DRY PROTECTIVE DRESSING Q DAY X14 DAYS one time a day .WILL NEED APPROX. (approximately) 90 GRAMS OF SANTYL FOR TREATMENT . Review of the Physician's order dated 5/26/17 revealed .[MEDICATION NAME] Tablet 500 MG (milligrams) ([MEDICATION NAME]) Apply to LT POSTERIOR HIP WOUND topically one time a day .SPRINKLE IN WOUND BED AT DRESSING CHANGE . Review of the TAR dated (MONTH) (YEAR) revealed no documentation of treatments on the sacral wound on 5/5/17 and 5/10/17. Review of the TAR dated (MONTH) (YEAR) revealed no documentation of treatments on left posterior thigh wound on 5/8/17, 5/10/17, 5/17/17 and 5/18/17. Review of the TAR dated (MONTH) (YEAR) revealed no documentation of Santyl Ointment applied with wound treatments on left posterior thigh on 5/27/17 and 5/28/17. Review of the TAR dated (MONTH) (YEAR) revealed no documentation of [MEDICATION NAME] sprinkled in the wound bed of left posterior hip wound with wound treatments on 5/27/17 and 5/28/17. Review of the TAR dated (MONTH) (YEAR) revealed no documentation of skin assessment on 5/13/17 and 5/27/17. Review of the Physician's order dated 6/1/17-6/30/17 revealed .Santyl Ointment 250 UNIT/GM (grams) Apply to LEFT POSTERIOR THIGH topically one time a day .Santyl Ointment 250 UNIT/GM Apply to SACRUM topically one time a day .[MEDICATION NAME] Tablet 500 MG (milligram) Apply to LT POSTERIOR HIP WOUND topically one time a day .CRUSH [MEDICATION NAME] AND SPRINKLE IN WOUND BED AT DRESSING CHANGE .weekly skin assessment every evening shift every Sat (Saturday) for assessment . Review of the TAR dated (MONTH) (YEAR) revealed no documentation of treatments on left posterior thigh wound or the sacral wound on 6/24/17. Review of the TAR dated (MONTH) (YEAR) revealed no documentation of the Santyl Ointment applied to the left posterior thigh or the sacral wound on 6/1/17. Review of the TAR dated (MONTH) (YEAR) revealed no documentation of the [MEDICATION NAME] sprinkled in the wound bed of the left posterior hip wound on 6/1/17, 6/2/17, 6/3/17 and 6/4/17. Review of TAR dated (MONTH) (YEAR) revealed no documentation of skin assessment on 6/10/17. Wound care observation of Resident #10 on 6/28/17 at 9:54 AM, revealed a sacral wound measuring 4.0 cm x 2.9 cm x 3.3 cm, and a left posterior thigh wound measuring 6.9 cm x 6.5 cm x 4.5 cm. Interview with the Wound Care Nurse on 6/28/17 at 10:05 AM outside the resident's room, the Wound Care Nurse stated, We had a care plan conference with (named Resident #10) due to her noncompliance with re-positioning, she refuses to go back to bed because she likes to smoke and doesn't want to miss her smoke times . 5. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with a readmission of 3/2/15 with [DIAGNOSES REDACTED]. The Weekly Pressure Sore logs revealed a pressure sore on the left hip that measured 2.5 cm. x 1.7 cm. x 0.1cm. on 3/26/17. The record revealed Resident #12 declined in nutritional status due to dysphagia with a decline in intake. Review of the Physician's order dated 4/6/17 revealed .Cleanse Left Hip Wound with wound cleanser. pat dry. Apply skin prep to peri-wound and cover with a [MEDICATION NAME] dressing QOD (every other day) x 14 days one time a day every other day . Review of the Physician's order dated 4/6/17 revealed .[MEDICATION NAME] Cream 1 % (Silver [MEDICATION NAME]) Apply to left hip wound topically one time a day for left hip wound . Review of Physician's orders dated 4/19/17 revealed .Cleanse Left Hip wound with wound cleanser. Pat dry. Apply Santyl Ointment q day and cover with a dry protective dressing x 14 days one time a day for UNSTAGEABLE WOUND . Review of the Physician's order dated 4/26/17 revealed .Santyl Ointment 250 UNIT/GM ([MEDICATION NAME]) Apply to Left Hip topically one time a day for unstageable wound . Review of the TAR dated (MONTH) (YEAR), revealed no documentation of treatments on the left hip on 4/9/17, 4/11/17, 4/17/17, 4/21/17, 4/22/17 and 4/25/17. Review of the Physician's order dated 5/5/17 revealed .Santyl Ointment 250 UNIT/GM ([MEDICATION NAME]) Apply to left hip topically one time a day . Review of the Physician's order dated 5/25/17 revealed .CLEANSE LEFT HIP WOUND WITH WOUND CLEANSER. PAT DRY. APPLY CALCIUM ALGINATE AND COVER WITH A DRY PROTECTIVE DRESSING Q DAY X14 DAYS one time a day . Review of the TAR dated (MONTH) (YEAR) revealed no documentation of treatments on the left hip on 5/2/17, 5/5/17, 5/10/17, and 5/28/17. Review of the Physician's order dated 6/13/ 17 revealed .CLEANSE LEFT HIP WOUND WITH WOUND CLEANSER, AT DRY, APPLY CALCIUM ALGINATE AND COVER WITH A DRY PROTECTIVE DRESSING Q DAY X14 DAYS, one time a day . Review of the TAR dated (MONTH) (YEAR) revealed no documentation of treatments on the left hip on 6/3/17, 6/4/17 and 6/7/17. Wound care observations of Resident #12 on 6/28/17 at 3:11 PM, revealed the wound resolved with a scab remaining on the left hip measuring 0.3 cm x 0.3 cm. Interview with the Wound Care Nurse on 6/28/17 at 3:15 PM on the 200 hall the Wound Care Nurse stated, We have resolved this area, no treatments currently being done. 6. Interview with the Wound Care Nurse on 6/29/17 at 10:03 AM on the 200 hall, the Wound Care Nurse was asked where the wound care treatments were documented for the residents. The Wound Care Nurse stated, They are documented on the TAR and the nurse's progress notes. The Wound Care Nurse was asked if it was acceptable to not follow doctors' orders for wound care and the Wound Care Nurse stated, No. 8. Interview with Licensed Practical Nurse (LPN) #1 on 6/29/17 at 1:54 PM in the conference room LPN #1 was asked who is responsible for the resident dressing change when the wound care nurse is off. LPN #1 stated, .The charge nurse changes the dressing if they know that the wound care nurse is not going to be here .",2020-09-01
565,DIVERSICARE OF DOVER,445155,"537 SPRING STREET, PO BOX 399",DOVER,TN,37058,2020-01-09,686,D,1,0,5J8E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to provide complete and weekly assessments for pressure ulcers for 1 of 3 sampled residents (Resident #2) reviewed with pressure ulcers. The findings include: The facility's undated policy titled, Skin Care Guideline, documented, .When an open area is identified .Document evaluation of wound in electronic medical record including .Location and staging .Size (length .width .depth .Weekly skin evaluations are completed and documented . Review of the medical record, showed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan documented, .Focus .11/23/2019 stage 2 right ankle .Interventions .Weekly Wound Assessment . The Progress Notes dated 11/22/19 documented, .resident has open area on right outer foot .measures 0.4 cm (centimeters) x (by) 1 cm . There was no stage of the pressure injury. The Progress Notes dated 12/5/19 documented, .has stage 2 pressure ulcer on right mid outer foot, white center with pink edges, no drainage . There were no measurements of the pressure injury. The Progress Notes dated 1/2/20 documented, .outer right foot .measures 0.5 cm x 0.5 cm . There was no stage of the pressure injury. The Progress Notes dated 1/6/20 documented, .wound to right outer foot is 1 cm x 1 cm . There was no stage of the pressure injury. Medical record review from 11/22/19 - 1/6/20, showed the only wound assessments performed were on 11/22/19, 12/5/19, 1/2/20, and 1/6/20. Observation in the resident's room on 12/27/19 at 10:07 AM, showed Resident #2 had 2 small open areas to the right outer foot. The facility was unable to provide documentation that weekly wound assessments and complete wound assessments with measurements and staging were performed for Resident #2's pressure injury. During an interview conducted on 12/27/19 at 12:10 PM, the Wound Care Nurse was asked about Resident #2's pressure injury on her right foot. The Wound Care Nurse stated, .started (MONTH) 23rd .one is almost healed .still working on the other spot .is a stage 2 . During a phone interview conducted on 1/9/20 at 9:30 AM, the Director of Nursing (DON) confirmed weekly wound assessments and complete wound assessments with measurements and staging were not performed and stated, .not getting assessed correctly .",2020-09-01
614,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2019-11-19,677,E,1,1,H2CG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to provide nail care for 3 of 3 (Resident #30, #39, and #55) sampled residents reviewed for Activities of Daily Living (ADL) care. The findings include: 1. The facility's Care of Fingernails/Toenails policy with a revision date of (MONTH) 2010 documented, .to clean the nail bed, to keep nails trimmed and to prevent infection .daily cleaning and regular trimming . 2. Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #30 required extensive staff assistance for personal hygiene. Observations in Resident #30's room on 11/17/19 at 10:52 AM, 11/17/19 at 4:49 PM, and on 11/18/19 at 9:43 AM, revealed Resident #30 had long thick toe nails and the right great toe nail was curled upward back toward the resident. Interview with Licensed Practical Nurse (LPN) #6 on 11/19/19 at 2:21 PM, in Resident #30's room, LPN #6 was asked to describe Resident #30's toenails. LPN #6 stated, Thick and fungal .didn't know they were like that . 3. Medical record review revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #39 required total dependence of staff for personal hygiene. Observations in Resident #39's room on 11/17/19 at 10:00 AM, revealed Resident #39's fingernails were long with a dark brown substance under the nails. Interview with LPN #3 on 11/19/19 at 3:23 PM, at the 1 East Nurses' Station, LPN #3 stated Resident #39's fingernails are dirty. LPN #3 was asked how the nurses were made aware residents nails needed trimming. LPN #3 stated .the CNAs (Certified Nursing Assistants) and nurses should assess resident's skin and nails and determine if the nails need trimming . 4. Medical record review Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #55 required extensive staff assistance for his personal hygiene. Observations in Resident #55's room on 11/17/19 at 10:35 AM and 4:40 PM, 11/18/19 at 8:04 AM, 11/19/19 at 7:25 AM, and on 11/19/19 at 4:13 PM, revealed Resident #55 had long, thick toe nails. Interview with CNA #3 on 11/19/19 at 1:40 PM, at the 1 West Nurses' Station, CNA #3 was asked about Resident #55's toenails CNA #3 stated, .they look awful .need to be cut . Interview with LPN #5 on 11/19/19 at 1:55 PM, in Resident #55's room, LPN #3 was asked to look at Resident #55's toenails. LPN #5 stated, .yes they need to be trimmed . Interview with the Director of Nursing (DON) on 11/19/19 at 6:22 PM, in the Conference Room, the DON was asked should nails be clean and neatly trimmed. The DON stated, .Yes .",2020-09-01
3173,"COLLIERVILLE NURSING AND REHABILITATION, LLC",445495,490 WEST POPLAR AVENUE,COLLIERVILLE,TN,38017,2019-02-06,659,D,1,1,XLPJ11,"**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 nutritional interventions according to the care plan for 1 of 5 (Resident #45) sampled residents reviewed with an enteral feeding. The findings include: The Care Plans, Comprehensive Person-Centered undated policy documented, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The comprehensive, person-centered care plan will .describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Medical record review for Resident #45 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #45 was cognitively in a vegetative state, totally dependent for Activities of Daily Living (ADL's) and received nutrition through a PEG feeding tube. The care plan dated 4/16/18 and revised on 11/6/18 documented, .Provide my T/F (tube feeding) as ordered . A physician's orders [REDACTED].(symbol for increase) [MEDICATION NAME] 1.5 to 60ml (milliliters)/hr (hour) . Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Observations in Resident #45's room on 1/9/19 at 1:00 PM, revealed the tube feeding of [MEDICATION NAME] 1.5 was infusing at 55 ml/hr. Interview with Registered Nurse (RN) #1 on 1/9/19 at 1:20 PM, in the Nurses' Station, RN #1 was asked about the order to increase the feeding and she stated, .was not aware of that order . The facility failed to ensure the care plan intervention was implemented as ordered.",2020-09-01
679,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2018-07-12,695,D,1,0,MQID11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to provide proper [MEDICAL CONDITION] care for 1 of 3 (Resident #3) residents observed with a [MEDICAL CONDITION]. The findings included: 1. The facility's [MEDICAL CONDITION] Care policy documented, .[MEDICAL CONDITION] should be changed as ordered and as needed . 2. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with a readmission date of [DATE] with the [DIAGNOSES REDACTED]. The physician's orders [REDACTED].TRACH ([MEDICAL CONDITION]) CARE Q SHIFT (every shift) . The admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 was assessed with [REDACTED]. Review of Medication Administration Record [REDACTED]. Review of the MARs dated (MONTH) and (MONTH) (YEAR) revealed no documentation of [MEDICAL CONDITION] care provided on either shift. Observations in Resident #3's room on 7/3/18 at 10:00 AM, revealed a large amount of thick, creamy secretions flowed from the end of the resident's [MEDICAL CONDITION] and pooled on her upper chest. Observations in Resident #3's room on 7/3/18 at 1:19 PM, revealed a small amount of thick, creamy secretions flowed from the end of the residents [MEDICAL CONDITION]. Interview with Licensed Practical Nurse (LPN) #1 on 7/3/18 at 10:00 AM, in Resident #3's room, LPN #1 was asked how often [MEDICAL CONDITION] care is performed on the resident. LPN #1 stated, .It's not due .the night shift nurse told me she did it . Interview with the Director of Nursing (DON) on 7/3/18 at 1:38 PM, in the administrator's office, the DON was asked how often [MEDICAL CONDITION] care should be performed. The DON stated, Every shift .and as needed. The DON was asked if she could tell me where the [MEDICAL CONDITION] care was documented. The DON stated, .On the MAR's . The DON was asked if it was acceptable to not perform or document [MEDICAL CONDITION] care. The DON stated, .No .it should be documented .",2020-09-01
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
874,PALMYRA HEALTH AND REHABILITATION,445184,2727 PALMYRA RD,PALMYRA,TN,37142,2017-05-25,280,D,1,0,K3HH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observation, and interview, the facility failed to revise the care plan to reflect current status for 3 of 20 (Resident #38, 6, and 42) sampled residents reviewed of the 33 residents included in stage 2. The findings included: 1. Review of the facility's CARE PLANS - COMPREHENSIVE policy documented, .Care plans are revised as changes in the resident's condition dictates. Reviews are made at least quarterly and upon change of condition . 2. Review of an incident documented, .On 2/19 (2/19/17 at 10:40 AM) resident #3289 (Resident #38) was witnessed by other residents in dining room running into chair of resident (Resident #6). During this event resident (Resident #38) attempted to hit resident (Resident #6) causing a small scratch on lip. Residents were separated and monitored throughout the day. Mobile Crisis notified as was the DON(Director of Nursing) and Administrator . 3. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #38's care plan dated 5/12/16 revealed no documentation of the altercation with Resident #6 that occurred on 2/19/17. 4. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's care plan for behaviors dated 2/3/15 revealed no documentation of the altercation with Resident #3 that occurred on 2/19/17. Interview with the Interim Director of Nursing (IDON) on 5/23/17 at 4:53 PM, in the DON's office, the IDON was asked if she would expect the care plans to be updated to reflect the altercation that occurred on 5/9/17. The IDON stated, Yes. The IDON was asked if the care plans for Resident #38 and 6 had been updated to reflect the altercation that occurred on 2/19/17. The IDON stated, No. 5. Medical record review revealed Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #42 had a fall on 5/19/17 at 9:51 AM while attempting to cross the threshold of the front entrance foyer when his wheelchair tipped over backwards resulting in a skin tear to his left forearm and the intervention included weights to be placed on the front of Resident #42's wheelchair and the furniture in front entrance foyer rearranged. Review of Resident #42's care plan dated 11/8/16 revealed no documentation of Resident #42's risk for falls or the fall that occurred on 5/19/17. Interview with the Minimum Data Set (MDS) Coordinator on 5/24/17 at 1:39 PM, in the Social Service's Office, the MDS Coordinator was asked if a resident who had a [DIAGNOSES REDACTED]. The MDS Coordinator stated, Yes. The MDS Coordinator was then asked if Resident #42 had a fall on 5/19/17 should the care plan have been updated to reflect that fall and the interventions that were put into place. The MDS Coordinator stated, Yes, it should .",2020-09-01
4206,TOWNE SQUARE CARE OF PURYEAR,445470,220 COLLEGE STREET,PURYEAR,TN,38251,2016-12-13,514,F,1,0,R71K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observations and interview, the facility failed to ensure medical records were complete and readily accessible for 7 of 7 (Resident #1, 2, 3, 4, 5, 6, and 7) sampled residents. The findings included: 1. Review of the MDS 3.0 Process policy documented, .The facility will maintain all resident assessments completed within the previous fifteen (15) months and allow accessibility to the staff as necessary for the provision of care and the state survey agency. Review of the Comprehensive Care Plan policy documented, .Each resident will have a comprehensive care plan developed within (7) days of completion of the comprehensive (MDS) resident assessment .Medical records/charts of residents to be discussed shall be brought to the meeting for review and discussion .The discussion should be summarized by writing a PCC (Point Click Care)Care Plan Meeting Note for inclusion in the medical record . Review of the Charting and Documentation policy documented, .Each resident will have an active medical record that contains accurately documented information, systematically organized and readily accessible to authorized persons . 2. Medical record review of Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The record contained a Care Plan Meeting note dated [DATE] that documented family concerns about the residents nutritional status with interventions planned by the team. There were no nurses notes, dietary notes, social notes, activity notes, Minimum Data Set (MDS) assessments or care plan available or accessible for review. 3. Medical record review of Resident #2 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The record revealed the resident was placed under Hospice care on [DATE] and a Physician's Progress note dated [DATE] documented slow decline . There were no nurses notes, dietary notes, social notes, activity notes, MDS assessments, or current care plan available or accessible for review. 4. Medical record review of Resident #3 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Observations on [DATE] at 11:10 AM revealed Resident #3 was receiving personal care, her wheelchair was at bedside, a fall matt on the left side of her bed and another one folded and placed between her night stand and dresser. There were no nurses notes, dietary notes, social notes, activity notes, MDS assessments, or current care plan available or accessible for review. 5. Medical record review of Resident #4 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Observations on [DATE] at 11:05 AM revealed Resident #4 seated in the day room watching TV, well groomed. She was observed to ambulate independently in the hallway. There were no nurses notes, dietary notes, social notes, activity notes, MDS assessments, or current care plan available or accessible for review. 6. Medical record review for Resident #5 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The record revealed Resident #5 had experienced a weight loss since admission with interventions implemented. Observations on [DATE] and [DATE] during the noon meal confirmed the dietary interventions were implemented. There were no nurses notes, dietary notes, social notes, activity notes, MDS assessments, or current care plan available or accessible for review. 7. Medical record review for Resident #6 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The record documented the resident expired [DATE]. There were no nurses notes, dietary notes, social notes, activity notes, MDS assessments, or care plan available or accessible for review. 8. Medical record review for Resident #7 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The record documented the resident had a fall on [DATE] with a forehead contusion and hematoma. On [DATE] the resident was evaluated in the emergency room after complaining of right leg pain and found to have a fractured right hip. Observations on [DATE] at 10:30 AM revealed Resident #7 with a bruise above and below the left eye area. She was seated in a gerichair in the hallway and was assessed as not interviewable. In an interview on [DATE] at 10:25 AM at the nursing station, LPN#1 stated, She fell on [DATE], she leaned over in her wheelchair, hit her head and complained of left sided pain, we sent her in to ER, they xrayed her left side with nothing found .later on [DATE] she complained of right pain and rubbed her right leg, she wouldn't stand so I sent her back in and that is when they found the right [MEDICAL CONDITION], she had a surgical repair and came back to us on [DATE], we placed her in the gerichair for socialization and comfort. The bruise on her face is from the [DATE] fall. There were no nurses notes, dietary notes, social notes, activity notes, MDS assessments, or current care plan available or accessible for review. 9. In an interview on [DATE] at 9:25 AM in the conference room, the Administrator was asked about medical records and stated, The PCC(point click care) system is down, has been down since Thursday or Friday, we do not have access to the records, it is a payment issue. In an interview on [DATE] at 4:15 PM in the conference room, the Administrator was asked about the availability of medical records and stated, The PCC system is still down, we have no access to the records, it is backed up and somewhere in a safe house . In an interview on [DATE] at 7:45 AM in the conference room, the MDS Coordinator was asked for MDS's and care plans and stated, I have no copies of the MDS's or care plans, they are all on the computer, the updated care plans are on the computer .",2019-11-01
4688,THE PALACE HEALTH CARE AND REHABILITATION CENTER,445329,309 MAIN ST,RED BOILING SPRINGS,TN,37150,2016-08-18,323,E,1,1,PN1C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observations and interview, the facility failed to ensure residents were safely smoking during 1 of 4 (8/15/16) smoking observations and the facility failed to follow policy for 1 of 1 (Resident #74) sampled residents reviewed requiring use of lifts for transfer. The findings included: 1. Review of the facility's Smoking policy documented, .Designated staff will supervise residents during assigned smoking times . 2. Review of the facility's SMOKING GUIDELINES documented, .All smoke breaks are supervised by a staff member, and they (staff) will light all smokes . 3. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) for Resident #6 dated 7/19/16 and a significant change MDS dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 indicating Resident #6 was moderately impaired cognitively. Review of the facility SAFE SMOKING EVALUATION for Resident #6 dated 4/17/16 and 7/12/16 documented resident is safe to smoke. On 7/12/16 the resident's SAFE SMOKING EVALUATION documented, .Resident is able to light cigarette safely with a lighter . with a checkmark in the box and .Resident smokes safely . with a checkmark in the box. Observations on 8/15/16 at 4:11 PM, revealed Resident #6 outside smoking without supervision. Staff Member (SM)#1 was standing inside the building in the dining room beside the sink on the other side of the room from the smoking area while the resident smokers were outside alone. 4. Medical record review revealed Resident #15 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly MDS for Resident #15 dated 7/25/16 documented a BIMS score of 15 indicating Resident #15 was cognitively intact. Review of a SAFE SMOKING EVALUATION dated 7/25/16 documented Resident #15 was a safe smoker and must wear an apron .staff lights . Observations on 8/15/16 at 4:11 PM, revealed Resident #15 sitting outside with a smoking apron on, lighting her own cigarette from another cigarette while SM #1 was inside the building. Interview with Registered Nurse (RN) #1 on 8/18/16 at 10:00 AM, verified the evaluation documented staff lights (the resident's cigarettes). 5. Medical record review revealed Resident #27 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly MDS for Resident #27 dated 7/18/16 documented a BIMS score of 6 indicating severe cognitive impairment. Observations on 8/15/16 at 4:11 PM revealed Resident #27 outside smoking without supervision. Resident #27 lit one cigarette off another. 6. Medical record review revealed Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly MDS for Resident #29 dated 7/8/16 documented a BIMS score of 15 indicating the resident was cognitively intact. Review of a Safe Smoking Evaluation dated 7/7/16 documented, .Resident is determined to be: Safe Smoker . Observations on 8/15/16 at 4:11 PM, revealed SM #1 standing inside in the dining room while the resident smokers were outside alone. 7. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly MDS dated [DATE] documented Resident #38 had a BIMS score of 15 indicating Resident #38 was cognitively intact. Review of a SAFE SMOKING EVALUATION dated 6/20/16 documented Resident #38 was a safe smoker and staff was to light his cigarettes. Observations on 8/15/16 at 4:11 PM, revealed Resident #38 was outside smoking with no staff member in attendance. 8. Medical record review revealed Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly MDS for Resident #92 dated 7/8/16 documented a BIMS score of 13 indicating Resident #92 was cognitively intact. Review of the Admission/Readmission Data Collection documented SAFE SMOKING EVALUATION dated 7/6/16 documented Resident #92 was a safe smoker and staff lights cigarettes. Observations on 8/15/16 at 4:11 PM, revealed Resident #92 was smoking without staff in attendance. 9. Medical record review revealed Resident #126 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an annual MDS for Resident #126 dated 8/10/16 documented a BIMS score of 14 indicating Resident #126 was cognitively intact. Review of the ADMISSION/READMISSION DATA COLLECTION dated 8/1/16 documented Resident #126 is determined to be a (checkmark in box) Safe Smoker. Observations on 8/15/16 at 4:11 PM, revealed Resident #126 was sitting outside smoking without staff in attendance and lighting her own cigarette off of another. Interview with the Administrator on 8/17/16 at 5:00 PM, in the Dining Room, the Administrator was asked what she expects with residents that smoke. The Administrator stated, .I expect them to be assessed for safe smoking .the staff should light their cigarettes, they should be supervised by staff . The Administrator was then asked if the residents should always have staff supervision. The Administrator stated, .Yes . The Administrator was asked if the residents should ever be left alone and lighting their own cigarettes off another cigarette. The Administrator stated, No, never . 10. Review of the facility's Lifting and Moving Resident policy documented, .Use resident transfer equipment as required. (Do not attempt to lift any resident alone that has been designated as a 2 or 4 person lift.) .two staff members must be present when transferring a resident with a mechanical .Hoyer .lift . 11. Medical record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 7/14/16 documented, .Problem TOTAL CARE FOR ALL HER WANTS AND NEEDS .MARISSA LIFT . Review of the facility's NURSE TECH INFORMATION KARDEX documented, .BATHING .Assist of (staff) .TRANSFERS .Assist of 2 .TRANSFER ASSIST .Full body lift . Interview with the Director of Nursing (DON) on 8/16/216 at 5:43 PM, in the DON office, the DON was asked if Resident #74 was a one person assist and lift. The DON stated, .no .she is a two person lift .anytime we use a lift you are supposed to use two people . The DON was asked if the (Named Company) Certified Nursing Assistant (CNA) had used a one person lift .The DON stated, Yes . Interview with CNA #1 on 8/17/16 at 11:45 AM, in the admission office, CNA #1 was asked what kind of lift does Resident #74 use. CNA #1 stated, .full body lift . CNA #1 was asked how many people you use for that lift. CNA #1 stated, Two for every lift . CNA #1 was asked about the day she had seen the (Named Company) CNA in the shower room with Resident #74. CNA #1 stated, .she was using the Marissa lift .she used the wrong sling with the wrong lift .it's not safe .not hooked on right .a different sling .the Marissa lift uses a blue sling .with black hook . CNA #1 was asked how do you know which lift you are supposed to use on Resident #74. CNA #1 stated, .on the resident door will say TL which means total lift .which means that she can't help her transfer or stand at all .or it's on the Kardex . Interview with the DON on 8/17/16 at 5:40 PM, in the DON's office, the DON was asked if there are certain slings that go with certain lifts. The DON stated, Yes . The DON was then asked if the (Named Company) CNA had used the wrong sling with the lift. The DON stated, .per what the CNA told me yes .It could have caused the sling to come undone from the lift .it could have been bad . Phone interview with (CNA) #3 on 8/18/16 at 9:16 AM, CNA #3 was asked if Resident #74 was a one or two person transfer. CNA #3 stated, .she is probably a two person transfer . CNA #3 was asked why she didn't get someone to help her transfer Resident #74 to the shower room. CNA #3 stated, .they were in there .helped me put her in the sling . CNA #3 was then asked if the CNA's in the bathroom had told her she was using the wrong sling for the lift for Resident #74. CNA #3 stated, No . Phone Interview with CNA #2 on 8/18/16 at 9:41 AM, CNA #2 was asked if Resident #2 was a two person transfer. CNA #1 stated, Yes Ma'am. CNA #2 was asked how you know that Resident #74 is a transfer. CNA #2 stated, .it's on the door (referring to Resident #4's doorway) .have a card at the nurse's station . CNA #2 was asked if she had seen (Named CNA) in the shower room with Resident #74. CNA #2 stated, .had the lift for the wrong sling . CNA #2 was asked why she didn't go help the CNA with Resident #74. CNA #2 stated, .she already had her connected to the lift .",2019-08-01
2111,LAUDERDALE COMMUNITY LIVING CENTER,445354,215 LACKEY LANE,RIPLEY,TN,38063,2017-05-05,282,E,1,0,QMFO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observations, and interview, the facility failed to follow a care plan for neuro-checks, lifts, activities of daily living,(ADLs) and geri sleeves for 4 of 18 (Resident #16, 45, 50 and 61) sampled residents reviewed of the 34 residents included in the stage 2 review. The findings included: 1.The facility's NEUROLOGICAL CHECKS policy documented, .It is the policy of this facility to conduct and document neurological checks when the resident's condition warrants .neuro check should be done as follows, until 72 hours are completed or as ordered by the physician .Every 15 minutes x (times) 4 .Every 30 minutes X4 .Every 1 hour X5 . Every 4 hours X4 .Every 8 hours X6 .Document findings on the Neurological Assessment Flow Sheet .Then it should be placed in the active medical record . 2. Medical record review revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] revealed Resident #16 was severely cognitively impaired for daily decision making. The Progress Notes dated 11/24/16 documented, .Called to resident's room .resident in floor beside bed .scratch to left side of face .No other apparent injuries noted .Neuro checks involved . The care plan dated 11/25/16, documented, Focus .resident has had an ACTUAL FALL 11/24/2016 - fall from bed - scratch to cheek .Intervention .Neuro-checks as per policy upon hospital return .Date Initiated 11/25/2016 . The facility was unable to find documentation that neuro-checks were done for Resident #16 after her fall on 11/24/16. The facility failed to follow their policy related to neuro-checks. Interview with Regional Nurse Consultant (RNC) #1 on 4/30/17 in the Conference Room, RNC #1 was asked if she was able to find the neuro checks ordered every 8 hours on Resident #16. RNC #1 stated, We did not have the last 2 . RNC #1 was asked should it have been done. RNC #1 stated, Yes. 3. Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], Anxiety Disorder, Kyphosis, Major [MEDICAL CONDITION], Kyphosis, [MEDICAL CONDITION], and Dementia with Behavioral Disturbances. The annual MDS dated [DATE] and quarterly MDS dated [DATE] revealed Resident #45 was severely cognitively impaired for daily decision making and was a two person assist with transfers. The care plan initiated on 10/31/15 and revised on 5/12/16 documented, ADL SELF PERFORMANCE DEFICIT self r/t (related to) dx (diagnosis) [MEDICAL CONDITION], Kyphosis, Bilateral lower extremity contractures as evidenced by need for up to total staff assistance with daily tasks .Interventions .TRANSFER: The resident uses .lift with transfers. Provide with up to extensive staff assistance with this task . Interview with Certified Nursing Assistant (CNA) #2 on 4/26/17 at 7:32 AM in the Conference Room,CNA #2 was asked how many people are needed to get Resident #45 up. CNA #2 stated, Sometimes it is 2 . CNA #2 was asked if a lift was used to get Resident #45 up. CNA #2 stated, No. CNA #2 was asked does it hurt .when you get her up. CNA #2 stated, Doesn't seem to . Interview with CNA #1 on 4/26/17 at 1:04 PM in the Conference Room, CNA #1 was asked how many people it takes to put Resident #45 to bed. CNA #1 stated, One. CNA #1 was asked how do you do that. CNA #1 stated, She is not heavy .if you set her up in the chair and then you put your arms under her arms and bring her around to the bed, she will be sitting down on the bed. CNA #1 was asked does she moan when you put her in the bed. CNA #1 stated, Sometimes. Interview with CNA #5 on 4/26/17 at 2:05 PM in the Conference Room, CNA #5 was asked how she transferred Resident #45. CNA #5 stated, I grab my gait belt or me and the sitter will put the geri chair by the bed and get her like that . CNA #5 was asked how she knew who transferred with the lift. CNA #5 stated, They let us know. Resident #45 can't transfer with a lift . Interview with the Director of Nursing (DON) on 4/28/17 at 7:53 AM in the Conference Room, the DON was asked how she would expect Resident #45 to be transferred. The DON stated, .she can be transferred by the staff or a mechanical lift. The DON was asked if the care plan documented a lift to be used, would she expect for a lift to be used. The DON stated, If it is in her care plan, then, yes . The DON was asked, if the staff used a lift to get Resident #45 up. The DON stated I'm not sure. 4. Medical record review revealed Resident #50 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] and the quarterly MDS dated [DATE] revealed Resident #50 was severely cognitively impaired for daily decision making, required extensive assistance with personal hygiene, totally dependent with bathing and no falls since admission. The care plan dated 3/2/17 documented, Focus .resident has had an ACTUAL FALL r/t Poor Balance, Unsteady gait 3/2/17- Laceration to Head .Intervention .Neuro-checks as per policy upon hospital return .Date Initiated 03/02/2017 .Sent to emergency room (ER) post fall due to altered mental status and incoherent speech . The fall investigation documented, .3/2/17 .While being assisted to activities, resident stumbled back and fell in floor hitting back of her head on housekeeping cart. Small laceration noted to back of head .Pressure applied .Neuro checks initiated .transferred to .ER for eval (evaluation) and tx (treatment) . The Neurological Check dated 3/2/17 documented, .10:00 AM .Triggering: Fall 3/2/2017 .Level of Consciousness .Alert .Pupil Response .PERL (pupil equal reactive light) .Motor Functions .Hand Grasps .Moves all extremities .Pain Response .Appropriate pain response .Blood Pressure .142/93 .Temperature .97.5 .Axilla .Pulse .81 .Regular .Respiration .18 . The Progress Notes dated 3/2/17 at 10:10 documented, Resident transferred to .ER (emergency room ) for eval (evaluation)and tx (treatment) . The facility failed to provide documentation that neuro checks were continued when Resident #50 returned from the ER. Interview with the DON on 4/28/17 at 8:55 AM in the DON's office, the DON was asked what time did Resident #50 leave the facility to go to the ER after her fall. The DON stated, Left at 10:10. The DON was asked what time did she return. The DON was unable to find the time Resident #50 returned to the facility. The DON was asked should neuro checks have been continued when Resident #50 returned from the hospital. The DON stated, Yes . The DON was unable to find any documentation of the neuro checks being performed. Review of the facility's Shower List revealed Resident #50's showers were to be given on the 1st shift on every Monday, Wednesday and Friday. The care plan dated 1/6/16 and revised on 11/1/16, documented, Focus .resident has an ADL (Activity of Daily Living) SELF PERFORMANCE deficit r/t Dementia, Confusion; as evidenced by need for staff cueing and direction with daily tasks .Interventions .BATHING: Per shower schedule. Provide with up to extensive staff assistance with bathing . Review of the (MONTH) (YEAR) ADL flow record revealed there was no documentation that bathing was provided for Resident #50 on 26 of 30 days in April, (MONTH) 1, 2, 3, 4, 5,6, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 20, 21, 22, 23, 24, 25, 27, 28, 29, and 30. Interview with Licensed Practical Nurse (LPN) #6 on 4/28/17 at 10:20 AM in the C unit, LPN #6 was asked how often Resident #50 is bathed. LPN #6 stated, I think they do every other day .gets her bath on Monday, Wednesday and Friday on 1st shift . LPN #6 was shown Resident #50's bathing schedule that had been documented for (MONTH) and was asked what days had Resident #50 received her bath or shower. LPN #6 stated, .Bed bath on the 7th .Bed bath on the 14th .19th shower . LPN #6 was asked how often residents are supposed to be bathed or showered. LPN #6 stated, .every resident is scheduled three days a week . Interview with CNA #8 on 4/28/17 at 10:45 AM in the C hall, CNA #8 was asked how often Resident #50 gets her bath/shower. CNA #8 stated, .three times a week .second shift Monday, Wednesday and Friday . CNA #8 was asked to show the Resident's shower documentation and CNA #8 stated, Shows she is on the 1st shift .but the girl on the second shift gives it too her . CNA #8 was asked if the staff follow the shower list. CNA #8 stated. Yes .but when they moved her back here .was told she was on the second shift . CNA #8 was asked how long Resident #50 been on C hall. CNA #8 stated, .Two months . CNA #8 was shown Resident #50's ADL documentation and was asked how many baths/showers the resident received between (MONTH) 1st through the 24th. CNA #8 stated .three . CNA #8 was asked should she have had more bath/showers than that. CNA #8 stated Yes, supposed to get them 3 times a week . Interview with the DON on 4/28/17 at 11:03 AM, in the DON's office, the DON was shown the Resident's shower list and was asked when Resident #50 was supposed to have her shower. The DON stated, Monday, Wednesday and Friday on first shift. The DON was shown Resident #50's ADL documentation and was asked when Resident #50 had a bath or shower for the month of April. The DON stated, (MONTH) the 7th bed bath .April 14th bed bath .April 19th shower .April 26th had a bed bath . The DON was asked if Resident #50 received a bath or shower three times a week. The DON stated, According to this she is not . The DON was asked if there was documentation Resident #50 had refused her bath or shower. The DON was unable to provide documentation that Resident #50 had refused any baths or showers and stated I know what happened, her room changed and the shower list was not updated . 5 Medical record review revealed Resident #61 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] was coded severely cognitively impaired for daily decision making, required extensive assistance with personal hygiene and was totally dependent with bathing. The care plan dated 1/6/16 and revised on 11/1/16, documented, Focus .resident has an ADL SELF PERFORMANCE deficit r/t Dementia, Confusion; as evidenced by need for staff cueing and direction with daily tasks .Interventions .BATHING: Per shower schedule. Provide with up to extensive staff assistance with bathing . Review of the (MONTH) (YEAR) ADL flow record revealed there was no documentation that bathing was provided for Resident #61 on (MONTH) 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, and 24. The care plan dated 11/18/16 and revised on 4/12/17 documented, Focus .resident has potential for impairment to SKIN integrity r/t Immobility, Tube feeding .poor skin integrity, and hx (history) of biting left hand .Interventions .Provide with geri sleeves when short sleeves are worn to minimize risk for skin tears .Date Initiated: 04/06/2017 . Observations in Resident #61's room on 4/24/17 at 9:47 AM, 4/24/17 at 3:21 PM, 4/25/17 at 7:50 AM, and 4/27/17 at 10:48 AM revealed, Resident #61 was in the bed with no Geri sleeves on either arm. Interview with RNC #2 on 4/30/17 at 9:05 PM at the Nurse's Station in the A hall, RNC #2 was asked if geri -sleeves are documented on the care plan, should the resident have them on. The RNC #2 stated, Yes.",2020-09-01
4935,COUNTRYSIDE HEALTHCARE AND REHABILITATION,445280,3051 BUFFALO ROAD,LAWRENCEBURG,TN,38464,2016-06-26,280,E,1,0,MKNE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observations, and interview, the facility failed to revise the comprehensive care plan to include interventions for 3 of 4 (Resident #1, 3, and 4) sampled residents experiencing falls. The findings included: 1. The facility's Care Plans - Comprehensive policy documented, .An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, mental, and psychological needs is developed for each resident .Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition changes . 2. Medical record review revealed Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan documented, .Problem onset: 12/08/2015 Resident is at risk for falls d/t (due to) impaired mobility .5/22/16 Pt (patient) to be ambulated when very anxious or restless in chair . Observations in the Common Area on the East Wing on 6/26/16 at 3:00 PM, revealed Resident #1 was seated in a wheelchair, stood upright from the wheelchair leaning forward over a lapbuddy device. Two staff assisted the resident to return to a seated position. There was no nonslip item in the wheelchair to prevent slipping from the seat of the chair. The resident attempted to stand multiple times and the Certified Nursing Assistant #1 repeated, Sit down, until the resident was seated again. Interview with the Administrator near the Nurses' station on the East Wing on 6/26/16 at 3:00 PM, the Administrator was asked if Resident #1 was ambulated when restless and attempting to stand. The Administrator stated, They used to. Not anymore. She doesn't walk now. Her condition has declined. Interview with the Director of Nursing (DON) in the dining room on 6/26/16 at 3:10 PM, the DON was asked if Resident #1 was ambulated by staff when restless. The DON stated, She can't bear weight .She can't walk. The DON was asked if the current comprehensive care plan was revised to reflect Resident #1's current condition and care provided. The DON stated, No . 3. Medical record review revealed Resident #3 was admitted on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Nurses' Notes dated 6/15/16 at 12:30 AM, documented, Resident in room yelling. When nurse entered room resident laying on side on mat in floor next to bed on R (right) side . Review of the Care Plan documented, .Problem Onset: 10/7/15 Resident is at risk for falls d/t left above the knee amputation . The Care Plan was not revised to include the fall on 6/15/16 or an intervention for the fall. Interview with LPN #2 at the Nurses' Station on the East Wing, LPN #2 was asked what the intervention was after the fall on 6/15/16. LPN #2 reviewed the Care Plan and stated, I don't see an intervention after the fall on the 15th (6/15/16) . During an interview with LPN #4 at the Nurses' Station on the East Wing, LPN #3 stated, There is not an intervention. 4. Medical record review revealed Resident #4 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Resident Incident Report dated 5/29/16 documented, .Appears resident got out of bed and fell causing a 1/2 (inch) laceration to forehead . The Plan of Prevention dated 5/29/16 documented, .Interventions 1. Clip alarm while in bed . Review of the Resident Incident Report dated 6/9/16 documented, .resident fell on to porch . The Plan of Correction dated 6/9/16 documented, .Interventions 1. Resident is to have staff member present to sit on smoke porch . Review of the Care Plan documented, .Problem Onset: 05/27/2015 HX (history): Multiple falls . The Care Plan did not include the falls or interventions for the falls Resident #4 experienced on 5/29/16 or 6/9/16. Interview with the DON on 6/26/16 at 4:35 PM in the dining room, the DON was asked if Resident #4's care plan was updated and revised to reflect current interventions. The DON stated, No, they (care plans) are not.",2019-06-01
2228,NORTHSIDE HEALTH CARE NURSING AND REHABILITATION C,445373,202 EAST MTCS ROAD,MURFREESBORO,TN,37130,2017-09-27,221,D,1,0,O5S911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, observations, interviews, the facility failed to ensure 1 resident (#6) of 20 sampled residents was free from the use of a restraint. The findings included: Review of the undated facility policy entitled, Director of Nursing Training Manual .Restraints documented .CMS (Centers for Medicare & Medicaid Services) defines physical restraints in the State Operations Manual (SOM), Appendix PP as, any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body .This includes, but is not limited to, any article, device, or garment that interferes with the freedom of movement of the patient and that he or she is unable to remove easily . Remove Easily means that the manual method, device, material, or equipment can be removed intentionally by the patient in the same manner as it was applied by the staff .The use of physical restraints is not prohibited in nursing home .While a restraint-free environment is not a Federal Requirement, the use of restraints should be the exception, not the rule .A physician's order is required prior to implementation of restrictive procedures. Falls alone do not warrant the use of a physical restraint .Before a patient is restrained, the facility must determine that the patient has a specific medical symptom that cannot be addressed by another, less restrictive intervention and a restraint is required to treat medical symptom .If restraints are absolutely necessary, check every 30 minutes and release and reposition every two hours. The applicable consent form must be signed by the responsible party upon utilizing a restraint . Per electronic record review, Resident #6 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], Section C for Cognition, identified Resident #6 had a Brief Interview Mental Status (BIMS) score of 3/15, which indicated the resident was severely cognitively impaired. Review of the care plan revealed it had been revised 7/20/17. The problem identified the resident was at risk for falls. The care plan intervention dated 8/26/17, identified a breakaway lap buddy (lap hugger) was to be added to the wheelchair for comfort, positioning, and trunk control. Review of the clinical record revealed no physician orders for a restraint (lap hugger). Further review of the clinical record revealed no evidence of an assessment prior to the use of a restraint. There was no documentation that the restraint was needed to treat a specific medical symptom, and there was no evidence the facility had attempted less restrictive measures. Observation on 9/25/17 at 9:23 AM revealed Resident #6 was in the main hallway, next to the main nursing station holding a baby doll. The resident was observed sitting in a wheelchair with a device located around her middle section of her abdomen and the ends were secured with Velcro straps attached to the arms of the wheelchair. There was an attached tag to this device that identified it as a lap hugger. Observation on 9/26/17 at 6:30 AM revealed Resident #6 was in the main hallway, and in front of the main nursing station, again, with a restraint around her mid-section. The resident had her eyes closed at this time. Observation on 9/26/17 at 7:01 AM revealed Resident #6 was observed next to the main nursing station, with the lap hugger on, her head was up and her eyes were now open. Resident #6 was not observed during the complaint investigation attempting to remove her lap hugger. An interview was conducted with the Director of Nursing (DON), in her office, on 9/27/17 at 8:25 AM. The DON confirmed that there was not a previous physician's order for the use of [REDACTED]. An interview was conducted with NA #3 on 9/27/17 at 8:35 AM. The interview was conducted in the main dining room and Resident #6 was present. Resident #6 was observed with the lap hugger on. Per interview with NA #3, she said the resident was able to take off the lap hugger all of the time. When NA #3 was asked to have Resident #6 remove the lap hugger, NA #3 stated the resident was not competent to remove the lap hugger if directed by staff to so.",2020-09-01
5305,MAGNOLIA CREEK NURSING AND REHABILITATION,445461,1992 HWY 51 S,COVINGTON,TN,38019,2016-04-13,280,E,1,0,53WE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, review of a fall investigation report and interview, the facility failed to revise the care plans to reflect current status related to anticoagulant therapy and bruising, skin tears, and fall interventions for 4 of 7 (Residents #3, 4, 5, and 7) sampled residents. The findings included: 1. The facility's Care Plans policy documented, .A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four (24) hours of admission . the Interdisciplinary team will review the Attending physician's orders [REDACTED].) and implement a nursing care plan to meet the resident's immediate care needs . The facility's Care Plans -Comprehensive policy documented, .Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change . The facility's Falls and Fall Risk, Managing policy documented, .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . When a resident falls, the following information should be recorded in the resident's medical record . appropriate interventions taken to prevent future falls . 2. Closed medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician order [REDACTED].[MEDICATION NAME] (blood thinner, anticoagulant) 40 mg (milligrams) / 0.4 ml (milliliters) subq (subcutaneous) once daily x (times) 14 days . Review of the interim care plan dated 3/22/16 did not include anticoagulant therapy and bruising. Interview with the Regional Consultant (RC) on 4/13/16 at 3:30 PM, in room [ROOM NUMBER], the RC was asked if a resident was admitted to the facility receiving anticoagulants, should the interim care plan include anticoagulants as a potential problem for the resident. The RC stated, Yes. 3. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician order [REDACTED].Clean Left upper arm wound (proximal elbow) c (sign for with) N/S (normal saline) & (and) apply TAO (triple antibiotic ointment) then apply gauze dressing Daily . Review of a physician order [REDACTED].Clean skin tear right arm with normal saline pat dry apply TAO and dry dressing Q (every) Day . Review of a physician order [REDACTED].Clean skin tears to (L) (left) elbow & (R) (right) (sign for lower) leg c NS Pat dry. Apply TAO every day till healed . Review of a care plan dated 11/13/15 and revised on 1/17/16 did not include skin tears. Interview with the Nurse Consultant (NC) on 4/13/16 at 3:30 PM, in room [ROOM NUMBER], the NC was asked if a resident has skin tears, should the care plan be revised to include the skin tears. The NC stated, Should be. The NC verified the skin tears were not on the care plan. 4. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a Nurse's Note dated 1/8/16 documented, .notified of pt (patient) receiving ST (skin tear) to L outer hand . Observation of Resident #4 on 4/12/16 at 11:35 AM, revealed Resident #4 had a Band-Aid dressing to the top of her left hand. Review of a Nurse's Note dated 4/12/16 documented, .Resident hit hand on bed this AM, resulting in 1/2 skin tear to L hand . Review of a care plan dated 11/13/15 with revisions did not include skin tears as a problem. Interview with the NC on 4/13/16 at 3:30 PM, in room [ROOM NUMBER], the NC verified the care plan did not include skin tears. 5. Medical record review revealed Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. The care plan dated 2/17/16 documented, .Falls Potential for R/T (related to) weakness, dementia . Review of a facility fall investigation report dated 3/17/16 revealed Resident #7 was found in her room sitting on her knees on the floor with no injury noted. The care plan was not revised with an appropriate intervention related to the 3/17/16 fall. Interview with LPN #1 on 4/13/16 at 3:55 PM, in the Minimum Data Set (MDS) office, LPN #1 was asked if the resident's care plan should have been updated for the 3/17/16 fall. LPN #1 stated, Apparently, yes.",2019-04-01
1310,DIVERSICARE OF MARTIN,445249,158 MT PELIA RD,MARTIN,TN,38237,2018-05-31,610,D,1,1,Q6Y111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, medical record review, review of the facility's investigation, and interview, the facility failed to follow the abuse policy and failed to thoroughly investigate misappropriation for 1 of 3 (Resident #69) residents reviewed for abuse. The findings included: 1. The facility's Abuse Policy documented, .Misappropriation of patient/resident property .means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident/patient's belongings or money without the resident/patient's consent .all alleged violations .which involve mistreatment, neglect, abuse, injuries of unknown origin and misappropriation of resident/patient property .are reported immediately to the Administrator/Director of Nursing .Such violations will also be reported to state agencies and law enforcement in accordance with existing state law. The Administrator/Director of Nursing will direct a thorough investigation . 2. Medical record review revealed Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. 3. Review of the facility investigation revealed on 4/9/18 at 7:00 AM, during the morning narcotic count, it was reported a medication card containing [MEDICATION NAME] salts ([MEDICATION NAME]) 20 mg appeared to have been tampered with, and 5 pills had been removed and replaced with another medication ([MEDICATION NAME]). A total of 4 nurses (Licensed Practical Nurse (LPN) #3, LPN #5, LPN #7, and Registered Nurse (RN) #1) were sent for drug testing. Review of the working schedule revealed a total of 6 nurses (LPN #3, LPN#4, LPN #5, LPN#6, LPN #8, and RN #1) had access to the medication cart which contained the missing [MEDICATION NAME] during the time period of 4/4/18-4/9/18. No drug screens were performed on LPN #4, #6, or #8. Interview with the Director of Nursing (DON) on 5/31/18 at 2:56 PM, in the conference room, the DON was asked how they determined which nurses should be sent for drug screening. The DON stated, No other second shift or first shift nurses were tested .We determined that it most likely happened on third shift since that is the shift the medication is given on. The DON was asked if nurses working other shifts had access to the medications and knowledge of its presence on the cart. The DON stated, Yes . Interview with the Administrator on 5/31/18 at 4:53 PM, in the conference room, the Administrator was asked if she thought it was appropriate that only the third shift nurses were drug screened when nurses on other shifts also had access to the medication. The Administrator stated, .Corporate told us to test the nurses with the most access and opportunity. 4. Interview with RN #1 on 5/30/18 at 5:25 PM, in the conference room, RN #1 confirmed that on 4/9/18 at approximately 6:30 AM, she noticed that Resident #69's [MEDICATION NAME] appeared to have been tampered with. She reported this to the oncoming nurse and asked her to notify the DON. RN #1 was asked what the policy stated about notification of misappropriation. RN #1 stated, .Policy is probably to call immediately, but I had to take my child to school . Interview with the Administrator on 5/31/18 at 4:53 PM, in the conference room, the Administrator was asked if it was appropriate for the nurses to wait until Administration arrived in the building to report the medication misappropriation. The Administrator stated, Technically it should have been reported immediately. 5. Interview with the Administrator on 5/30/18 at 3:30 PM, in the Administrator's office, the Administrator asked if a police report was filed related to the misappropriation. The Administrator stated, No, I did not call the police . Interview with the Administrator on 5/31/18 at 4:53 PM, in the conference room, the Administrator was asked if she considered a staff member removing a controlled substance from the building a crime such as theft. The Administrator stated, I would consider it misappropriation. The Administrator was asked if she would consider misappropriation of other items such as cash belonging to a resident to be a theft or a crime. The Administrator stated, By definition, Yes",2020-09-01
4275,MIDTOWN CENTER FOR HEALTH AND REHABILITATION,445139,141 N MCLEAN BLVD,MEMPHIS,TN,38104,2016-10-13,431,D,1,1,LFXZ11,"**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 by 1 of 4 (Licensed Practical Nurse (LPN) #5) nurses observed during medication administration observation leaving medications unattended and leaving an unattended, unlocked medication cart. The findings included: 1. The facility's Storage of Medication policy revealed, .The medication supply shall only be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . 2. Observations on 10/12/16 beginning at 9:24 AM, during medication administration pass for Resident #59, LPN #5 prepared medications to be given per percutaneous (PEG) tube. LPN #5 placed the med tray that contained crushed medications on the over bed table. LPN #5 went into Resident #59's bathroom to wash her hands leaving medications on the over bed table unattended and out of sight 5 times. Observations on 10/12/16 at 10:06 AM, during medication administration pass, LPN #5 unlocked the medication cart, walked away and entered room [ROOM NUMBER] leaving the medication cart unlocked and eye drops on top of the medication cart and the medication out of eye sight and unattended. LPN #5 returned to the medication cart and stated, Oh no, I left those eye drops out . 3. Interview with LPN #5 on 10/12/16 at 6:19 PM, at the 4th floor nurse's station, LPN #5 was asked if it is acceptable to leave the medication cart unlocked and unattended. LPN #5 stated, No ma'am. LPN #5 was asked if it is acceptable to leave medications unattended. LPN #5 stated, No, never. Interview with LPN #6 on 10/12/16 at 6:21 PM, LPN #6 was asked if it is acceptable to leave your medication cart unlocked when unattended. LPN #6 stated, No ma'am. LPN #6 was asked if it is acceptable to leave your medication cart unlocked and unattended. LPN #6 stated, No ma'am. Interview with the Director of Nursing on 10/13/16 at 4:51 PM, in the DON office, the DON was asked if it is acceptable to leave the med cart unlocked and unattended. The DON stated, No. The DON was asked if it is acceptable for medications to be left unattended, the DON stated, No.",2019-10-01
2116,LAUDERDALE COMMUNITY LIVING CENTER,445354,215 LACKEY LANE,RIPLEY,TN,38063,2017-05-05,441,D,1,0,QMFO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, observation and interview the facility failed to ensure practices to prevent the potential spread of infection were maintained by 2 of 2 (Licensed Practical Nurse (LPN) #2 and 7) staff members during Percutaneous Endoscopic Gastrostomy (PEG) site care and Urinary Catheter site care, and failed to ensure the resident's urinary catheter bag did not touch the floor and infection control practices were followed for catheter care provided for 2 of 3 (Resident #56 and 61) residents reviewed with an indwelling urinary catheter. The findings included: 1. The facility's Indwelling Urinary Catheter policy documented, .Avoid letting the drainage bag touch the floor .Catheter care should be provided daily as needed. Soap and water or pre-moistened wipes should be used . Medical record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #61's room on 4/26/17 at 3:55 AM, revealed Resident #61 lying in bed resting quietly with an indwelling urinary catheter in a privacy bag lying on the floor with the catheter tubing touching the floor. Interview with LPN #7 on 4/26/17 at 4:10 AM in Resident #61's room, LPN #7 was asked should the indwelling urinary catheter bag and tubing be on the floor. LPN #7 stated, No, Ma'am. Interview with the Director of Nursing (DON) on 4/28/17 at 1:53 PM in the DON's office, the DON was asked if it was acceptable for the indwelling urinary catheter bag to be on the floor. The DON stated, No. The facility's Enteral Feeding Tube Site Care documented, .2. Wash hands before and after all procedures. Wear gloves when appropriate . Observations in Resident #61's room on 4/26/17 at 4:22 AM, revealed LPN #7 hung the new [MEDICATION NAME] enteral feeding and flush for the PEG, started to connect the tubing, wiped the tubing on the bed covers, then connected it to the PE[NAME] Observations of PEG site care in Resident #61's room on 4/26/17 at 4:35 AM, revealed LPN #7 removed items from the roommate's over bed table to use as Resident #61 did not have an overbed table. LPN #7 did not clean the borrowed table, placed two paper towels on the overbed table to use as a barrier, placed a bottle of wound cleanser and tube of Calazine on the table off the barrier and placed the sponge gauze and unopened 4X4 gauze on the clean barrier. LPN #7 donned gloves, opened the 4x4's and placed them half on the barrier and half off barrier on the table that had not been cleaned prior to use. LPN #7 then sprayed the PEG site with wound cleanser, wiped the site 4 times with the same gauze. Removed another gauze, sprayed with wound cleanser and wiped the wound 3 more times without changing the side of the gauze LPN #7 removed the gloves and left the room. LPN #7 never washed her hands before or after PEG site care. 2. Review of Lippincott Manual of Nursing Practice 10th Edition .Procedure Guidelines 21-3 .Management of the Patient with an Indwelling (Self-Retaining) Catheter and Closed Drainage System .Maintaining a closed drainage system, Page 782 documented 1. Wash hands immediately before and after handling any part of the system . Medical record review revealed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations of catheter care on 4/26/17 at 1:43 PM in Resident #56's room revealed LPN #2 filled a basin with soap and water, tied a plastic bag to the right side rail, used hand sanitizer, donned gloves, cleaned the skin around the suprapubic catheter tubing with the wash cloth, cleaned the catheter tubing 2-3 inches down, returned the wash cloth to the basin of soapy water, then wrung out the wash cloth and wiped the area of skin around the catheter tubing with the contaminated cloth. LPN # 2 used a clean towel to dry the area, then closed Resident #56's brief, changed the water in the basin, removed gloves, sanitized hands, donned gloves, applied soap and water to a fresh wash cloth, wiped around PEG site from inside out, returned used cloth to water and dried the area thoroughly with a clean towel. LPN #6 never washed her hands before or after suprapubic catheter care or before performing PEG site care. Interview with the DON on 4/28/17 at 1:53 PM in the DON's office, the DON was asked if it is acceptable to perform catheter care with a washcloth, place the soiled wash cloth back in the basin of water, and then wipe around the catheter site with the same washcloth. The DON stated, No.",2020-09-01
2604,AHC LEWIS COUNTY,445430,"119 KITTRELL ST, PO BOX 129",HOHENWALD,TN,38462,2018-07-17,584,D,1,0,2LC711,"**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 the environment was clean, sanitary and odor free as evidenced by dried brown substance on floor, dried vomitus on floor, urine odor in room, mildew odor in closets, gray and black substance on the walls and door frames, door handle with scattered mold in 4 of 66 (Rooms 207, 209, 211 and 407) resident rooms and an unidentified brown substance on shower chairs in 1 (400 hall shower room) of 2 shower rooms. The findings included: 1. Review of the facility's Housekeeping Duties policy documented, .Clean zone area. Doors and door frames, walls .Disinfect sinks and toilets, all door handles . Review of the facility's Cleaning policy documented, .SHOWER AND WHIRLPOOL ROOMS .Shower chairs clean .In addition to a routine cleaning schedule, everything should be cleaned on an as needed basis . 2. Observations on the 400 hall revealed the following: a. room [ROOM NUMBER]A on 7/17/18 at 12:10 AM and 3:50 PM and on 7/18/18 at 11:05 AM , there was an unidentified dried brown substance on the floor. b. room [ROOM NUMBER]B on 7/18/18 at 11:05 AM and 12:10 PM, there was an unidentified dried brown substance on the floor next to the trash can at the bedside and used toilet tissue and urine in the bedside commode. There was a urine odor in the room. 3. Observations on the 200 hall revealed the following: a. room [ROOM NUMBER] on 7/18/18 at 11:20 AM, there were scattered gray and black areas on the walls of the closets near the baseboards, moist peeling paint on the closet doors and door frames and scattered rust spots on the door frame of the bathroom door. There was a foul odor in the closets. b. room [ROOM NUMBER] on 7/18/18 at 1:05 PM, there were scattered gray and black areas on the walls of the closets near the baseboards, moist peeling paint on the closet doors and door frames and scattered rust spots on the door frame of the bathroom door. There was a foul odor in the closets. c. room [ROOM NUMBER] on 7/18/18 at 1:10 PM, there were scattered gray and black areas on the walls of the closets and a black substance on the door handle of the closet. There was a foul odor in the closet. 4. Observations in the 400 hall shower revealed the following: a. In the 400 Hall Shower room on 7/18/18 at 11:12 AM, there was an unidentified dried brown substance on two shower chairs. Interview with Resident #3 on 7/18/18 at 11:05 AM, in room [ROOM NUMBER]B, Resident #3 stated, I vomited around 8:00 last night. The housekeeper emptied the trash earlier today, but left the puke on the floor . Interview with Certified Nurse Aide (CNA) #1 on 7/18/18 at 11:28 AM, in the 400 Hall Shower room CNA #1 observed the brown substance on the shower chairs and stated, .It definitely needs cleaning. Looks like BM (bowel movement). Interview with the Administrator on 7/18/18 at 12:12 AM, in room [ROOM NUMBER]B, the Administrator observed the dried vomitus on the floor and stated, .That needs to be cleaned up. That shouldn't be left. Interview with the Maintenance Supervisor on 7/18/18 at 1:10 PM, in room [ROOM NUMBER], the Maintenance Supervisor was asked what the substance was on the door handle. The Maintenance Supervisor stated, That's mold. Interview with the Maintenance Supervisor on 7/18/18 at 1:25 PM, in room [ROOM NUMBER], the Maintenance Supervisor stated, It's a mildew smell That paint is bubbled up and peeling from moisture .",2020-09-01
683,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2019-10-22,880,D,1,1,IWI711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, observation and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 3 (Registered Nurse (RN) #1) nurses failed to properly disinfect a glucometer (glucose testing machine) after use and when 1 of 1 (Respiratory Therapist (RT) #1) staff failed to perform proper hand hygiene during [MEDICAL CONDITION] care. The findings include: 1. The undated policy Cleaning and Disinfecting Your Even-Care G2 Meter documented, .Purpose: Cleaning and disinfecting your meter and lancing device is very important in the prevention of infectious diseases .Cleaning also allows for subsequent disinfection to ensure germs and disease causing agents are destroyed on the meter and lancing device surface . 4. To disinfect your meter clean the meter with one of the validated disinfecting wipes listed below .Micro-Kill Bleach Germicidal Bleach Wipes . Observations in Resident #36's room on 10/16/19 at 4:23 PM, revealed RN #1 preformed a blood glucose check and then cleaned the glucometer with an alcohol pad. RN #1 did not use the Micro-Kill Bleach Germicidal Bleach Wipe to disinfect the glucometer. Interview with the Director of Nursing (DON) on 10/21/19 at 1:25 PM, in the Conference Room, the DON confirmed the glucometers should be disinfected with Micro-Kill Bleach Germicidal Bleach Wipes. 2. The [MEDICAL CONDITION] Care policy with a revision date of (MONTH) 2014 documented, Remove old dressings .Wash hands .Put on sterile gloves .remove the inner cannula .Remove and discard gloves .Wash hands and put on fresh gloves .Replace the cannula . Observations of [MEDICAL CONDITION] care in Resident #10's room on 10/22/19 at 8:07 AM, revealed RT #1 removed the [MEDICAL CONDITION] dressing and inner cannula with sterile gloves and then performed [MEDICAL CONDITION] care and replaced the sterile inner cannula without performing hand hygiene or applying new sterile gloves. Interview with the Director of Nursing (DON) on 10/22/19 at 10:09 AM, in the Administrator Office, the DON was asked should the Respiratory Therapist change gloves and perform hand hygiene after removing a dirty inner cannula and cleaning the [MEDICAL CONDITION] site. The DON stated, Yes.",2020-09-01
3728,ALLENBROOKE NURSING AND REHABILITATION CENTER,445485,3933 ALLENBROOKE COVE,MEMPHIS,TN,38118,2017-03-02,164,D,1,0,CJSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, observation and interview, the facility failed to ensure staff maintained resident privacy when providing Activity of Daily Living (ADL) care for 1 of 3 (Resident #76) residents observed receiving ADL care. The findings included: 1. The facility's INCONTINENT CARE policy documented .provide privacy .Avoid unnecessary exposure of the resident . 2. Medical record review revealed Resident #76 was admitted to the facility 7/15/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the Brief Interview of Mental Status (BIMS) score was left blank, indicating severe cognitive impairment. Admission Minimum Data Set (MDS) assessment dated [DATE] documented the BIMS was left blank, indicating severe cognitive impairment. Resident #76 was severely cognitively impaired and was totally dependent for Activity of Daily Living (ADL) care. Observations in Resident #76's room on 1/11/17 at 9:00 AM, revealed Certified Nursing Assistant (CNA)s #4 & #8 entered Resident #76's room after donning gloves and applying mask and gown. The CNAs did not close the door or pull the privacy curtain but proceeded to pull the covers back from Resident #76 and remove her brief. The surveyor asked the CNAs was there anything else they should have done before exposing the resident and CNA #4 stated, We should have pulled the curtain. CNA #4 pulled the curtain at that time but the resident was already exposed. Interview with the Director of Nursing (DON) on 1/18/17 at 2:19 PM, in the conference room, the DON was asked what is the expectation of staff when providing incontinence or peri care for a resident on contact isolation. The DON stated. Staff should follow the isolation protocol, wash their hands, put on gloves, gown and mask as indicated. The DON was asked if it was acceptable for staff to provide peri care with the door open and the privacy curtain not pulled. The DON stated, No, it is not acceptable.",2020-03-01
4168,AHC HARBOR VIEW,445428,1513 N 2ND STREET,MEMPHIS,TN,38107,2016-12-22,164,D,1,0,XY5611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, observation, and interview, the facility failed to ensure 1 of 3(Certified Nursing Assistants (CNA) #1) CNAs provided privacy during personal care of a resident. The findings included: 1. The facility's Resident Right policy documented, .LISTING OF RESIDENT RIGHTS (a) To privacy in treatment and personal care . 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was severely cognitively impaired. Review of the MDS dated [DATE] revealed Resident #1 was moderately cognitively impaired. Observations in Resident #1's room on 12/20/16 at 12:55 PM, revealed CNA #1 provided perineal care and changed Resident #1's gown without closing the window blinds in the resident's room. There was a walkway outside Resident #1's window that ran from the main parking lot in front of the building, along the side of the building to an entrance to the building. The resident was exposed to anyone walking by and looking through the window. Interview with the Director of Nursing (DON) on 12/20/16 at 4:10 PM, in the conference room, the DON was asked what the expectations were for nursing staff while providing personal care to the residents. The DON stated, .provide privacy. The DON was asked if it would be appropriate to leave the blinds open while providing personal care. The DON stated, No.",2019-11-01
3177,"COLLIERVILLE NURSING AND REHABILITATION, LLC",445495,490 WEST POPLAR AVENUE,COLLIERVILLE,TN,38017,2020-02-06,584,E,1,0,WVF211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, observation, and interview, the facility failed to ensure a sanitary environment for 9 of 51 rooms (room [ROOM NUMBER], #202, #203, #208, #301, #303, #307, #308, and #320), which had the potential to result in infection control issues for the residents residing in these rooms. The findings include: Review of the facility's undated policy titled, Daily Resident/Patient Room Cleaning, showed, .Dust mop the floor and sweep all trash and debris to the door and pick it up with the dust pan.Wet mop the room using disinfectant. Review of the facility's undated policy titled, Method of Cleaning, showed, .Top Down: always start cleaning surfaces, ledges.at the top and work your way down. Clean the face of areas as well.Move furniture around, clean behind.Check privacy curtains. Review of the facility's undated policy titled, Cleaning Privacy Curtains, showed, .Curtains should be changed with every detailed cleaning or as needed.curtains should be checked daily. Review of the facility's undated policy titled, Wall and Handrail Cleaning, showed, .If the paint is not washable, spot clean by spraying the quaternary disinfectant on the specific spots, and clean with a cloth. Observation of the residents' rooms on 2/6/2020 showed: room [ROOM NUMBER] C: the privacy curtain between the C & D beds had numerous dried substances. room [ROOM NUMBER] D: numerous dried tan substances on the floor near the bed. room [ROOM NUMBER] W: the privacy curtain had multiple dried stains, the wall to the right of the bed had numerous splattered type red stains, and a long approximately 3 wide gray stain down the wall to the floor. room [ROOM NUMBER] D: the right side of the bed frame had brown and black flecks of debris and under the head of the bed had debris on the floor. room [ROOM NUMBER] W: a softball size dried orange substance under the head of the bed near the wall, black flecks of debris under the head of the bed on the floor and along the walls. room [ROOM NUMBER] D: an unoccupied bed with debris under the head of bed, a plastic cup, and black flecks of debris on the floor and along the walls. room [ROOM NUMBER] W: the privacy curtain had numerous various sizes of dried tan spots, and the wall above the head board had numerous dried tan spots. room [ROOM NUMBER] W: the corner of the room near the night stand had a plastic needle cap with tape, a plastic bottle top, two plastic caps for enteral tubing, numerous dried tan liquid spots were on the floor, mats, the wall above the head of the bed, under and to the right of the light, the privacy curtain had numerous various sizes of dried tan spots, a dried tan substance on the top left side rail and the foot board, and plastic cups under the bed. room [ROOM NUMBER] W: the window sill with two brown pine needles, black flecks of debris, white flecks of debris, brown flecks of debris, and numerous various sizes of dried tan spots on the window sill, along the wall, on the floor, the wall above the head of bed, and the base of Intravenous (IV) pole. Under the head of the bed had a softball sized dried puddle of tan substance, black flecks of debris, and a plastic hanger, along the walls on the floor had black flecks of debris, and a privacy curtain had stains. room [ROOM NUMBER] W: a large amount of tan dried substance on the floor beside, under the bed, and on the IV pole, and splatters of tan dried substance under the D bed. During an interview conducted during the tour on 2/6/2020 at 2:30 PM, the Administrator confirmed the findings and stated, .Yes, I see it.this is unacceptable.both nursing and housekeeping are responsible.when the nurses spike the enteral feedings and housekeeping doing their job.",2020-09-01
3604,REELFOOT MANOR HEALTH AND REHAB,445285,1034 REELFOOT DRIVE,TIPTONVILLE,TN,38079,2017-04-20,226,D,1,0,VW4711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, personnel file review and interview, the facility failed to ensure abuse screening was conducted for 1 of 13 (Certified Nursing Assistant (CNA) #1) staff members reviewed for abuse screenings. The findings included: The facility's Background Screening Investigations policy documented, .For any individual applying for a position as a Certified Nursing Assistant, the state nurse aide registry will be contacted to determine if any findings of abuse, neglect, mistreatment of [REDACTED]. Review of CNA #1's personnel file revealed no documentation the abuse registry was checked prior to hire. Interview with the Human Resources Administrator/Payroll Clerk on 4/19/17 at 2:22 PM, in the Conference Room, the Human Resources Administrator/Payroll Clerk was asked whether CNA #1 had an abuse registry screening. The Human Resources Administrator/Payroll Clerk stated, I couldn't find it . The facility was unable to provide documentation that the abuse registry screening was completed for CNA #1 upon hire.",2020-08-01
5009,MAPLEWOOD HEALTH CARE CENTER,445412,100 CHERRYWOOD PLACE,JACKSON,TN,38305,2016-06-29,205,E,1,0,IW9S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, record review, and interview the facility failed to provide the written notification of the bed hold policy within for 3 of 3 (Resident #1, 2 and 3) sampled residents priot to discharge to a hospital/ behavioral center. The findings included: 1. The facility's ADMISSION AGREEMENT documented, .3.6 Bed Hold Policy. Before a resident may be transferred to a hospital or for a therapeutic leave, the Center is required to provide the Center's bed hold policy to the resident and a family member or Legal Representative. The bed hold policy includes any State bed hold requirements and information on how Medicare only and private pay residents may request and obtain a bed hold . The facility's Attachment D - Bed Hold Policy documented, .the time the Resident is to leave the Center for a temporary stay in a hospital or for therapeutic leave, (or within (not visable on copy) hours in case of an emergency transfer) the Resident/Legal Representative will be given a written copy of the Bed (not visable on copy) Policy . 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #1 was discharged to a behavioral center on 8/20/15 and did not return to this facility. There was no documentation of the bed hold policy being given to the resident or family when the resident was discharged . 3. Medical record review revealed Resident #2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident was discharged to a hospital on [DATE] with readmission on 7/13/16 at 9:30 PM. There was no documentation of the bed hold policy being given to the resident or family when the resident was discharged . 4. Medical record review revealed Resident #3 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident was discharged to a behavioral center on 3/22/16 with readmission 4/5/16. There was no documentation of bed hold policy being given to the resident or family when the resident was discharged . 5. Interview with the Director of Nursing (DON) on 6/27/16 at 1:00 PM, in the Activity Office, the DON was asked what do you do if a resident has been in the hospital and looking to return. The DON stated, .bed hold or discharge depending on how long they've been in the hospital .Social handles that . Interview with the Social Services Director (SSD) on 6/27/16 at 2:10 PM, in the Activity Office, the SSD was asked if she sends a bed hold policy if a resident goes to the hospital or call the family to talk to them about a bed hold. The SSD stated, .medicaid .don't call .ten day hold on the bed .VA (Veteran Affairs) and private, I will call .After the tenth day for Medicaid, I will talk to the family. The SSD was asked if there was documentation of notifying family members of their bed hold options, the SSD stated, Sometimes .",2019-06-01
5028,"COLLIERVILLE NURSING AND REHABILITATION, LLC",445495,490 WEST POPLAR AVENUE,COLLIERVILLE,TN,38017,2016-06-29,309,D,1,0,MZ6611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, record review, observation and interview, the facility failed to provide appropriate positioning for 2 of 4 (Resident #1 and 2) sampled residents. Findings included: 1. Review of the facility's Repositioning policy, dated 5/28/13, revealed, .1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. 2. Assessment of a resident's skin integrity after pressure has been reduced or redistributed should guide the development and implementation of repositioning plans. Such plans should be addressed in the comprehensive plan of care consistent with the resident's needs and goals. 3. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning . 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the At risk for pressure ulcers care plan dated 9/9/15, with no current update, included the intervention: Reposition 2-3 times per shift, and as needed as tolerated. The Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had moderate cognitive impairment and the resident totally dependent on staff for bed mobility, transfers, locomotion, dressing, toilet use, personal hygiene and bathing. The MDS revealed the resident had functional impairment on one arm and one leg, was always incontinent of bowel and bladder, and at risk for development of pressure ulcers. The Norton Plus Pressure Ulcer Scaled dated 2/29/16 recorded the resident's score of 6, with 10 or less being high risk. Continuous observations on 6/28/16 from 12:10 PM to 2:32 PM revealed the resident in bed with the head of the bed raised to approximately 90 degrees. The resident's heels appeared flat on the bed, however, the blanket covered them. Observation at 2:32 PM, Certified Nursing Assistant (CNA) #2 and CNA #3 entered the room to check the resident, and it was revealed the resident's heels lay directly on a pillow. Observation revealed neither CNA #2 nor CNA #3 repositioned the resident or asked if they could reposition the resident. Interview at 2:41 PM with CNA #2 revealed staff last checked the resident at 11:30 AM, and did not reposition the resident's heels or body. CNA #2 acknowledged they did not reposition the resident for 3 hours, and stated, (Resident #1) refuses a lot. Review of the Behavior monitoring sheets for March, April, (MONTH) and June, (YEAR) revealed no documentation of the resident refusing repositioning. Observation on 6/29/16 at 9:30 AM revealed the resident in a Geri chair with feet on the footrest, and heels directly on a pillow on the footrest, not floated. Interview on 6/29/16 at 9:31 AM, on the second floor nursing unit, the Wound Care Nurse (WC Nurse) stated the resident's heels, Need to be floated, not on a pillow .floating the heels will work well for (the resident, instead of boots). The WC Nurse stated the resident had bilateral heel pressure ulcers last December, (YEAR) which healed; it was discovered in Doppler studies the resident's heels had arterial ulcers, not pressure ulcers, and were unavoidable. The WC Nurse acknowledged arterial insufficiency may put the resident at even higher risk for pressure ulcers, and a resident with arterial insufficiency can still develop pressure ulcers. The WC Nurse stated interventions for the resident should include floating the heels and turning/repositioning every 1 hour to prevent pressure ulcers, because (the resident) is high risk. The WC Nurse stated in-service education needs to be done with the nurses and CNAs what floating the heels means: it does not mean to place the heels on the pillow, but let them float free. During interview on 6/29/16 at 4:08 PM, in the conference room, the Director of Nursing (DON) acknowledged staff did not reposition the resident for 3 hours or float the resident's heels. The facility failed to provide appropriate and timely repositioning for this dependent resident. 3. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] after a hospital stay. He had [DIAGNOSES REDACTED]. Resident #2 was in persistent vegetative state, encounter, presence of a [MEDICAL CONDITION], gastrostomy, and pressure ulcer of sacral region and had stiffness of bilateral knees. The current care plan dated 11/25/15 revealed Resident #2 was admitted with a Stage III pressure wound to the right buttock. The care plan indicated Resident #2 was at risk for pressure ulcers and was admitted with stage III pressure ulcer sacrum. The care plan goal indicated Resident #2 would be free of further skin breakdown until 7/12/16. The care plan identified approaches of daily observation of skin with daily care, a specialized air mattress was in place mattress and a wedge for positioning was in place. Approaches to the care plan revealed two person assistance was required for turning and repositioning Resident #2. The care plan indicated frequent repositioning for Resident #2. The Minimum Data Set ((MDS) dated [DATE], indicated Resident #2 was totally dependent on two staff members for bed mobility and was totally dependent on one staff for transfer. Resident #2 was totally dependent on staff for personal hygiene, bathing, dressing, eating, and toileting and was non ambulatory. The MDS indicated Resident #2 was incontinent of bowel and had an indwelling catheter in place. The MDS indicated the resident had stage III or IV pressure ulcers (PU) and was at risk for developing more pressure ulcers. The MDS indicated the resident was on oxygen therapy, received suctioning treatment and [MEDICAL CONDITION] (trach) care. On 6/28/16 between 12:15 PM and 1:45 PM, Resident #2 was observed periodically, while in bed. During the observations, the resident was lying on his right side and a positioning wedge was placed along his back, on his right side. On that date, Resident #2 was observed at the following times: At 12:15 PM, at 12:30 PM, at 12:45 PM, at 1:03 PM and 1:45 PM. At all those times, Resident #2 was lying on his right side and a positioning wedge was placed along his back, on his right side. On 6/28/16 at 2:09 PM, CNA #1 was observed while in Resident #2's room. She stated she had just finished cleaning the resident up and had repositioned the resident for the second time on that date. CNA #1 confirmed Resident #2 was positioned on his right side prior to repositioning at about 2:00 PM. CNA #1 stated Resident #2 was positioned on his right side, facing the window, at about 2:00 PM, she repositioned the Resident on his left side, facing the door. CNA #1 stated Resident #2 was to be turned at least every two hours. CNA #1 stated she reported on duty this morning at 7:00 AM and did walking rounds with the outgoing night shift staff. CNA #1 stated, at 7:00 AM, the Resident was positioned on his back during rounding. CNA #1 stated, at about 8:00 AM, she checked on everybody, including Resident #2 and no repositioning was provided for resident #2, at that time. CNA #1 explained, at 8:00 AM, she briefly checked on Resident #2, checked his oxygen levels and no repositioning was provided at that time. CNA #1 further explained, at 8:00 AM Resident #2 was on his back and CNA #1 did not turn the Resident at that time. CNA #1 stated at about 11:00 AM she came into the Resident #2's room, gave him a bath, provided oral care, and turned him onto his right side, so he faced the window. CNA #1 further stated on the day shift (on 6/28/16), Resident #2 was first turned from his back to his right side, at 11:00 AM or past 11:00 AM. On 6/28/16 at 2:28 PM, Registered Nurse (RN) #A was interviewed. In the interview RN #A stated, she expected repositioning to be done at least every two hours and as needed, for Resident #2. On 6/29/16 at 12:30 PM, the DON was interviewed. The DON stated she expected normal rounding to be done every two hours. The resident was to be turned at least every two hours and no resident was to be left without repositioning for three hours. The facility failed to provide timely repositioning for Resident #2, who was totally dependent on staff for repositioning needs. Interview with CNA #1 revealed on 6/28/16, Resident #2 was positioned on his back, without repositioning from 7:00 AM to 11:00 AM, a period of four hours, for a resident, in a vegetative state, with stage III right buttock pressure sore, with stiff bilateral lower extremities and was totally dependent on staff for repositioning. Resident #2 was to be repositioned at least every two hours as indicated below in staff interviews. Again, Resident #2 was provided no repositioning from 11:00 AM to 2:00 PM, a period of about three hours, for a resident who was to be repositioned by staff, at least every two hours.",2019-06-01
5027,"COLLIERVILLE NURSING AND REHABILITATION, LLC",445495,490 WEST POPLAR AVENUE,COLLIERVILLE,TN,38017,2016-06-29,280,D,1,0,MZ6611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, record review, observation and interview, the facility failed to provide appropriate revision of the care plan for 1 of 4 (Resident #1) sampled residents. Findings included: 1. Review of the facility's undated/unsigned Care Plan policy revealed, Policy. An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .5. Assessments of resident are ongoing and care plans are revised as information about the resident and the resident s condition change. 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was moderately cognitively impaired and was totally dependent on staff for bed mobility, transfers, locomotion, dressing, toilet use, personal hygiene and bathing. The MDS revealed the resident had functional impairment on one arm and one leg, was always incontinent of bowel and bladder, and at risk for development of pressure ulcers. Review of the medical record revealed the resident was readmitted from the hospital on [DATE] with [DIAGNOSES REDACTED]. The care plan did not include the resident's infection, antibiotic use/adverse reactions or PICC line care. Review of the Physical Therapy Plan of Care dated 3/26/15 revealed the resident required Multi Podus boots. Review of the Weekly Body Audit dated 5/30/16 recorded the resident had dark discoloration on the left heel, and dry skin on the right heel. The At risk for pressure ulcer care plan dated 9/9/15 was not revised to include interventions for the new heel areas, and not updated since 9/9/15. Observation on 6/28/16 at 12:10 PM revealed the resident in bed watching TV with the head of the bed at approximately 90 degrees. During interview on 6/28/16 at 2:01 PM, on the second floor nursing unit, the Director of Nursing (DON) stated the care plan was not updated. The DON agreed it was difficult to tell if many of the care plans in the resident record were still in effect because some of the dates of revision were from December, (YEAR) or February, (YEAR). At 4:08 PM, the DON stated when a resident re-admits, staff should use the previous care plan and update it. During interview on 6/29/16 at 10:26 AM, in the therapy room, the Therapy Department Director stated the Physical Therapist initiated the boots and should be applied by nursing staff 2 hours per day for help with bilateral ankle/knee contracture prevention. The Director stated the boots were never discontinued, should still be in use, and therapy staff documented training with nursing staff. The nursing care plan lacked any information for the use of Multi Podus boots. During interview on 6/29/16 at 1:19 PM, in the conference room, the MDS nurse stated nurses on the floor should update the care plans with new orders. The MDS nurse stated for the resident's 6/18/16 readmission, the clinical team should have updated the care plan to include the infection, PICC line, antibiotic use/adverse effects and the Multi Podus boots. The MDS nurse was not sure who should update it because, it's a team approach, and I can't tell you who exactly did them. The MDS nurse acknowledged most of the resident's care plan was not updated quarterly or revised with new care goals and interventions after a change of condition. The MDS nurse stated, I have no proof I reviewed the care plan, all I can do is tell you I review them. The facility failed to revise this dependent resident's plan of care.",2019-06-01
460,SIGNATURE HEALTHCARE OF PRIMACY,445140,6025 PRIMACY PARKWAY,MEMPHIS,TN,38119,2018-05-21,658,D,1,0,K56Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, resident rights review, job description review, medical record review, and interview, the facility failed to ensure that licensed nurses did not borrow medications prescribed to one resident and administer those medications to another resident for 1 of 3 (Resident #1) sampled residents reviewed for medication administration. The findings included: 1. The facility's Medication Administration . policy documented, .Medications supplied for one resident are never administered to another resident . 2. The JOB DESCRIPTION .Charge Nurse (LPN or RN) (Licensed Practical Nurse or Registered Nurse) documented, .Essential Duties & Responsibilities .Prepare and administer medication as ordered by the physician .Verify that prescribed medication for one resident is not administered to another . 3. Medical record review revealed Resident #1 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 did not have a comprehensive assessment completed because he was only in the facility for approximately 31 hours before leaving against medical advice. The physician admission orders [REDACTED]. The pharmacy's Shipping Manifest Pharmaceuticals dated 4/21/18 at 12:36 PM, revealed [MEDICATION NAME], and Duloxetine were delivered to the facility for Resident #1. The pharmacy's Shipping Manifest Pharmaceuticals dated 4/21/18 at 5:17 PM, revealed [MEDICATION NAME] was delivered to the facility for Resident #1. The (MONTH) Medication Administration Record [REDACTED]. No [MEDICATION NAME] was delivered from the pharmacy due to no written prescription was available and sent to the pharmacy. Interview with the Director of Nursing (DON) on 5/9/18 beginning at 9:35 AM, in the conference room, the DON provided a narcotic sign out sheet for a random resident that revealed 1 [MEDICATION NAME] was signed out on 4/21/18 at 12:00 AM. The DON reviewed the MAR for the same resident and revealed documentation that 1 [MEDICATION NAME] was administered to that resident. Review of Resident #1's MAR indicated [REDACTED]. The DON was asked about Resident #1's MAR indicated [REDACTED]. The DON stated that even though other resident medications should not be borrowed, she confirmed the nurses did borrow medications from other residents and documented they were administered on Resident #1's MAR. The DON stated that the nurses should not borrow medications. The (MONTH) MAR indicated [REDACTED]. Telephone interview with LPN #1 on 5/9/18 at 10:00 AM, in the conference room, LPN #1 confirmed that she signed the [MEDICATION NAME] as given on the random resident's MAR indicated [REDACTED]. LPN #1 confirmed she administered the borrowed [MEDICATION NAME] it to Resident #1. Telephone interview with LPN #1 on 5/17/18 at 8:04 AM, LPN #1 was asked if she administered [MEDICATION NAME] to Resident #1. LPN #1 stated that she did give him a [MEDICATION NAME] sometime during that first night and she confirmed that he did take the medication. LPN #1 confirmed that she did borrow medications from other residents.",2020-09-01
461,SIGNATURE HEALTHCARE OF PRIMACY,445140,6025 PRIMACY PARKWAY,MEMPHIS,TN,38119,2018-05-21,697,D,1,0,K56Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, resident rights review, medical record review, and interview, the facility failed to manage or prevent pain to help residents attain or maintain the highest practicable level of well-being for 1 of 3 (Resident #1) sampled residents reviewed for pain. The findings included: 1. The facility's Pain Management policy documented, .The purpose of this policy is to outline guidelines that will promote effective pain management, including .timely response to complaints of pain .Our facility is committed to help each resident attain or maintain their highest reasonable level of well-being and to prevent or manage pain to the extent possible. Our pain management policy includes recognizing when the resident experiences pain .and management or prevention of pain consistent with professional standards of care and in accordance with the plan of care .MANAGEMENT .When treating pain, start with drugs appropriate to the resident's current level of pain and progress by increasing the dose of that drug until maximum benefit is obtained . 2. The Residents Rights documented, .Nursing home residents have the right .to reside and receive services with reasonable accommodation .to voice grievances about care or treatment they do or do not receive .and to receive prompt response from the facility . 3. Medical record review revealed Resident #1 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 did not have a comprehensive assessment completed because he was only in the facility for approximately 32 hours. The Baseline Admission Care Plan documented, .Problem .Resident has pain .Related to .Diabetic [MEDICAL CONDITION] .Approach .Administer pain medications per physicians orders . The hospital physician admission orders [REDACTED]. The original handwritten prescriptions signed by the physician for these medications were not found when Resident #1 arrived to the facility via ambulance. Medical record review revealed Resident #1 did not receive [MEDICATION NAME] for pain, [MEDICATION NAME] for anxiety, or [MEDICATION NAME] for [MEDICAL CONDITION] during his stay at the facility. Review of the hospital medication reconciliation discharge paperwork dated 4/20/18 revealed Resident #1 had last received [MEDICATION NAME] on 4/15/18 at 3:14 AM, [MEDICATION NAME] on 4/19/18 at 9:50 PM, [MEDICATION NAME] on 4/20/18 at 11:22 AM, and [MEDICATION NAME] on 1/16/18 at 12:00 AM, while a patient in the hospital. The nurse's notes dated 4/21/18 at 2:57 AM, Licensed Practical Nurse (LPN) #1 documented, .CONCERNED WITH MEDS (Medications) NOT BEING HERE .RESIDENT NOT PLEASED .ASKING TO GO BACK TO HOSPITAL .NOW AT DESK REQUESTING PAIN PILL. MEDS STILL NOT AVAILABLE FROM PHARMACY .4:12 AM .AT DESK AT THIS TIME TALKING AGGRESSIVELY TO NURSE ABOUT HIS MEDS. WILL NOT ALLOW NURSE TO EXPLAIN MED SITUATION TO HIM. KEEPS OVERTALKING NURSE AND YELLING ABOUT THIS IS NOT RIGHT. REQUESTING THAT I CALL AMBULANCE FOR HIM TO GO BACK TO HOSPITAL. ADVISED THAT HE (Resident #1) MAY DO SO BUT IT WOULD NOT BE AN EMERGENCY TRANSFER FROM FACILITY .(RESIDENT #1) STATING .NURSE TOLD HIM THAT MEDS WERE ON THE WAY .I CANNOT GIVE HIM MEDS THAT I DO NOT HAVE . The (MONTH) MAR indicated [REDACTED]. Resident #1 was not administered any [MEDICATION NAME] from 4/20/18 at 11:22 AM (at the hospital) until 4/21/18 at 4:33 AM (at the nursing home facility). Resident #1 did not have any pain medication for a total of 17 hours and 11 minutes. Resident #1 did not receive any additional pain medication for an additional 21 hours and 17 minutes during his stay at this facility and he left against medical advice on 4/22/18 at 1:50 AM. On 4/21/18 at 5:43 AM, LPN #2 documented, .Writer then Called NP (Nurse Practitioner) on call .and explained the issue, she was given his dx (diagnosis) with chronic pain she ordered to give Tylenol 650mg every 4 hours as needed for pain. he refused to receive it saying it upsets his stomach. DON (Director of Nursing) then notified about issue. (Named Medical Director) was called but could not be reached at the time .DON was notified of unresolved issue, she ordered to transfer resident to hospital for uncontrolled pain .he refused and stated that [MEDICATION NAME] would be fine at the moment . The nurse's note dated 4/22/18 at 4:02 AM, documented, REPORTED PER VS (VITAL SIGNS) THAT BP (BLOOD PRESSURE) IS 176/99. PRN (AS NEEDED) [MEDICATION NAME] OFFERED WITH TYLENOL FOR C/O (COMPLAINT OF) PAIN. DECLINED TYLENOL. STATED IT CAUSES GI (GASTROINTESTINAL) UPSET. RESIDENT OBSERVED PACKING BELONGINGS AND STATED THAT HE WILL BE LEAVING TONIGHT .SAID HE WOULD CALL 911 OR AMBULANCE SERVICE. ADVISED TO ALLOW NURSE TO GIVEN HIM PRN FOR BP. STATED THAT HE COULD NOT TAKE IF HE DIDN'T HAVE HIS PAIN MED (MEDICATION) ALSO. INFORMED THAT NO PAIN MED AT THIS TIME EXCEPT TYLENOL AVAILABLE. (RESIDENT #1) REMAINED DETERMINED TO LEAVE. FINISHED PACKING ALL BELONGINGS AND AT DESK ASKING WHAT PAPER TO SIGN TO GET OUT OF HERE. PRESENTED WITH AMA (AGAINST MEDICAL ADVICE) PAPERS. READ OVER PAPERS AND SIGNED .OBSEVRED EXTING (OBSERVED EXITING) UNIT WITH PERSONAL BELONGS TOWARD FRONT DOOR OF FACILITY. ALARM SOUNDED OF EXIT AT 0150 AM .6:23 AM FACILITY ADMINISTRATOR AND DON MADE AWARE OF AMA OF RESIDENT. The pharmacy's Shipping Manifest Pharmaceuticals dated 4/21/18 at 12:36 PM, revealed the following medications were delivered to the facility for Resident #1. [MEDICATION NAME] 30 tablets, Atorvastatin 30 tablets, [MEDICATION NAME] 30 tablets and Duloxetine 60 tablets. The pharmacy's Shipping Manifest Pharmaceuticals dated 4/21/18 at 5:17 PM, revealed the following medications were delivered to the facility for Resident #1. Losartan 60 tablets, [MEDICATION NAME] 30 tablets, [MEDICATION NAME] 30 tablets and [MEDICATION NAME] 7 tablets. The DON provided a narcotic sign out sheet for a random resident that revealed 1 [MEDICATION NAME] was signed out on 4/21/18 at 12:00 AM. Review of Resident #1's (MONTH) MAR indicated [REDACTED]. Interview with Resident #1 on 5/8/18 beginning at 2:14 PM, in the conference room, he was asked about his stay at this facility in April. Resident #1 confirmed he was admitted to the facility at approximately 5:50 PM on 4/20/18 and the hospital sent written prescriptions with him in an envelope. He stated they lost the prescriptions and he did not get any pain medicine when he was there. He stated that he had [MEDICAL CONDITION] pain and anxiety. Interview with the DON on 5/9/18 beginning at 9:35 AM, in the conference room, she was asked about the facility's process if narcotic prescriptions are lost when residents are admitted to the facility. The DON stated that they cannot get narcotics if there is no written prescription. The DON stated that the facility was looking into the incident and would be doing a process improvement plan. The DON confirmed that Resident #1 should not have gone so long without pain medication. The DON was asked about Resident #1's continued requests for medication. The DON confirmed that Resident #1 was hard to manage and he was not truthful. She stated that they offered to send him to the ER but he refused. Telephone interview with Resident #1 on 5/9/18 at 2:10 PM, revealed he was upset with how he was treated. He stated that he felt they didn't care about him and he told them if he couldn't get his medicine and he was hurting that he was going to leave. He stated that he asked the supervisor to call an ambulance so he could go to the hospital and that she told him you have a phone, you can call and get over there yourself and it wasn't an emergency. He stated that they didn't want to do anything to help him. He continued to say he did not get his medications especially his pain medication. During a telephone interview with the Nurse Practitioner on 5/9/18 at 2:40 PM, the Nurse Practitioner was asked about Resident #1 and did she receive a call from the nursing staff that he needed pain medication. The Nurse Practitioner stated, I don't have my computer up and I don't have my notes but they called me about a patient and it was a while back, but when they call about a patient, the hospital is supposed to send their scripts (handwritten prescriptions) with them, with the amount of issues with controlled substances of that nature, we don't write narcotics until you actually see that patient, so if they call and say we don't have the script, then the patient typically gets Tylenol until either I will tell them to call the hospital and ask them where's the script at, find the script so you guys can go pick it up and do it that way, but in the meantime there is a Tylenol ordered to give them a chance to maintain them until then. Telephone interview with LPN #1 on 5/17/18 at 8:04 AM, LPN #1 was asked if she administered (Named Narcotic) to Resident #1. LPN #1 stated that she did give him a [MEDICATION NAME] sometime during that first night, because he was acting out. She was asked if she administered any other medications to him during his stay. She stated that she gave him one other medicine that morning at about 6:00 AM. LPN #1 was asked if she administered any other medications to Resident #1. She stated that she did not give him anything else because his medications had not come from the pharmacy yet. LPN #1 confirmed that she did borrow those 2 medications from other residents.",2020-09-01
4157,MAPLEWOOD HEALTH CARE CENTER,445412,100 CHERRYWOOD PLACE,JACKSON,TN,38305,2016-11-10,226,D,1,0,5EH511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, review of a time detail sheet and assignment sheets, personnel file review, facility investigation review, medical record review and interview, the facility failed to implement their abuse policy as evidenced by failure to provide social services following an abuse allegation, failure to transfer the alleged victim to the hospital following the allegation of physical abuse, and failure to protect residents from potential abuse during an abuse investigation for 1 of 5 (Resident #166) sampled residents reviewed for abuse of the 28 residents included in the stage 2 review. The findings included: 1. The facility's ABUSE PREVENTION POLICY & PR[NAME]EDURE documented, .This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse, corporal punishment .by facility staff member .A basic definition describes abuse 'as the harmful treatment of [REDACTED].' REPORTING/INVESTIGATION/RESPONSE POLICY .Any complaint, allegation, observation or suspicion of resident abuse .is to be thoroughly reported, investigated and documented in a uniform manner .Facility Social Worker is to provide counseling and support to the resident and possibly the family .counseling is to be provided as long as necessary. The psychosocial intervention is to be documented in the resident's clinical record .Administrator shall take the following actions to address issues of resident care raised by suspected abuse .If the incident has resulted in an injury .the resident will be transferred to the hospital emergency room .The facility will take all steps necessary to ensure that further potential abuse will not occur while the investigation is in progress .Any employee suspected (alleged) of abuse will be suspended as the incident is reported; pending outcome of the investigation . 2. Medical record review revealed Resident #166 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., Dysthymic Disorder, [MEDICAL CONDITION] of Buttock, and a History of Femur Fracture. The quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment, no behaviors, and Resident #166 required staff assistance with all activities of daily living (ADLs). The care plan dated 5/17/16 documented, .At risk for skin breakdown .bruises easily .frequently confused .10/30/2016 bruising noted to wrists and hands/ ST (skin tear) to left upper arm .Short term memory loss r/t (related to) dementia, has some forgetfulness, confusion .hx (history) of combativeness, and agitation .Approaches .If resident is combative, allow resident to calm down and then return later . A Resident Incident Report dated 10/30/16 documented .Incident Type: Skin Tear-superficial .Date/Time: 10/30/16 01:31 AM .Type of Injury: Skin tear, Bruise, Other .Narrative .Per (Licensed Practical Nurse (LPN) #5) resident (Resident #166) was falling out of a w/c (wheelchair) asleep instructed cna's (certified nursing assistant) to put resident to bed .(LPN #5) instructed cna to put resident to bed the resident started fighting aznd (and) they was holding hands .resident has bilaterally (bilateral) bruises to both wrists and hands with deformity to left thumb also complain of chest pain left shoulder pain .Immediate Actions Taken .eval. (evaluate) resident , she refused to go to her room for further evaluation .Exam by Physician: No .Taken to Hospital: No . Review of LPN #5's personnel file revealed a PERSONNEL CONSULTATION FORM dated 11/2/16, that documented, .A resident on 10/30/16 was resisting going to bed .employees continued to provide care even when she (Resident #166) resisted .employee should have respected her right to refuse/resist . Review of CNA #2's personnel file revealed a PERSONNEL CONSULTATION FORM dated 11/2/16, that documented, .A resident on 10/30/16 was resisting going to bed .employees continued to provide care even when she (Resident #166) resisted .employee should have respected her right to refuse/resist . Review of CNA #3's personnel file revealed a PERSONNEL CONSULTATION FORM dated 11/2/16, that documented, .A resident on 10/30/16 was resisting going to bed .employees continued to provide care even when she (Resident #166) resisted .employee should have respected her right to refuse/resist . A nurse's note dated 10/30/16 at 12:52 PM and signed by LPN #5 documented, .Category .Change of Status .RESIDENT COMPLAINING OF CHEST PAIN, ALERT AND ORIENTED MOBILE .CHEST XRAY INFORMATION GIVEN .WILL CONTINUE TO MONITOR RESIDENT . A Time Card Report for LPN #5 documented, .Oct (October)-29 16 .In .7:01p .Out .12:58p . Amount .17.50 .Hours . The nurses' notes documented, .10/30/2016 at 6:56 PM .At the start of shift (7 am) I observed resident with significant black and blue bruising on bilateral hands and arms. She also has a small skin tear on her left upper arm .Resident is c/o (complaining of) soreness all over and generalized muscle aches .10/30/2016 .9:09 PM .Resident RP .in facility & (and) asked what happened to resident's hand, this nurse informed her that at this time we were not sure .10/30/2016 .11:55 PM .sitting in a chair complaining of left shoulder, chest, left hand pain tender on palpation .10/31/2016 .3:16 AM .bruising remains to BUE (bilateral upper extremities) .10/31/2016 .10:34 AM .resident remains with scattered discolorations to BUE . Nursing staff assignment sheets were reviewed and documented LPN #5 was assigned to Resident #166's hall on 11/5/16 and 11/6/16; and CNA #2 was assigned to Resident #166's hall on 11/4/16, 11/5/16 (specifically to odd-numbered rooms, Resident #166 had an odd-numbered room), and 11/6/16. The facility investigation was reviewed and contained an e-mail (electronic mail) from the Administrator to the Director of Nursing (DON) dated 11/1/16. The e-mail documented, .discussion with (Family Member #1) .I explained that I did not think this was abuse of an intentional nature .found no evidence of abuse .I said so I believe those employees will be returning to work. (Family Member #1) said well, I just wish they didn't have to take care of (Resident #166) because she is still scared. I said I understand but we'll just wait and see and maybe she'll get over that . Interview with the Social Worker on 11/10/16 at 10:13 AM, in the Activity Room, Social Worker (SW) #1 was asked whether she had talked with Resident #166 after the abuse allegation incident on 10/30/16. SW #1 stated, I did not. The facility failed to provide social services to Resident #166 and her family after the abuse allegation per facility policy. Additionally, the facility failed to transfer Resident #166 to the hospital emergency department for evaluation of injuries (bruising and skin tear to hands/arms) following the abuse allegation per the facility's policy. Interview with the DON on 11/10/16 at 10:41 AM, in the Activity Room, the DON was asked whether she had been involved in the abuse allegation investigation made by Resident #166 on 10/30/16. The DON stated, No. (Administrator) did the whole thing. The DON was asked whether the 3 accused employees had been reassigned after they returned to work after completion of the facility's investigation. The DON stated, No, they did not. I asked did he want me to change it, and he said no . There was no documentation in the medical record that a physical examination was completed for Resident #166 by a physician/nurse practitioner (NP). During the DON's interview on 11/10/16 at 10:41 AM, in the Activity Room, the DON was asked whether Resident #166 was examined by a physician. The DON stated the NP had examined Resident #166. The DON was asked to provide the NP's documentation. The DON stated she was not sure whether the NP had made a written note, but did later obtain the NP's progress note from the NP's office. The NP progress note documented, .Nursing Home .Encounter Date .10/31/2016 .(Resident #166) was examined briefly .Physical Exam .Skin There is ecchymosis dorsum left hand 1st, 2nd, 3rd MP (metacarpophalangeal) joints to wrist .Right hand, dorsum with ecchymosis over 3rd and 4th MP joints extending down to wrist and over to below MP joint of thumb .Assessment .Ecchymosis .Electronically signed by .(named NP) .[DATE] (YEAR) . Interview with the Administrator on 11/10/16 at 12:00 PM, in his office, the Administrator was asked what happened regarding the abuse allegation made by Resident #166. The Administrator stated, .Some employees got ahead of themselves. Instead of waiting, they decided it was more important to provide care. The resident got agitated and started fighting them and biting. I think they held her wrists. She wasn't willing to receive their efforts, and it turned into an unfortunate occurrence . The Administrator was asked whether the accused employees were suspended during the investigation. The Administrator stated, Yes. The Administrator was asked whether LPN #5 worked through the afternoon on the day the alleged incident took place. The Administrator stated, .The shift ends at 7AM. We held her around for interviews. She was not working on the floor as an LPN during that time . The Administrator was asked whether the accused employees continued to care for Resident #166 when they returned to work after the investigation. The Administrator stated, They did. The Administrator was asked whether he had felt it was not necessary to reassign them, even after the family had requested they not care for the resident again. The Administrator stated, No. I did not. The Administrator confirmed the accused staff (CNA #2, CNA #3, LPN #5) had not been reassigned upon return to work. The facility failed to protect Resident #166 after an abuse allegation was made as evidenced by accused LPN #5 continued to care for Resident #166 during and after the time of the facility's investigation.",2019-11-01
3789,COUNTRYSIDE HEALTHCARE AND REHABILITATION,445280,3051 BUFFALO ROAD,LAWRENCEBURG,TN,38464,2017-02-08,225,D,1,0,2N4U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, review of an incident report, and interview, the facility staff failed to report an allegation of verbal abuse timely for 1 of 4 (Resident #47) sampled residents reviewed for abuse. The findings included: The facility's Abuse Prohibition policy documented, .This facility is committed to protecting the physical and emotional well-being and personal possessions of every resident. This facility has systems, procedures and a program of employee training and supervision in place to foster dignified treatment, respect, and [MEDICATION NAME] for residents. Any form of mistreatment of [REDACTED].Training Upon hire .all employees receive training in the following areas: .Proper techniques for reporting suspected abuse facts without fear of reprisal .Prevention .Employees are instructed on how and to whom they may report concerns, incidents, grievances and feedback without fear of retribution: .As part of the facility's on-going abuse prevention and improvement programs, factors contributing to the potential for abuse, neglect, and misappropriation of property are identified and corrected, such as: .Inappropriate behaviors by staff (e.g. (for example) derogatory language, rough handling, ignoring, or infantilizing residents .Investigation .The facility will immediately investigate any alleged abuse resident neglect, mistreatment, and/or physical, verbal .abuse .using the Resident protective investigative procedure . Review of an incident report dated 1/31/17 documented, .CNA (Certified Nursing Assistant) was overheard talking mean to pt (patient) and CNA herself stated she uses profanity reg. (regularly) in front of pts & probably did this time also . Review of a report incident with a date of occurrence of 1/28/17 documented, .This incident was reported to mgmt. (management) of the facility on Tuesday, (MONTH) 31 by a witness stating that on Saturday night, a staff member was giving care to a resident in the resident's room. The witnesses were walking down the hall and overheard the staff member being mean in her tone of voice. She told her to turn over real mean and I feel like it was in anger. The witnesses said that the employee was very loud and hateful to the resident, telling her to turn over now, ******(curse word) . Review of a MONTHLY IN-SERVICE SIGN IN SHEET dated 1/31/17 documented, .Abuse Reporting; Report immediately to supervisor if suspected abuse . The form contained the names of the witnesses to the allegation. Interview with Licensed Practical Nurse (LPN) #2 on 2/7/17 at 4:25 PM, in the Conference Room, LPN #2 stated, .the incident occurred on 1/28/17 (Saturday). They reported it to me on Tuesday 1/31/17 .We told them (the witnesses) they should have reported it immediately . Interview with the Director of Nursing (DON) on 2/7/17 at 4:35 PM, in the Conference Room, the DON was asked what the expectations were if a staff member witnesses abuse to a resident. The DON stated, They should report it to someone immediately .",2020-02-01
3739,"COLLIERVILLE NURSING AND REHABILITATION, LLC",445495,490 WEST POPLAR AVENUE,COLLIERVILLE,TN,38017,2017-03-02,225,D,1,0,4B1111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, review of an incident report, observation, and interview, the facility staff failed to report an allegation of verbal abuse timely, the facility failed to conduct a thorough investigation for 1 of 6 (Resident #1) sampled residents reviewed for abuse/injury of unknown origin. The findings included: 1. The facility's Reporting of Alleged Abuse to Facility Management policy documented, .It is the responsibility of our employees .to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source .to facility management .Injury of unknown source .is defined as an injury that meets both of the following conditions .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 .The injury is suspicious because of .the extent of the injury .The Administrator or Director of Nursing Services must be immediately notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and/or Director of Nursing Services must be called at home or must be paged and informed .An immediate investigation will be made . The facility's Abuse Investigations policy documented, .Should an incident or suspected incident of .injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident .The individual conducting the investigation will, as a minimum .Interview other residents with whom the individual provides care or services and/or interacts . The facility's ABUSE PREVENTION PROGRAM policy documented, .All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials .The Administrator/designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances .Social Service will follow up with resident to monitor resident's emotional well-being following the incident . 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], and the annual MDS dated [DATE], documented Resident #1 was severely cognitively impaired and was totally dependent on staff for all ADLs. The care plan documented, .Problem Onset: 01/09/2017 .Fracture: Pain/Complications, potential for, related to fracture of right ankle . The Resident Incident Report dated 1/9/17 documented, .Incident Type: Other .Type of Injury: Fracture .Equipment: N/A (not applicable) - Unknown .Property Involved: N/A - Unknown .Activity at time: Unknown .Narrative of Incident and description of injuries: LPN (Licensed Practical Nurse) noticed Right ankle swollen and red. Resident grimaced when right ankle touched .what CAUSED this injury/incident? Unknown . The nurse practitioner's progress notes dated 1/10/17 documented, .bedridden male due to [MEDICAL CONDITION] (TBI) .seen this morning for follow up of right foot swelling .had an xray of right foot and ankle .xray results revealed an acute right ankle fracture .[DIAGNOSES REDACTED]. The hospital emergency department provider notes dated 1/10/17 documented, .TBI patient .chronically debilitated and noncommunicative. Was found this morning at the nursing home to have swelling in the right ankle and reported unknown mechanism of injury. X-rays were done which showed ankle fracture .Impression .Distal fibular and tibial fractures are noted. Spiral fracture through the distal tibia with mild medial displacement of the distal fragment relative to the proximal fragment. The distal tibial fracture is comminuted. Fracture fragments are displaced slightly medially. There is also a fracture line extending through the medial malleolus proper as well as the spiral-like fracture through the distal tibia . Observations in Resident #1's room on 3/1/17 at 1:50 PM, revealed Resident #1 was in bed, and had a hard cast to the right lower leg. Interview with CNA #6, on 2/27/17 at 11:00 AM, in the second floor lobby, CNA #6 was asked whether she had found Resident #1's ankle swollen when she came to work on the morning of 1/9/17. CNA #6 confirmed she had. CNA #6 was asked whether the prior shift CNA had told her about the swelling during the change of shift report. CNA #6 stated, No one said anything about it to me. Telephone interview with CNA #7 (worked 11 PM to 7 AM shift on 1/8/17), on 2/28/17 at 3:16 PM, CNA #7 was asked what happened to Resident #1's ankle. CNA #7 stated, Well, I don't know what happened .I noticed that his leg was swollen. I thought he was uncomfortable. I propped his leg up on a pillow .I didn't think nothing of it. I just thought it was positioning .I've always heard if something's swollen, to elevate it . CNA #7 confirmed that she did not report the swollen ankle to anyone. Interview with Social Services Director #1 (SSD #1) on 3/2/17 at 8:45 AM in her office, SSD #1 was asked about the incident regarding Resident #1's ankle fracture. SSD #1 stated, I just knew that he had a fracture. SSD #1 was asked whether she had been involved in the investigation or follow-up. SSD #1 stated she had not. SSD #1 was asked when Social Services staff would be involved in an incident. SSD #1 stated, Social Services are involved if there is an abuse allegation . The facility's investigation was reviewed. There was no documentation that any other residents were interviewed or received a physical examination other than the alleged victim, Resident #1. There was no documentation that Social Services participated in the investigation, nor followed up with Resident #1 to assess his well-being during or after the incident.",2020-03-01
3875,REGIONAL ONE HEALTH SUBACUTE CARE,445521,877 JEFFERSON AVENUE ADAMS PAVILION 3RD FLOOR,MEMPHIS,TN,38103,2017-02-15,225,D,1,1,0TNJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, review of an incident report, review of a root cause analysis, and interview, the facility staff failed to report an allegation of physical abuse timely and failed to suspend the accused staff member during the investigation for 1 of 3 (Resident #13) sampled residents reviewed for abuse. The findings included: 1. The facility's Patient Abuse and Neglect policy documented, .strives to ensure that patients are protected and free from neglect and abuse .Additionally .must provide protection for the patient's emotional health and safety as well as physical safety. Any employee, house staff (resident), student, volunteer, contracted staff, medical and allied health staff, vendor, contractor or agent who suspects a violation of this policy .standard of conduct is responsible for reporting such concern as set forth below. Medical staff, house staff (resident), students, volunteers, contracted staff, allied health staff, vendors, contractors, agents, patients, family members or general public are encouraged to report any suspected abuse or neglect .Process .I. If a patient abuse and/or neglect is alleged, the following should occur: [NAME] Responsibilities of employees, house staff (residents, students, volunteers, contracted staff, credentialed staff, vendors, contractors, and agents: 1. Report the complaint/incident immediately to the Supervisor. 2. Complete and submit an Incident Report before the end of the shift .Process for house staff (resident), student. II. Supervisor will notify the staff member(s) of the allegation of abuse and/or neglect and place the staff member(s) on administrative leave, pending results of the investigation . 2. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented Resident #13 was cognitively intact, required extensive assistance with activities of daily living, had functional limitations in range of motion with impairment in both lower extremities, and required respiratory therapy and suctioning. The 30 day MDS dated [DATE] documented Resident #13 was cognitively intact, required limited assistance with activities of daily living, had functional limitations in range of motion with impairment in both lower extremities, and required respiratory therapy and suctioning. Written statement by the Director of Nursing (DON) (undated) documented, .Re (regarding): (Registered Nurse (RN) #1), 08/17/16: I (DON) called the unit this morning to check on the night staff and after speaking with the night shift nurse she told me she needed to inform me that the CNA (Certified Nursing Assistant) working with her tonight report that (RN #1) aggressively suctioned the patient in room [ROOM NUMBER] in an attempt to make him not call her to be suctioned again. I talked to the CNA in question and she confirmed this. She told me that (RN #1) and (Licensed Practical Nurse (LPN) #1 were having a conversation about this patient being worrisome and calling out a lot. She said (RN #1) said something like, I've got something for him. (RN #1) went to the room and when she came out she said I suctioned the[***]out of his ass, I bet you he won't call anymore. According to the CNA the patient did not call out anymore. The Root Cause Analysis and Action Plan Framework Template (undated) documented, .7. Were there any other factors that directly influenced this outcome? .Delay in notification, Staff conversating amongst each other but failed to notify DON and Administrator immediately .The reporting of the alleged abuse did not happen until 8/17/16 am by the charge nurse who apparently overheard the CNA from the night shift talking about it .In addition, this event was not reported in a timely manner. 3. Interview with the DON on 2/14/17 at 12:33 PM, in her office, the DON was asked what was the date of the alleged incident. The DON stated, .8/10/16 . The DON was asked when she was notified. The DON stated, .8/17/16 . The DON was asked what day was RN #1 suspended. The DON stated, .8/18/16 and terminated 8/22/16 . The DON was asked if RN #1 worked anytime during the investigation. The DON stated, .According to the time sheet, she (RN #1) worked part of the day shift on 8/18/16 . The DON was asked why RN #1 was allowed to work during the investigation of the alleged abuse. The DON stated, .I don't know .I know better now .to suspend the staff member as soon as the alleged complaint is made .",2020-02-01
5472,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2016-02-04,425,D,1,0,E7MR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, review of narcotic logs, medical record review and interview, the facility failed to ensure 1 of 10 (Nurse #1) nurses followed the facility's policy for the disposal of a controlled substance. The findings included: The facility's Medication Administration Controlled Substances policy documented, .When a dose of a controlled medication is removed from the container for administration . not given for any reason, it is not placed back in the container. It must be destroyed according to policy and the disposal documented on the accountability record on the line representing that dose . The facility's Disposal of Medications, Syringes and Needles Disposal of Medications policy documented, .If a controlled medication is unused, refused by the resident or not given for any reason, it cannot be returned to the container. It is destroyed by two licensed nurses employed by the nursing care center and the disposal is documented on the accountability record on the line representing that dose with the required signatures . Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Norco Tablet 10-325mg (milligrams) (Hydrocodone 10 mg - Acetaminophen 325 mg) Give 1 tablet by mouth every 4 hours for pain . The (MONTH) (YEAR) MAR and the (MONTH) (YEAR) narcotic log for the medication Norco 10-325 mg revealed Resident #1 received the scheduled doses at 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM on 12/31/15. The (MONTH) (YEAR) narcotic log documented Nurse #1 signed out an additional dose on 12/31/15 at 2:00 PM. Resident #1 did not have a scheduled dose due at 2:00 PM. Interview with Nurse #1, on 1/31/16 at 10:20 AM, in the conference room, Nurse #1 was asked if there was an extra dose signed out on 12/31/15 at 2:00 PM. Nurse #1 stated, Yes, she (Resident #1) got the medication at 8:00 AM and noon by me. I pulled a dose at 2:00 PM accidentally. (Named Nurse #3) was on the other cart. I meant to go back and complete as wasted but I didn't go back and do it. I put the pill in the sharps box. I should have documented the date, wasted, time and why wasted. I sign and the other nurse signs then put the pill in the sharps box. I messed up.",2019-02-01
4617,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2016-08-16,441,D,1,0,1VM611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, review of the Certified Nursing Assistant (CNA) orientation check off list, observations, and interview the facility failed to maintain practices to reduce the spread of infections and prevent cross-containment during ice pass on 1 hallway (100) of 4 hallways observed for infection control. The findings included: Review of the policy Ice Machines and Ice Storage Chests revised 4/12 revealed .2.b .Keep .storage container tops closed when not in use .2.e. Keep the ice scoop/bin in a covered container when not in use .2.h .Do not distribute ice directly from an open container . Review of the CNA Orientation check off list for Hospitality Aide #1 revealed on 5/18/16 the Hospitality Aide was checked off as completed by the orientor for nourishment procedure related to hydration. Observations on 8/15/16, beginning at 2:55 PM, revealed the Hospitality Aide passing ice on the 100 hall. Continued observation revealed the Hospitality Aide pulled the ice chest on a rolling cart into room [ROOM NUMBER], open the ice chest with ice scoop inside on top of the ice, filled the water pitcher with ice for 122A, dropped the ice scoop back into the ice chest, leaving the lid on the ice chest up, placed the water pitcher within the resident's reach, filled the water pitcher with ice for 122B, dropped the ice scoop back into the ice chest, closed the lid of the ice chest, placed the water pitcher within the resident's reach, exited the room. Further observation revealed the Hospitality Aide did not wash her hands between residents or prior to exiting the room. Interview with the Hospitality Aide on 8/15/16, at 3:00 PM, in hallway outside room [ROOM NUMBER] revealed when asked if she left the ice scoop in the ice the Hospitality Aide stated yes. When asked if she usually left the ice scoop in the ice chest the aide stated .not all the time . Continued interview revealed when the Hospitality Aide was asked if she pulled the ice cart into the resident's room the aide stated yes but not all the time, usually leave it outside the door . Further interview revealed the Hospitality Aide confirmed she did not wash her hands between residents or prior to leaving the room. When the Hospitality Aide was asked if she was aware of the policy for ice pass related to not taking the ice cart into resident's rooms, closing the lid on the ice chest between residents, not leaving the ice scoop in the ice chest on top of the ice, and washing hands between residents and prior to leaving the room, the Hospitality Aide stated I found out the other day, I forgot. Interview with Certified Nursing Assistant (CNA) #2, a mentor/trainer for the Hospitality Aide, on 8/16/16, at 11:00 AM, in the 300 Hall Activity Room, confirmed the policy for ice pass included the ice chest is not to go inside a resident's room, fill 1 cup/pitcher at a time, wash hands between each water pitcher, close lid of the ice chest after each water pitcher is filled with ice, wash hands prior to leaving the room, and never leave the ice scoop in the ice chest. Continued interview with CNA #2 confirmed the Hospitality Aide did not follow the facility's policy and did not follow proper infection control practices to prevent spread of infections or cross contamination.",2019-08-01
2229,NORTHSIDE HEALTH CARE NURSING AND REHABILITATION C,445373,202 EAST MTCS ROAD,MURFREESBORO,TN,37130,2017-09-27,309,D,1,0,O5S911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, review of the Lippencott Manual, review of the facility Licensed practical Nurse (LPN) job description, interviews, medical record review, review of physician orders, the facility failed to ensure medications were administered as ordered by the physician on 12/8/16 for 4 residents ( #7, #8, #9, and #10 ) of 20 sampled residents. The findings included: Review of the facility policy entitled, Medication Administration dated as revised 9/5/13, revealed, .Medications may only be administered by licensed medical or licensed nursing personnel acting within the scope of their license. Review of Lippincott Procedures safe Medication Administration Practices, General revised (MONTH) 2, (YEAR) revealed .Implementation .follow a written or typed order .confirm the patient's identity using at least two patient identifiers .medications that are administered more frequently than daily but less frequently than every 4 hours (e.g. twice daily, 3 times per day should be administered no more than 1 hour before or after the scheduled time .Document all medications administered in the patient's MAR (Medication Administration Record [REDACTED]. If a medication wasn't administered, document the reason why, any interventions taken, practitioner notification, and the patient's response to interventions. The facility provided a job description for LPNs, undated and it stated .Order from pharmacy, prepare and administer medications as ordered by physician. The facility submitted a facility incident report to the State Agency. The incident report stated that on 12/7/16, the facility administrative staff was informed by a Nursing Assistant (NA #4) that she suspected Licensed Practical Nurse (LPN#2) was not administering scheduled medications to the residents on the night shift. An internal investigation ensued. Per the report, the Director of Nursing (DON) and the Staffing Coordinator audited medications on 12/8/16. They identified and counted only the medications which were to be administered during the night shift that LPN#2 worked. LPN#2 worked the night shift on 12/8/16. On 12/9/16, the medications were again audited by counting the number of medications still left in the medication cart. Per the report, the routine medications were identified not to have been administered during the night shift. Review of the facility's audit: -The audit for Resident #7 showed the resident had 7 tablets of Trazadone 50 milligrams (mg) on 12/8/16. When the medications were recounted on 12/9/16, the resident had the same amount remaining in the medication cart. -The audit for Resident #8 showed the resident had 4 tablets of [MEDICATION NAME] 30 mg on 12/8/16. When the medications were recounted on 12/9/16, the resident had the same amount remaining in the medication cart. -The audit for Resident #9 showed the resident had 3 tablets of [MEDICATION NAME] mg on 12/8/16. When the medications were recounted on 12/9/16, the resident had the same amount remaining in the medication cart. -The audit for Resident #10 showed the resident had 12 tablets of [MEDICATION NAME] 15 mg (1/2 tablets) on 12/8/16. When the medications were recounted on 12/9/16, the resident had the same amount remaining in the medication cart. The audit also showed the resident had 19 tablets of [MEDICATION NAME] 37.5 mg on 12/8/16. When the medications were recounted on 12/9/16, the resident had the same amount remaining in the medication cart. The audit showed the resident had 4 tablets of [MEDICATION NAME] 50 mcg on 12/8/16. When the medications were recounted on 12/9/16, the resident had the same amount remaining in the medication cart. Review of the clinical records: 1. Per clinical record review, Resident #7 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A physician's order dated 12/9/15, revealed an order for [REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE], Section C for Cognition identified Resident #7 had a Brief Interview Mental Status (BIMS) score of 3/15 which indicated the resident was severely cognitively impaired. Resident #7 was a current resident at the time of this survey. No interview was conducted with Resident #7 due to cognitive impairment. A care plan, with a goal date of 9/22/16, identified Resident #7 was to receive an antidepressant drug due to her [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED]. 2. Per clinical record review, Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Physician orders dated 11/4/16, revealed the following orders, [MEDICATION NAME] 30 mg tablet to be administered by mouth daily for GERD. The scheduled time for administration was 6:00 AM. The [MEDICATION NAME] 50 mcg tablet was to be administered by mouth 1 time a day. The scheduled time for administration was 6:00 AM. A significant change MDS assessment dated [DATE], Section C for Cognition identified Resident #8 had a BIMS score of 4/15 which indicated the resident was severely cognitively impaired. Resident #8 was a current resident at the time of this survey. An interview was not conducted with Resident #8 due to cognitive impairment. A care plan, undated as revised and/or initiated in the problem section, identified Resident #8 had a history of [REDACTED].#8 was at risk for complications related to her [DIAGNOSES REDACTED]. The MAR for 12/16 was reviewed. The MAR indicated [REDACTED]. 3. Per clinical record review, Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's order dated 8/6/15, revealed an order for [REDACTED]. The MAR for 12/16 was reviewed. The MAR indicated [REDACTED]. A significant change MDS assessment dated [DATE], Section C for Cognition was blank. There was no score identified. The resident had passed away during this assessment period. A care plan, with a goal date of 5/10/17, identified Resident #9 was to have medications administered as ordered. 4. Per clinical record review, Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's order dated 7/25/15, revealed an order for [REDACTED]. The scheduled time for the administration of this medication was 8:00 p.m. A physician's order dated 5/13/16 for [MEDICATION NAME] 50 mcg to be administered 1 time per day. The scheduled time for administration was 6:00 a.m. The MAR for 12/16 was reviewed. The MAR indicated [REDACTED]. A quarterly MDS assessment dated [DATE], Section C for Cognition documented Resident #10's BIMS score was 00 since the resident could not complete this assessment, which indicated the resident was severely cognitively impaired. Resident #10 was a current resident at the time of this survey. An interview was not conducted with Resident #8 due to cognitive impairment. A care plan, undated as revised and/or initiated in the problem section, identified Resident #10 received antidepressants and she was to be administered these medications. This same care plan identified Resident #10 had a history of [REDACTED]. A telephonic interview was conducted with the previous Administrator on 9/26/17 at 8:30 AM. The Administrator stated initially the administrative staff believed LPN#2 diverted narcotics, but this was not the case. The Administrator said that there were pills not administered to residents on 12/8/16 and he had placed LPN#2 on administrative leave. The Administrator said LPN#2 was to meet with he and the DON on 12/12/16 but LPN#2 sent him a text and resigned without notice. The Administrator said the DON wrote the medications not administered by LPN#2, as medication errors. The DON was interviewed, in the conference room, on 9/26/17 at 9:22 AM. For routine medications, the DON said there were the same number of pills, not administered on 12/9/17, as previously identified on 12/8/16. The DON confirmed nursing staff work 12-hour shifts, 7:00 a.m. to 7:00 p.m. and 7:00 p.m. to 7:00 a.m. During this interview, the DON shared the results of her audits which identified LPN#2 failed to administer routine medications for 4 residents on the night shift of 12/8/16. A telephonic interview was conducted with NA #4 on 9/26/17 at 2:28 PM. NA #4 said that she noticed LPN#2 was not going into the rooms of residents to administer medications and shared her observations with the administrative staff.",2020-09-01
840,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-06-12,604,J,1,0,HPNL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, review of the facility investigation, medical record review, facility video footage review and interview the facility failed to ensure 1 resident (Resident #2) of 3 residents was free from the use of restraints related to Resident #2 being restrained with a gait belt to his wheelchair. The findings include: Review of the facility policy, Use of Restraints, undated, revealed .Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted . Review of facility policy, Gait Belts, undated, revealed .Gait belts must be used by all Therapy Rehabilitation staff during balance activities, transfers, and gait training of patients to promote safety during therapeutic activities, unless contraindicated . Review of the facility investigation revealed an investigation was started on 5/2/19 related to allegation of abuse by the alleged perpertrator (AP) to Resident #2. Continued review revealed initial written statements were obtained from the Respiratory Therapist (RT #1) Certified Nurse Aide (CNA) #3 and CNA #4. Further review revealed RT #1's initial written statement revealed I walked over to 2A's nsg (nursing) station at approximately 04:45 to discuss this [MEDICAL CONDITION] Care. As I arrived in the common area, I saw the Resident (#2) sitting in his wheelchair. He was secured (restrained) to the chair with a pink and grey gait belt. The belt was wrapped around the Resident (#2's) chest and the wheelchair. I talked briefly with him. He said the word [***] and motioned his hand as he pointed to the nurses station. When I looked at the nursing station the AP was the only person sitting there. The gait belt was obviously tightly secured because he could not lift his back off of the back of the wheelchair. Continued review of CNA #4's statement revealed I would like to see the video footage because I don't remember seeing any resident being abused while I was working 2A on 5/2/19. Further review revealed CNA #3's statement revealed I don't know really when I came out (of) the room (Resident #2) was already in the chair strapped in. Continued review revealed the initial statement for the AP dated 5/6/19 revealed .there was no intent of abuse .it was placed for his safety . Further review revealed the AP received abuse training upon employment with the facility on 8/22/18. Continued review revealed the AP's employment was terminated on 5/6/19. Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 01, indicating severe cognitive impairment. Further review revealed no restraints were used for Resident #2. Medical record review of Resident #2's Order Summary Report dated (MONTH) 2019 revealed no order for a restraint. Review of the facility's video footage on 5/2/19 with the Administrator on 6/11/19 at 11:52 AM in the conference room confirmed the AP restrained Resident #2 to his wheelchair at approximately 4:39 AM by putting a gait belt around his chest and fastening the gait belt to the back of the wheelchair, restraining Resident #2 in his wheelchair. Interview with the Administrator revealed the AP, CNA #3 and CNA #4 were identified by the Administrator on the video footage. Further review of the facility's video footage revealed CNA #4 was standing at the nurses station facing the AP and Resident #2 and it appeared that CNA #3, wearing a pink shirt, was in the sideline of the camera then CNA #3 walked by the AP and Resident #2 after the gait belt was applied. Further review revealed video footage did not show removal of the gait belt. Interview with the Administrator revealed the video footage containing conversation between RT #1 and Resident #2 was unavailable due to the system rolls over video footage after 14 days, and some video footage is self-erased. Interview with the Director of Nursing (DON) on 6/11/19 at 8:00 AM in the conference room revealed she was informed of the alleged abuse on 5/2/19 around 9:00 AM by Licensed Practical Nurse (LPN) #5. Continue interview revealed by the time the DON informed the Administrator, RT #1 had already reported it to the Administrator. Continued interview when asked when staff were to report abuse the DON confirmed all staff were expected to report suspected or witnessed abuse immediately. Interview with the Administrator on 6/11/19 at 8:15 AM in the conference room revealed the Administrator was informed on 5/2/19 around 10:00 AM by RT #1 of Resident #2 being restrained in his wheelchair with a gait belt around his chest. Continued interview revealed the Administrator reported the allegation to the State Agency as soon as he was aware of the allegation. Further interview when asked when staff were to report abuse the Administrator stated, Immediately, I expect them to notify me as soon as it happens. Interview on 6/11/19 at 1:45 PM with LPN #5 at nurses station 2A revealed she reported for work on 5/2/19 at 7:30 AM. Continued interview revealed, she stated, the RT (#1) reported to me that (Resident #2) was sitting in his wheelchair at the nurses station with a gait belt around his chest, secured to the wheelchair; I went immediately and assessed Resident #2 and he was in the bed with no restraint on and no injuries noted. Continued interview with LPN #5 revealed I reported to the DON around 8:30 AM RT #1 witnessed (Resident #2) being in a wheelchair with a gait belt around his chest, secured to the wheelchair. Interview with the RT #1 on 6/11/19 at 1:15 PM in the conference room revealed she reported for work on 5/2/19 around 5:30 AM to educate the night shift nurses on [MEDICAL CONDITION] care. Continued interview revealed when she went to station 2A around 5:45 AM and she observed Resident #2 sitting in a wheelchair with his back facing the nurses station. Resident #2 hollered (yelled) come here and motioned for RT #1 to come over to him. RT #1 went over to Resident #2 and he pointed at a gait belt that was around his chest, and said look what that [***] did to me, pointing toward the nurses station where the AP was sitting. Further interview revealed, when asked how was the gait belt placed on Resident #2 she confirmed the gait belt was around the upper part of Resident #2's chest snugly, and attached to the wheelchair. When asked to explain snuggly, RT #1 replied, he could not raise his back off the back of the wheelchair. Continued interview revealed RT #1 went inside the nurses station and spoke to the AP related to the training she was doing and the AP spoke hatefully saying, I don't have time to do the training. RT #1 left nurses station 2A and went to the 400 hall. Further interview revealed RT #1 reported her observation of Resident #2 with a gait belt around his chest restraining Resident #2 to his wheelchair to LPN #5 (Unit Manager for 200 Hall) when she (LPN #5) arrived at the facility at 7:30 AM. Continued interview revealed RT #1 reported her observation of Resident #2 in his wheelchair with a gait belt around his chest to the Administrator during the morning stand up meeting around 9:00 to 9:30 AM on 5/2/19. She stated, I guess I should have called someone and reported it sooner, I don't know, I just told ( LPN #5) as soon as she got here. Telephone interview with CNA #3 on 6/12/19 at 7:25 AM revealed she has been employed with the facility since (MONTH) (YEAR) and usually worked station 2A, the secured unit. Continued interview revealed CNA #3 was trained on abuse upon hire and quarterly. Further interview revealed CNA #3 named the types of abuse and had never suspected or witnessed abuse and would report suspected or witnessed abuse immediately to the supervisor and the DON. Continued interview when asked if she ever witnessed abuse, stated No I've never witnessed abuse, when they (Administrator and DON) called me and asked me about the (AP) securing (restraining) (Resident #2), I told them that I didn't know what they were talking about and I never seen anything, I even wrote a statement saying I never seen nothing. Further interview revealed CNA #3 was again questioned about observing abusive behavior toward residents, CNA #3 stated, I have never seen nobody being abused when I've worked. Telephone interview with CNA #4 on 6/12/19 at 8:17 AM revealed she has been employed with the facility for one year and usually worked on station 2A, the secured unit. Continued interview revealed CNA #4 received training on abuse upon hire during orientation and every month. CNA #4 named the types of abuse and would report suspected or witnessed abuse immediately to the supervisor. Further interview revealed CNA #4 had never observed any resident being abused while working at the facility. CNA #4 stated she had worked with the AP and had never observed her abuse any resident. Continued interview when asked if she recalled Resident #2 being restrained by the AP she stated I never saw him (Resident #2) with a gait belt on him, I only saw him sitting in the wheelchair. Further interview revealed CNA #4 was again questioned about observing abusive behavior toward residents with same answer given as stated above. Validation of the IJ removal plan was completed on 6/12/19 through review of the facility documentation, observations and interviews. Surveyor verified the IJ removal plan by: 1. Review of the personnel file for the AP revealed abuse training was appropriately provided at orientation and as needed. Continued review revealed the facility obtained background checks and reference checks with no negative findings. Immediately following the incident of 5/2/19 the AP was suspended pending investigation. Further review revealed the AP was terminated on 5/2/19 following review of video footage confirming application of a gait belt as a restraint by the AP to Resident #2. The disciplinary action was completed on 5/6/19. 2. Review of resident audits for all the residents on the secured unit. 3. Review of the restraint policy and abuse policy was done and the policies were appropriate. In-service education was completed for all staff on 5/3/19 to 5/6/19 as evidenced by sign-in rosters and staff interviews. Verification through interviews of internal audits initiated 6/12/19 to ongoing every 2 weeks then weekly for 3 months to assess for restraint use. 4. Presentation of all audits to the Quality Assurance Committee (QAC) monthly for 3 months; with the first presentation at the 6/12/19 meeting.",2020-09-01
3105,MCKENDREE VILLAGE,445491,4347 LEBANON ROAD,HERMITAGE,TN,37076,2018-01-19,760,D,1,0,7CQJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to ensure residents were free of significant medication errors for 1 resident (#1) of 3 residents observed. The findings include: Medical record review revealed 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 the Controlled Drug Receipt/Record/Disposition Form dated 11/7/17 revealed [MEDICATION NAME] (pain medication) tablet 5mg (milligram) ER, take 3 tablets by mouth (15mg) every 12 hours. Medical record review of the Controlled Drug Receipt/Record/Disposition Form revealed only one-5mg [MEDICATION NAME] tablet was given on 11/7/17 at 9:00 PM. Medical record review of the Controlled Drug Receipt/Record/Disposition Form revealed only one-5mg [MEDICATION NAME] tablet was given on 11/8/17 at 10:30 AM. Interview with the Director of Nursing (DON) on 1/19/18 at 7:56 AM in the conference room confirmed after reviewing the physician's orders [REDACTED].",2020-09-01
5029,"COLLIERVILLE NURSING AND REHABILITATION, LLC",445495,490 WEST POPLAR AVENUE,COLLIERVILLE,TN,38017,2016-06-29,312,D,1,0,MZ6611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation and interview, the facility failed to ensure activities of daily living (ADLs) were appropriately provided for 1 of 4 ( Resident #2) sampled residents. The findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE], and was last re-admitted to the facility on [DATE], after a hospital stay. He had [DIAGNOSES REDACTED]. Resident was in a vegetative state. Record review on 6/28/16, revealed a care plan dated 11/25/15, identified Resident #2 needed total assistance with all activities of daily living (ADLs). The goals indicated Resident #2 would not sustain injuries related to (r/t) ADLs. The approaches indicated Resident #2 needed total assistance with bathing, transfer, bed mobility, incontinence care, dressing, grooming, and oral care hygiene. The most current Minimum Data Set ((MDS) dated [DATE], indicated Resident #2 was totally dependent on two staff members for bed mobility and was totally dependent on one staff for transfer. Resident #2 was totally dependent on staff for personal hygiene, bathing, dressing, eating, and toileting and was non ambulatory. The MDS indicated Resident #2 was incontinent of bowel and had an indwelling catheter in place. The MDS indicated Resident #2 had stage III or IV pressure ulcers (PU) and was at risk for developing more pressure ulcers. The MDS indicated the Resident was on oxygen therapy, received suctioning treatment and received [MEDICAL CONDITION] (trach) care. Observations on 6/29/16 from 11:50 AM to 11:57 AM, the Wound Care Nurse was observed to provide wound care for Resident #2. The Resident was observed in bed with a specialized air mattress in place. A white draw sheet, soiled with brown matter was placed on top the air mattress, so Resident #2 was lying on top of the soiled draw sheet, during that observation. Resident #2's wife and CNA #1 were at the bedside, during wound care observations. CNA #1 stated she had just finished providing incontinence care as Resident #2 had a bowel movement. Using the soiled draw sheet, CNA #1 turned Resident #2 towards the left side of the bed. CNA #1 then held onto Resident #2 for safety so his right wound buttock was visible to the Wound Care Nurse for wound care provision. During that observation, Resident #2 was odorous of bowel movement, although CNA #1 indicated Resident #2 was cleaned prior to wound care. The Wound Care Nurse cleansed the right buttock/sacrum wound and provided treatment as prescribed by the physician. After wound care was provided, the soiled draw sheet was used to reposition Resident #2 in bed. Again, Resident #2 was left lying on the soiled draw sheet after wound care was done. Although Resident #2 was left odorous of bowel movement no further cleaning was offered or provided, before or after wound care was provided. After wound care observations, the Wound Care Nurse and CNA #1 left Resident #2's room. Resident #2's wife stayed at the bedside. On 6/28/16 at 10:45 AM, a family member was interviewed. In that interview, the family member voiced he/she was told, the day shift CNAs had no time to provide ADL cares for Resident #2, between 7:00 AM and 10:00 AM. Therefore, Resident #2 remained in the position that the night shift left him until the day shift had time for repositioning and provision of cares. On 6/29/16 at 12:00 PM, at the nurse's station on the 200 unit, the Wound Care Nurse was interviewed. The Wound Care Nurse was asked if staff was finished with cleaning Resident #2. The Wound care Nurse stated CNAs #1 was finished with cleaning Resident #2 and the Wound Care Nurse was done with wound care. On 6/29/16 at 12:20 PM, the Director of Nursing (DON) was notified of the findings above. At that time, the DON and surveyor observed Resident #2. Resident #2 was observed in bed. When Resident #2 was uncovered, the DON stated, the draw sheet was stained with fecal matter. The DON called CNA #1 for assistance with turning Resident #2. When CNA #1 turned Resident#2 toward the left side of the bed, the Resident was odorous of feces, yet CNA #1 had just provided incontinence care and the Wound Care Nurse provided wound care after incontinence care was done. The DON asked CNA #1 to give the resident a bed bath right away. On 6/29/16 at 12:30 PM, the DON stated the facility had no ADLs policy. On 6/29/16 at 12:45 PM, in a subsequent interview, the DON confirmed, Resident #2 was odorous of feces. The DON stated when the Resident #2 was cleaned with wet wipe and he remained odorous of feces, he should have been given a bath at that time. The DON further stated Resident #2 should not have been left lying on a soiled draw sheet, after he was provided incontinence care. The facility failed to provide appropriate incontinence care for Resident #2.",2019-06-01
3107,MCKENDREE VILLAGE,445491,4347 LEBANON ROAD,HERMITAGE,TN,37076,2018-01-19,842,D,1,0,7CQJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the 'Nurse Aide Documentation', review of the 'Catheter Care' policy and procedure, and staff interview, the facility failed to ensure outputs for residents with indwelling catheters were completely documented and systemically organized. This involved 3 of 5 Residents (Residents #3, #6, and #11) sampled for the review of care of indwelling urinary catheters. The findings include: On 1/18/18 at 2:00 PM the Administrator provided a copy of the facility's 'Catheter Care' policy and procedure. Review of the policy revealed at letter I. l) to Empty the drainage bag every 8 hours or more often if needed and at I. g) to Maintain an accurate record of the residents output. 1. Review of Resident #6's Face Sheet in her medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED]. A Nurse's Note dated 11/2/17 and timed 10:00 PM indicated the catheter was out and the resident refused to have it reinserted. Review of a Telephone Order dated 11/3/17 revealed the catheter was discontinued due to resident's refusal. On 1/17/18 at 2:50 PM Registered Nurse #1 stated she was the Patient Care Team Manager for the unit, where Resident #6 resided. She stated the resident was admitted with the indwelling catheter and continued to have it until 11/2/17 when the catheter was found to be laying in the bed and no longer inserted in the resident. She stated the resident's outputs are recorded by the Nurse Aides each shift on the 'Nurse Aide Documentation Sheets' in the first column labeled 'Incont/Cont # times.' Review of the 'Nurse Aide Documentation Sheets' for Resident #6 revealed the following: a) No outputs were recorded for 20 of 30 days in (September 2, 3, 6, 10, 11, 13-16, 18-21, 23-26, 28, and 30) (MONTH) (YEAR). b) Outputs were not consistently recorded for all shift on the days there were some recorded for (MONTH) (YEAR). The only two days the intakes were consistently recorded were on 9/1/17 and 9/17/17. c) No outputs were recorded for 10 of the 31 days in (October 1, 2, 10, 11, 13, 14, 22, 27, 30, and 31) (MONTH) (YEAR). d) Outputs for the 3:00 PM to 11:00 PM shift were only recorded once (10/25/17) for the entire month of (MONTH) and intakes on the 11:00 PM to 7:00 AM shift were only recorded six times (October 11, 15, 19, 23, 24, 25, and 29) in (MONTH) (YEAR). e) On 11/1/17 the output for the 3:00 PM to 11:00 PM shift was not recorded. On 1/18/18 at 9:12 AM RN #1 was interviewed regarding the output documentation while sitting behind the nursing station for Resident #6. During the interview, she verified the nurse aides had not been completing the outputs for the indwelling catheters and verified there were numerous blanks in the forms. She verified the facility had not maintained a complete and accurate record of Resident #6's urinary output. 2. Review of Resident #11's quarterly Minimum Data Set (MDS) Assessment signed on 11/22/17 and review of his 7/15/17 discharge return anticipated MDS assessment revealed the resident had an Indwelling Catheter marked as present under section H . Under section I1650 both the 7/15/17 and 11/22/17 assessments stated the resident has a [DIAGNOSES REDACTED]. Review of Resident #11's medical record revealed he had a Physician's Progress Note dated 12/1/17 indicating his [DIAGNOSES REDACTED]. The progress note indicated the resident was complaining of dysuria, suprapubic pain, and urgency today. The note went on to indicate the resident had a chronic Foley catheter but feels a burning sensation and an urgency to void. The physician wrote Patients urinalysis is very abnormal. A Physician's Note dated 12/5/17 indicated, Patient's urinalysis reveals 2+ leukocytes, positive [MEDICATION NAME], and many bacteria, WBC greater than 100. Urine culture is pending. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The Foley Catheter was added to the Care Plan however the date of when it was hand written was missing. In the approaches section of the Care Plan directed staff to observe for outputs. On 1/18/18 at 2:00 PM Resident #11's output records from 11/1/17 to 1/18/18 were reviewed with RN #1 (while sitting at the nursing station). The 'Nurse Aide Documentation Sheets' documented the resident had a Foley catheter in place from 11/1/17 through 1/18/18 and RN #1 verified Resident #11 had the catheter in place from 11/1/17 through 1/18/18. In addition, the resident had output records attached to his Medication Administration Record [REDACTED]. RN #1 stated she started this record for this resident because the Nurse Aides were not consistently recording the outputs. Review of both the 'Nurse Aide Documentation Sheets' and the outputs recorded on the 'Intake/Output Records' completed by the nurses revealed the following documentation for Resident #11: a) On 11/1/17 through 11/5/17 no outputs were recorded for the 7:00 AM through 3:00 PM shift and the 11:00 PM to 7:00 AM shift. b) No outputs were recorded for the 7:00 AM to 3:00 PM shift on 11/9/17, 11/13/17, 11/17/17, 11/18/17, 11/22/17, 11/24/17, 11/27/17, 11/28/17, 12/6/17, 12/8/17, 12/11/17, 12/12/17, 12/24/17, and 12/26/17. c) On 12/1/17 and 12/2/17 no outputs were recorded for any of the three shifts. There were no outputs recorded for the day. d) No outputs were recorded for the 7:00 AM to 3:00 PM shift nor for the 3:00 PM to 11:00 PM shift on 12/3/17, 12/7/17, 12/15/17, 12/16/17, 12/17/17, 12/20/17, 12/21/17, and 12/31/17. e) No outputs were recorded for the 3:00 PM -11:00 PM shift on 12/14/17, 12/22/17, 12/25/17, and 12/29/17. On 1/18/18 at 2:00 PM RN #1 was interviewed while sitting behind the nursing station. The outputs were reviewed with RN #1 and she verified the resident had a Foley catheter from 11/1/17 through 1/18/18 and verified the outputs were not consistently recorded in accordance with the facility policy and the Residents plan of care. 3. Review of Resident #3's admission orders [REDACTED]. Review of the medical record revealed the Indwelling Foley catheter continued as a physician's orders [REDACTED]. Review of the output documentation for 9/21/17 through 11/2/17 revealed the outputs were not recorded on each shift in accordance with the facility policy. Review of the 'Nurse Aide Documentation Sheets' for 9/21/17 through 11/2/17 revealed the following for Resident #3: a) No outputs were recorded for the 3:00 PM to 11:00 PM and the 11:00 PM to 7:00 AM shifts on 9/24/17. b) No outputs were recorded for the 11:00 PM to 7:00 AM shift on 9/26/17 through 9/30/17, 10/01/17, 10/4/17, 10/9/17, 10/14/17, 10/18/17, 10/23/17, 10/28/17, and 10/29/17. The spaces on the sheet for this time of day were left blank. On 1/17/18 at 1:50 PM RN #1 was interviewed in the conference room. She verified the resident had a Foley Catheter in place from 9/21/17 through 11/2/17 and verified the staff did not consistently document the outputs on each of the shifts per the facility policy. This Deficiency is related to information discovered during the investigation of Complaint TN 886 and TN 144.",2020-09-01
4925,CLAIBORNE AND HUGHES HLTH CNTR,445157,200 STRAHL STREET,FRANKLIN,TN,37064,2016-06-14,203,D,1,0,13100000000000.0,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews, and interviews, the facility failed to ensure a 30 Day notice of discharge was provided for 1 of 10 residents (Resident #7). Resident #7 was not provided with notice of discharge. The findings included: Review of the facility's Discharge Procedure policy (not dated) revealed When possible, the resident and family members should be notified in advance of discharge .Discharge occurs upon orders of the attending physician .Documentation of Discharge may include: a) physician's orders [REDACTED]. Review of the facility's Transfer and Discharge policy (not dated) revealed Transfer means the moving of a resident from the facility to another legally responsible institutional setting. Discharge means the moving of a resident to a non-institutional setting when the releasing facility ceases to be responsible for the resident's care. According to federal regulations, the facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless: 1) The transfer or discharge is necessary for the resident's welfare and resident's needs cannot be met in the facility; 2) The transfer or discharge is appropriate because the residents health has improved sufficiently so the resident no longer needs the service provided by the facility; 3) The safety of individuals in the facility is endangered; 4) The health of individuals in the facility is endangered; and 5) The resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility .The Social Services Designee should handle all non-emergency transfers or discharges. Procedures should include: a) Notify the resident in writing, and if known, a family member or legal representative, 30 days in advance, of the transfer or discharge, and the reasons for the transfer or discharge .g) The physician should document medical reasons for transfer or discharge in the medical record, when the reason for transfer or discharge is for any reason other than nonpayment of the stay. A copy of the physician's orders [REDACTED]. Medical record review for Resident #7 revealed the resident was admitted into the facility on ,[DATE]//16, and had [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], the resident was severely cognitively impaired, and exhibited behaviors of wandering during the assessment period. Further review of the MDS revealed Resident #7 required the extensive assistance of one person for bed mobility, dressing, toileting, and personal hygiene. The resident required the limited assistance of one person for transfers, walking in the room, and eating. Resident #7 required supervision only walking in the corridor, and locomotion on the unit. The resident did not utilize assistive devices for mobility, and had no impairment of upper and/or lower extremities. During the assessment period, Resident #7 was administered antipsychotic, and antidepressant medications. Record review of Resident #7's Nurse's Notes revealed the following: 4/18/16 - Resident alert with confusion .very aggressive this morning, pulled another resident's hair, very intrusive behaviors, yelling out/tearful. Attempts to redirect unsuccessful. 4/22/16 - Resident arrived back from hospital per private car with daughter. New [DIAGNOSES REDACTED]. [MEDICATION NAME] also increased .NO behaviors during hospital stay 4/22/16 - Patient ambulating/wandering in hallway at this time. Alert with confusion, tolerated meds well, requires total assist with ADLs. No signs/symptoms of pain. Will monitor. 4/24/16 at 12:00 a.m. - Resting in bed. No behavior issues noted this shift. Has been resting well. Took hs meds crushed without difficulty. Incontinent care provided. 4/24/16 at 10:00 a.m. - Wandering in hallway, calling out for Bubba. Difficult to redirect. Becomes tearful and pushes away. Call placed to son and daughter for possible comfort in their voice over the phone. Attention span very limited, pushed phone away and ambulated down the hall. Daughter will visit shortly. 4/25/16 - Resident alert with confusion. Ambulates at liberty. Wanders continues and rest, but only sits for short period. Very intrusive into other rooms. Easily upset with redirecting. Refused breakfast, took one bite and spit one floor. Screams randomly. Aggressive at times. Redirected frequently. Will monitor. 4/26/16 - Resident transferred to hospital due to behaviors. Family transported. Review of Hospital Consults revealed Resident #7 was admitted into the hospital due to an increase in behaviors (wandering, aggression, and agitation) on 4/18/16 and discharged back to the nursing facility on 4/22/16. Record review of Resident #7's physician's orders [REDACTED]. Further review of the orders revealed there was not a signed doctor's order for Resident #7 to be discharged . Review of the Interdisciplinary Discharge Summary dated 4/26/16 noted the resident was transferred to (Hospital) due to increased intrusive behaviors, resisting care, agitation. Will not return. The Summary was not signed by a physician. Review of Resident #7's Social Progress Notes revealed an entry on 2/1/16 - Admit Note: Resident admitted to facility from hospital. Resident is alert with confusion, hearing and vision adequate .Resident will be a long-term care resident .Social Services will continue to provide support and assistance as needed. There were no other Social Progress Notes in Resident #7's clinical record. Interview with the facility's Social Worker on 6/13/16 at 12:07 p.m. confirmed that Resident #7 and her family were not provided with a 30-day notification of discharge. According to the Social Worker, Resident #7 had become very difficult to redirect, and very aggressive. The resident was discharged due to wandering in and out of other residents' rooms, and for exhibiting physical aggression. The Social Worker said Resident #7 and her family were notified of the discharge on 4/26/16, the same day of discharge.",2019-06-01
2142,"LAKEBRIDGE, A WATERS COMMUNITY, LLC",445358,115 WOODLAWN DRIVE,JOHNSON CITY,TN,37604,2017-10-25,309,D,1,1,OMO511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on reveiw of the facility policy, medical record review, and interview, the facility failed to follow a physician's medication order for 1 resident (#200) of 37 residents reviewed. The findings included: Review of the facility policy, Medication Record: Transcription of Doctors Orders and Documentation, date revised 4/16, revealed .Transcribe Physician's written orders to MAR (medication administration record) .Dosage to be administered . Medical record review revealed Resident #200 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #200's admission orders [REDACTED].[MEDICATION NAME] (cholesterol medication) 40 mg TAB (tablet) take one-half tablet (total dose of 20 mg) by mouth at bedtime . Review of the Medication Administration Record [REDACTED].[MEDICATION NAME] Tablet 40 MG Give 1.5 tablet (total of 60 mg) by mouth at bedtime .[MEDICATION NAME] Tablet 200 MG Give 200 mg by mouth two times a day . Interview with the Director of Nursing (DON) on 10/25/17 at 3:46 PM, in the conference room, confirmed the Resident #200 had not received the medication as prescribed by the Physician's Orders. Continued interview confirmed the resident received the wrong dosage of 2 medications, and the facility's policy had not been followed.",2020-09-01
3968,TOWNE SQUARE CARE OF PURYEAR,445470,220 COLLEGE STREET,PURYEAR,TN,38251,2017-01-18,493,F,1,0,MXG911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review Electronic (E) Mail, invoices and interview, it was determined the facility failed to have a governing body that is legally responsible for establishing and implementing policies regarding the management and operations of the facility. The findings included: 1. Review of an [NAME] Mail related to the facility's electronic medical records and residents' accounts computer system dated 12/14/16 documented, .Recap of conversation (with Named contracted Electronic Documentation Program Representative) .asked (Named contracted Representative) about the contract, the original contract .didn't know where it was because it was so old and they would have to dig it up. That is definitely one of the first issues that need to be addressed after we get past this crisis. The second time that we spoke about was related to how payment is broken out. We spoke about per user license (the individual facility) vs.(versus) organization (multiple owned facilities) vs per module. (Named Representative) stated very clearly that the agreement we are under is per organization. This means, that when you have access inside (Named electronic documentation program) you have access to the entire organization past present. This is one of the reasons why they have cut complete access. They found out .that the (Named Facility in another state) had been sold. And had spoken about giving the owner access to copy data out of (Named Program) and into the old system. He stated this was not normally a problem, and how they would do business, at a reduced rate. However, with the history of non-payment and especially non-payment of the last two months after signing the second agreement, their lack of trust was there for continuing to provide access. We spoke in detail about what it would take to get access to read only data in case of emergency, how to get a backup on the data for the entire organization, and how to access just the financial modules if that's what we needed for billing. The conclusions were they do not have a way to just access the financial module, they can provide a copy of the (Named Server) backup that will contain all data except the application, and there is no Read Only mode option in the application currently. (Named Representative) final comments were related to non-payment history and that tgey (they) would be more than welcome to provide a backup, but he reiterated that until some payment was made that access would not be granted. The conversation covered the last payment arrangement of $25k (thousand) monthly ($5k for monthly payment and $20k for catvhing (catching) up the arrears) is now 3 months past due. My recommendation is to provide some form of pay for the past 3 months of payment $15k, and if posdoble(possible) one more month. Then asked that we renegotiate the arrears payment monthly starting in (MONTH) based on the corporate situation. I reccomnend (recommend) cuurrent (current) times 2 ($10k a month) Review of an [NAME] Mail related to the facility's electronic medical records and residents' accounts computer system dated 1/4/16 documented, .Recap of today's conversation with (Named Electronic Documentation Company Representative). I contacted (Named Representative) to discuss gaining access to (Named Electronic Program) for 30 days if (Named Health System) provides immediate funds of $15,000 as per our conversation over a month ago. The response was that amount was no longer enough. (Named Representative) informed me that they have been patient and understanding for a long time, they understand the trials and tribulations (Named Company) has gone through, however because of the following reasons, they are not willing to open access to (Named Program) for a 'small amount': Lack of payment over multiple periods Lack of honoring contracts and communication on payment issues And, the recent activity of another user(s) pulling information from the (Named Company Electronic Program access accounts and facilities and putting the data into another (Named Electronic Program) account for another company (he referenced (Named Facility in another state). They are willing to provide a backup of the current (Named Program) database that will have all of (Named Company's) information i a (Named Server) database backup format. After a second call, it was determined that (Named Program) would be willing to turn the product on for 60-75% of the total owed. Which, with the total amount being above $120km, that means over $65-75k . 2. Review of an invoice from a business the facility purchased supplies dated 11/1/16 documented, .(Named Company) FACILITIES MAINTENANCE (Supply) .AMT: $2,070.23 .Consider this communication our final demand. Payment in full is due immediately. Our client has been more than patient. Failure to comply may result in more stringent efforts, including legal action being taken in order to protect the creditor's interest . 3. Review of an invoice from a facility contracted laboratory service dated 11/1/16 documented, .(Named Laboratory Company) Past Due Account $988.90 (Feb (February - Sept (September)) Total due $1171.67 .Last payment received 2/26/16 Must have payment in full no later than 11/15/16, or this will be turned over to our legal department . 4. Review of the facility's telephone vendor invoice dated 11/15/16 documented, .DISCONNECT NOTICE .Your disconnect date is 11/29/16 .Past Due ($) 628.47 .Current Billing ($) 644.84 .Total Due ($) 1,273.31 . Review of an invoice (Telephone) dated 12/13/16 documented, .DISCONNECT NOTICE .Your disconnect date is 12/27/16 .Past Due ($) 644.84 .Current Billing ($) 616.81 .Total Due ($) 1,261.65 . 5. Review of the facility's Cable/Internet vendor invoice dated 11/25/16 documented, .Our records indicate that your account is overdue and the current amount due is ($) 939.67. This does not include late charges which may appear on your next statement . 6. Review of the facility's trash vendor invoice dated 12/20/16 documented, .Notice of Service Suspension (Trash) .We recently sent you a friendly reminder about your account with (Named Company) and had hoped to receive payment by now. Our records indicate that there remains a past due balance on your account .10/19/16 $25.00 .10/20/16 $835.88 .11/20/16 $824.51 .Total Amount Due $1,685.39 .We regret to inform you that we have suspended our service at your location and assessed a $35.00 service interruption fee. Your prompt payment of the balance due will ensure that service is resumed as quickly as possible .Unpaid Balance $1710.39 .Current Invoice Charges $970.00 .Pay This Amount $2680.39 . 7. Review of an invoice from a vendor the facility purchases supplies dated 12/21/16 documented, .Referred Balance $223.92 .Current Balance $223.92 .(Named Company is assisting (Named Company for body alarms) with an audit of their receivables .If everything is in order please call .to arrange for payment of the outstanding balance . 8. Interview with the Administrator on 1/12/17 beginning at 9:05 AM, in the Conference Room, the Administrator was asked if there was a functioning governing body. The Administrator stated, .Just (Named owner) . The Administrator was then asked if there was anyone to maintain operations other than the owner. The Administrator stated, No .his (the owner's) daughter is payroll .(Named owner) has not been here (to facility) in months . Interview with the Director of Nursing (DON) on 1/12/17 at 8:55 AM, outside when entering the facility for survey, the DON stated, .we're glad you are here, it's a hot mess . At 10:55 AM, in the DON office, the DON was asked what she was referring to when she said it is a hot mess. The DON stated, .the current issues in the building, not having payroll, (Named electronic documentation) .when I started in 14 (2014) there were rumors of checks bouncing .in (YEAR) checks did bounce, paydays were delayed a day or 2 .I have always been paid just delayed a day or two .Our vendors have changed a lot because of non-payment (Named Administrator) and I have used our own money to get supplies, but we have never not been able to get them . The DON was asked if there were staffing issues. The DON stated, .I'm still filling in a lot. Since (MONTH) we have lost of few (staff members) because the reputation in the community is so bad we can't fill vacancies. Everyone knows about (Named facility) No one will come here (to work) because they know you can't get paid . Interview with the Administrator on 1/12/17 at 9:05 AM, in the Conference Room, the Administrator was asked if everyone had received pay checks for the 1/10/17 payroll. The Administrator stated, .Roughly half of the employees received checks timely, yesterday a few more got paid .11 employees have not been paid .this has been going off and on for a yearish .the facility accountant (Named daughter of the owner) told me that her father had reached out to (Named Company Representative) and that he is trying to get some funding to pay employees .in hopes that (Named Company) would pay payroll . The Administrator was asked if there were bills of the facility that had not been paid. The Administrator stated, Oh yes .for our medical records we still don ' t have (Named electronic documentation system, it went down late night of the 8th or 9th in (MONTH) .because of non- payment .we don't have access to chart information, historical data prior to (MONTH) (2016) Interview with Certified Nursing Assistant (CNA) #1 on 1/12/17 at 10:12 AM, in room [ROOM NUMBER], CNA #1 was asked if she had ever not been paid. CNA #1 stated, .Yes .twice so far and I have been here since (MONTH) (YEAR) . Interview with Licensed Practical Nurse (LPN) #1 on 1/12/17 at 10:17 AM, at the Nurse's Station, LPN #1 was asked if she had ever not been paid. LPN #1 stated, .One time it was a week later . Interview with the Administrator on 1/17/17 at 9:10 AM, in the Conference Room, the Administrator was asked if everyone had been paid for the 1/10/17 pay date. The Administrator stated, .Everybody but me . Telephone interview with the Medical Director on 1/17/17 at 12:00 PM, the Medical Director was asked if he had always been paid by the facility. The Medical Director stated, .several months delayed .It has been 5 months behind but they always caught up . The Medical Director was asked if he had any concerns with the financial situation. The Medical Director stated, .from what I know we are living paycheck to paycheck . The Medical Director was asked if he was aware of the lack of electronic documentation system. The Medical Director stated, .oh yes, payment is way behind he (owner) didn't pay the bill . Telephone interview with the Account Manager (Registered Dietician Service) on 1/17/17 at 1:00 PM, the Account Manager was asked if the company had always received payment for services provided. The Account Manager stated, .it has been behind a little bit .",2020-01-01
4970,LIFE CARE CENTER OF MORRISTOWN,445314,501 WEST ECONOMY ROAD,MORRISTOWN,TN,37814,2016-06-15,281,G,1,0,SVOA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of Nursing 2012 Drug Handbook, medical record review, and interview, the facility failed to follow physician's orders for medication administration, and failed to follow the physician ordered plan of care, for 1 Resident (#174) of 6 residents reviewed for unnecessary medication administration of 27 sampled. This failure resulted in Harm to Resident #174. The findings included: Review of Lippincott (Nursing 2012 Drug Handbook) 8 Rights of Medication Administration dated 2012 revealed right dose .check the order .confirm appropriateness of the dose .check the order . Medical record review revealed Resident #174 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5 Day Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (a test for cognitive ability) score of 14, indicating the resident was cognitively intact. Medical record review of Resident #174's admission orders [REDACTED]. Medical record review of a faxed Physician/Prescriber order dated 6/29/15 revealed .Glimiperide (oral blood sugar lowering medication) 1 mg (milligram) PO (by mouth) BID (twice a day) (Hold if FS (finger stick blood sugar reading by glucometer) = (less than or equal to) 100) . Medical record review of the Fax Order Request/Notification Form dated 6/29/15 revealed .OK (with) Glimiperide (Hold if FS = 100) . Medical record review of Resident #174's Medication Administration Record (MAR) dated 6/15 and 7/15 revealed .Glimiperide 1 mg po BID start 6/29/15 9 am 5 pm . Further review revealed the Glimiperide 1 mg po had been given at 9:00 AM on 7/2/15 with a 6:00 AM finger stick blood sugar reading of 91. Continued review revealed the Glimiperide 1 mg po had been given at 5:00 PM on 7/2/15 with a 4:00 PM finger stick blood sugar reading of 74. Continued review revealed the physicians' order had not been followed. Continued review revealed no instruction documented on the MAR to hold Glimiperide 1 mg po bid if finger stick blood sugar reading was equal to or less than 100. Medical record review of Resident #174's Interim care plan, dated 6/26/15, revealed the [DIAGNOSES REDACTED]. Continued review revealed no intervention had been added on 6/29/15 regarding the guidelines for holding the Glimiperide for a blood sugar of 100 or less. Medical record review of Resident #174's electronic Nurses Notes dated 7/2/15 and entered at 10:56 PM revealed .less responsive, drooling from right side of mouth. No hand grips .Checked pt (patient) blood sugar .read 72. Transported by .EMS (Emergency Medical Service) Sent out at 8:45 pm . Medical record review of the EMS record dated 7/2/15 revealed EMS arrived at the facility at 8:36 PM .upon arrival found unresponsive female setting in wheel chair .nursing staff said they had checked her blood sugar and read 72 .ordering [MEDICATION NAME] (medication used to treat low blood sugar) to be given .Meds given and blood sugar checked and read 31 . Continued review revealed the EMS left the facility at 8:56 PM and transported the resident to a local hospital emergency department. Medical record review of the emergency room documentation dated 7/2/15 at 10:17 PM revealed .The patient presents with confusion, decreased mental status, decreased responsiveness . Continued review revealed at 11:20 PM the blood glucose was 31, with a critical range of less than 40. Continued review revealed Resident #174 was admitted to the hospital, with preliminary [DIAGNOSES REDACTED]. Interview with the Director of Nursing on 6/15/16 at 12:52 PM, in the conference room, confirmed the facility failed to correctly transcribe physician orders and failed to follow the physician's orders for Glimiperide administration for Resident #174. Interview with Resident #174's Primary Care Physician on 6/15/16 at 1:00 PM, in the conference room, confirmed the facility failed to follow the physician's orders for Glimiperide administration. This failure resulted in Harm to Resident #174.",2019-06-01
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
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
684,THE HIGHLANDS OF MEMPHIS HEALTH & REHABILITATION,445165,3549 NORRISWOOD,MEMPHIS,TN,38111,2017-11-15,281,G,1,0,JVWH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of The Lippincott Manual of Nursing Practice, 10th Edition, page 746, facility policy, medical record review, observation, and interview, the facility failed to ensure the implementation of professional standards of practice for 2 of 3 (Resident #1 and #2) sampled residents reviewed who were receiving Percutaneous Endoscopic Gastrostomy (PEG) Tube feedings. The failure to ensure staff provided appropriate care and services for the PEG tube feeding resulted in actual harm to Resident #1 when staff failed to ensure that PEG tube feedings were appropriately administered through the PEG tube to Resident #1 who had Nepro Carb Steady (carbohydrate nutritional product for residents with kidney disease) administered through his peritoneal [MEDICAL TREATMENT] catheter. The findings included: 1. The Lippincott Manual of Nursing Practice, 10th Edition page 746 documented, .For continuous tube feeding .flush tubing, attach to volume control infuser according to manufacturer's instructions, attach distal end to feeding tube . 2. The facility's Enteral Tube Feeding Continuous Pump policy, documented .The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally .Preparation .3. Ensure that the equipment and devices are working properly .General Guidelines .3 .Check the following information: .e. Access site (PEG insertion site) .Steps in the Procedure .Verify placement of tube: .7. Auscultate: (listening for internal sounds with a stethescope) a. Do not rely on this as the singular method to differentiate between respiratory, gastric, [MEDICAL CONDITION] and bowel placement. b. Attach 60 mL (milliliters) syringe containing approximately 10 mL air. c. Auscultate the abdomen (approximately 3 inches below the sternum) while injecting the air from the syringe into the tubing .8. When correct tube placement has been verified, flush tubing with at least 30 mL warm water (or prescribed amount) .Check gastric residual (stomach contents amount) volume (GRV): 1. Aspirate stomach contents .Reporting .1. Report complications .2. Report negative consequences of tube use .4. Report other information in accordance with facility policy and professional standards of practice . 2. Medical record review for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Physicians Orders received by Registered Nurse (RN) #1 on 10/31/17 and signed by the physician on 11/3/17 documented .TUBE FEEDING FORMULA Nepro Carb Steady RATE 45 mL/hr (milliliters per hour) .H2O (water) FLUSH 60 cc (cubic centimeters) 1 (one) HOURS .ENSURE PEG DISK ROTATES EVERY SHIFT .CHECK PEG TUBE PLACEMENT FOR AUSCULTATION .CHECK RESIDUAL . Review of the Initial Care Plan dated 10/27/17 revealed .FEEDING TUBES .Observe peg tube/[DEVICE] (gastrostomy tube) site for S/S (signs and symptoms) of infection/irritation .Peg care every shift & prn (as needed) .*check Peg tube placement By auscultation .* Check residual .Renal/[MEDICAL TREATMENT] .[MEDICAL TREATMENT] as ordered .Shunt care .*Peritoneal catheter (Not in use) (Lower Lt (left) Q (quadrant)) .*[MEDICAL TREATMENT] 3 x (times) wk (week) . Review of the Admission Evaluation and Interim Care Plan Skin Condition Body Diagram dated 10/27/17 revealed, .PEG site .Peritoneal Catheter (plastic flexible tube inserted into the abdomen to allow [MEDICAL TREATMENT] fluid to enter abdominal cavity, dwell inside for a prescribed amount of time and then drain back out again) .LA (left arm) AV fistula Review of the initial Admission/Readmission Nurses Notes dated 10/27/17 at 8:20 PM revealed .Resident is currently non verbal @ (at) this time but is alert & awake .Abd. (abdomen) soft nontender/nondistended c (with) bowel sounds in all 4 quads (quadrants) Noted peritoneal [MEDICAL TREATMENT] cath. (catheter) to LL (left lower) quad of Abd. Has a PEG which is patent & intact. Receives [MEDICAL TREATMENT] x (times) 3 days wkly (weekly). AV fistula to Lt. (left) upper arm c no problems . Review of a facility incident report revealed .(Resident #1) is alert but he is nonverbal. Resident was admitted to facility on 10/27/17 at 8:20 pm for skilled services under the care of (named Medical Director) .Resident admitted with a peg tube located in his left upper abd. quadrant and a peritoneal catheter in lower left abdominal catheter (quadrant). On the evening of 10/31/2017 (named RN #1) entered resident's room. (RN #1) was unaware that resident had a peritoneal catheter. (RN #1) connected the peg tube feeding to the peritoneal catheter. (RN #1) started the tube feeding at 8:45 pm. The error was discovered by the 11-7 (11:00 pm-7:00 am) nurse (Licensed Practical Nurse (LPN #1) at 5:45 am. (LPN #1) stopped the feeding immediately .called (RN #1) and she immediately came to the facility and notified The DON (Director of Nursing). I the DON notified (Medical Director) and orders were given to transfer resident to the hospital .(RN #1) called the family and spoke with the responsible party .resident was transported via 911 ambulance . Interview with the Administrator on 11/12/17 at 6:50 PM in the conference room, the Administrator was asked about Resident #1. She stated, .he was on a continuous feed (PEG tube infusion) until he went out to [MEDICAL TREATMENT] .then it was stopped .his peritoneal tube was not in use .he had a shunt for [MEDICAL TREATMENT] (indicated her left arm) .went to (named hospital) on the 1st (11/1/17) .was in ICU (Intensive Care Unit) for 3 days, then on the 4th day he went back on the vent (ventilator) . Interview with the DON on 11/12/17 at 6:50 PM in the conference room, the DON stated RN #1 .was not aware he had 2 tubes .she checked placement .checked residual .tubing had a flap on it, said she (RN #1) wondered why they did that .took the flap off and put an adapter on it . When the DON was asked if nurses undergo a skills check-off (nursing competency skills validation) the DON stated that they do a skills check-off upon hire and annually. Telephone interview with RN #1 on 11/15/17 at 11:34 AM, RN #1 was asked about the incident with Resident #1 on 10/31/17. She stated .I went in to prepare to give him (Resident #1) his feeding .I aspirated and hooked up his feeding and that's all . When she was asked if there were any problems with his feeding, she stated, .no .a cap was on it and I had to go get a connection for it .I took the cap off and put a connection on it . She was asked if she was aware that Resident #1 had a peritoneal catheter and she stated No. She further stated that she had taken care of him one other time in the past. Telephone interview with LPN #1 on 11/15/17 at 9:50 AM, LPN #1 stated, .I can't remember his (Resident #1) name .only had him one time .I remember the Unit Manager (RN #1) was on duty that night .she was on a cart .in report she (RN #1) said, '(named LPN #1) .I had to alter his (Resident #1) feeding tube because someone took the end off .I (RN #1) spent two hours trying to get that end on' .I (LPN #1) went down there (Resident #1's room) and checked to see what she (RN #1) was talking about and everything was running okay .end looked like a PEG tube .I thought she (RN #1) said the end was off .didn't check the site .he (Resident #1) don't get no midnight meds (medications), he (Resident #1) got 6:00 meds .I went down there with the aide and I told her to change his sheets and get him ready while I was giving him his meds .as soon as she turned him over and uncovered him, I saw he was hooked up to the wrong tube .peritoneal catheter .I unhooked it immediately .went and got the night supervisor (RN #2) .she (RN #2) came down there and checked him (Resident #1) .we knew it was a peritoneal catheter, but we checked the chart just to make sure .called the Unit Manager (RN #1) .she (RN #1) said call the doctor and get a KUB (kidney, ureter, and bladder study is an X-ray study) .we called (named Medical Director and Resident #1's provider), but he said don't get a KUB send him to the ER (emergency room ) .called the family and let them know what happened .I (LPN #1) stayed with him until he left . She was then asked if she had checked on him during the night, and she stated .yes .even at the time his stomach wasn't distended .didn't grimace or anything when I pressed on it .was fine through the night . When she was asked if she was aware, prior to that night, that he had two abdominal tubes, she stated, .I knew the first night he was admitted .I had him that night .another nurse admitted him .was told in report .was also written in his chart in the nurse's notes . Review of the hospital records revealed the following: .Operative Report dated 11/1/17 at 8:35 PM- .FINDINGS: The patient had copious white fluid within the abdominal cavity .There was copious white fluid that was suctioned out. We then retrieved the peritoneal [MEDICAL TREATMENT] catheter from the abdominal cavity .After suctioning all the fluid possible, we then irrigated the abdominal cavity in all 4 quadrants in the [MEDICAL CONDITION] (area under the diaphragm) space and subhepatic (area under the liver) spaces as well as the pelvis with 7 liters of warm saline. At the end of the irrigation, the effluent (outflowing fluid) was clear .He did have some changes of [MEDICAL CONDITION] (low blood pressure) during the operation. He was taken to the intensive care unit in guarded condition (a prognosis given by the physician when the outcome of a patient's illness is in doubt) . c) Progress Note dated 11/6/17 - .Back on vent (ventilator) for stridor (high pitched breath sound) . The failure of the facility to ensure nursing staff provided professional care according to resident's care plan, facility policy, Physician order [REDACTED].#1 when the nursing staff connected a PEG tube feeding of Nepro Carb Steady and administered the feeding through his peritoneal [MEDICAL TREATMENT] catheter for approximately 9 hours. Resident #1 was sent to the hospital, had emergent surgery and remained in the hospital on mechanical ventilation at the conclusion of this survey. 3. Medical record review for Resident #2, documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. A Physician order [REDACTED].Give Glucerna 1.2 1 (one) can ppt (per PEG Tube) tid (three times a day) . Physician's recertification orders signed 11/3/17, documented .H2O MED FLUSH 60 cc BEFORE & AFTER EACH MED PASS . Observations in Resident #2's room on 11/13/17 at 10:50 AM, revealed LPN #5 checked the tubing for the proper label as his PEG tube, checked placement per auscultation and aspiration, and then administered the bolus Glucerna 1.2. LPN #5 did not flush the PEG tube prior to administering the bolus. He stated, .I skipped a step .I'm just going to be honest .supposed to flush with 30 ccs before and after . LPN #5 flushed with 60 cc after administering the bolus of Glucerna 1.2. LPN #5 confirmed he failed to follow Physician order [REDACTED].",2020-09-01
2725,AHC DYERSBURG,445446,1900 PARR AVENUE,DYERSBURG,TN,38024,2017-10-06,323,K,1,1,DRLB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of The Lippincott Manual of Nursing Practice, 10th Edition, policy review, dialysis agreement review, medical record review, observation and interview, the facility failed to ensure residents at risk for falls were completely and accurately assessed for fall risk for 6 of 7 (Resident #58, #14, #41, #127, #142, and #167) sampled residents reviewed for falls; failed to ensure falls were thoroughly investigated with the implementation of new interventions to prevent further falls for 1 of 7 (Resident #58) sampled residents; and failed to ensure safety assessments were completed for 4 of 4 (Resident #58, #1, #240, and #242) sampled residents reviewed for outpatient dialysis prior to transportation without an escort outside the facility for medical services. The failure of the facility to provide the appropriate safety assessment/reassessment and safety plans for transportation resulted in Immediate Jeopardy for Resident #58; a resident who was blind in both eyes, and a bilateral lower extremity amputee (surgical removal of both legs), when the resident sustained [REDACTED]. This fall resulted in the resident being hospitalized , declining while in the hospital and death of the resident during hospitalization on [DATE], with [DIAGNOSES REDACTED]. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Regional Nurse Consultant (NC), and the Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 4:48 PM, in the conference room. The facility was cited an Immediate Jeopardy at F323-K which is Substandard Quality of Care. An extended survey was completed on [DATE]. An acceptable allegation of compliance (A[NAME]), which removed the IJ, was received on [DATE] at 6:57 PM. Corrective actions were validated onsite by the surveyors on [DATE] and [DATE]. The Immediate Jeopardy was effective [DATE]. The immediacy was removed [DATE]. The noncompliance continues at F323-E for monitoring of effectiveness of the corrective actions to ensure sustained compliance. The findings included: The Lippincott Manual of Nursing Practice, 10th Edition documented, .Nursing Practice And The Nursing Process .Ensuring Safety .Continually assess safety .particularly if the patient is very ill and the care plan is complex .Assess for the patient's personal safety issues-sensory deficits (a defect in the function of one or more of the senses, such as blindness) . The facility's Fall Risk/Fall Prevention Guidelines policy dated (MONTH) 2014, documented, .An assessment is the initial step in preventing avoidable falls. The completing of a fall risk assessment can be useful in identifying and managing risk factors. A Fall Risk Assessment .will be completed by a licensed nurse indicating the patient's risk factors .Upon admission/readmission to the facility .After a fall .Significant change in medical status .Quarterly .The licensed nurse completing the assessment will address the identified risk category, developing a plan of care, and the implementation of appropriate interventions to assist with fall prevention .Review of medications; eliminate unnecessary medications to reduce the risk of falls; patients receiving high risk medications .will be observed during routine care for possible adverse side effects .Post Fall Management is an opportunity to conduct a root cause analysis of a patients (patient's) fall, identifying specific factors that contributed to the fall. The fall determination will assist care givers in implementing interventions that are cause specific, possibly reducing future falls .Licensed Staff .Will complete the Nurse Event Note, detailing with as much information as possible, how/why the occurrence occurred .Attempt to determine the cause of the event, update the Fall Risk Assessment Tool, gather statements from staff members, resident, family and/or other witnesses; implement/modify the patient's current plan of care with intervention(s) associated with the cause of the fall .Nursing Administration .Will review all occurrences during the morning QA (Quality Assurance) meeting .The Interdisciplinary Team .will initiate a thorough investigation of the incident and discuss findings and potential interventions during the morning QA meeting .Finalize the Occurrence Investigation report, ensuring that all contributing factors have been identified, and the appropriate intervention has been implemented .Modify the patient's plan of care as needed .The DON or designee will input all fall data into the Facility's Monthly Fall Tracking Report .Fall Analysis .The Interdisciplinary Team will discuss falls in their morning QA meeting and perform a root cause analysis for each fall in order to identify why the fall occurred. The purpose of this process is to assist the clinician in implementing appropriate interventions that will reduce the occurrence of falls for the patient .The facility will share fall reporting data with the Medical Director, discussing any identified trends that may require further investigation and/or revision of the facility's procedures .Develop Corrective Action Plans as needed for identified trend(s) that may require further monitoring to achieve the optimum goal for fall reductions within the facility . The Dialysis Services Agreement documented, .Operator (Facility) shall be responsible for making arrangements to transport the patient to Provider's (Dialysis) Clinic .If the patient needs to be accompanied .Operator shall be responsible for making such arrangements. Operator shall also be responsible for ensuring that the patient is medically stable to be transported . Closed medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #58 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#58 being a bilateral lower extremity amputee (surgical removal of both legs). Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] and the quarterly MDS dated [DATE] revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment, had severely impaired vision, required extensive staff assistance x (of) 2 for transfers and extensive staff assist x 1 for locomotion, walking did not occur, was not steady for surface to surface transfers, and was only able to stabilize with human assistance. No use of mobility device was documented. The physician's orders [REDACTED].Dialysis Tuesday-Thursday-Saturday continuous (name of dialysis clinic) . Review of the Nursing Admission/Readmission Form dated [DATE] revealed a fall risk assessment score of 13, indicating Resident #58 was at moderate risk (score of ,[DATE]) for falls. Review of the Transfer to Dialysis Form dated [DATE] revealed Resident #58 was transported without an escort via wheelchair van to the dialysis clinic. The care plan dated [DATE] documented, .Dialysis on 3 days/week (verify schedule) is still Tu (Tuesday) /Th (Thursday) /Sa (Saturday) at .(Name of Dialysis Clinic); transported by w/c (wheel chair) van . The facility was unable to provide documentation an assessment/reassessment had been performed to determine the resident's ability to participate safely in a transportation van service independently or a safety plan developed and implemented for using a transportation van service for medical reasons for Resident #58, who was blind in both eyes and a bilateral amputee (surgical removal of both legs). The Physical Therapy (PT) progress notes dated [DATE] at 8:44 AM documented, .Pt (patient) presents with increased swelling with RUE (right upper extremity) which is limiting use and support required . The PT progress notes dated [DATE] at 2:23 PM documented, . Comments: Pt demonstrates fair participation with poor to fair tolerance to therapy sessions. Pt has dialysis Tue (Tuesday), Thurs (Thursday), and Sat (Saturday) in the am (AM). Treatment on those days cont (continue) to be performed post treatment in the pm in which pt demonstrates increased fatigue/weakness post dialysis treatments and tolerance/participation is limited. Pt presents with increased swelling with RUE which is limiting use and support required . The physician's orders [REDACTED].Discharge .PT service at this time to restorative care (therapies provided by nursing staff) . The Clinical Notes Report dated [DATE] at 1:51 PM documented, .resident returned from access center .he stated he slid out of chair on wheelchair van .No new orders noted .Wheelchair van driver came and told this nurse that he (Resident #58) did slide out of wheelchair . Review of the care plan dated [DATE] revealed no revisions to Resident #58's care plan with interventions associated with the fall on [DATE] while riding in the wheelchair van. The facility was unable to provide documentation that a fall investigation was conducted or that a fall risk assessment was completed after the fall on [DATE]. Review of the Transfer To Dialysis Form dated [DATE] revealed Resident #58 was transported without an escort via wheelchair van to the dialysis clinic. There was no documentation of a re-assessment for Resident #58, who was blind in both eyes and a bilateral lower extremity amputee with swelling to his RUE (right upper extremity) which limited use of his RUE, for safety risk for transport via wheelchair van without an escort to dialysis after sliding out of his chair during transport on the wheelchair van. Interview with the Director of Nursing (DON) on [DATE] at 4:50 PM, in the DON's Office, the DON was asked for the Nurse Event note for Resident #58's fall on [DATE] on the wheelchair van. The DON stated, .nurse didn't make one .It didn't happen here . Interview with PT #1 on [DATE] at 1:15 PM, in the conference room, PT #1 was asked when Resident #58 was discharged from PT. PT #1 stated on [DATE]. PT #1 stated Resident #58 was reaching a plateau and was more fatigued, and he was discharged to restorative nursing for that week. The physician's office history and physical dated [DATE] documented, .Assessment .Common bile duct stone .Discussion/Summary .Pt (patient) was scheduled for an ERCP (Endoscopic Retrograde Cholangiopancreatography, a procedure that enables your physician to examine the pancreatic and bile ducts using a bendable lighted tube inserted through the mouth into the stomach and the small intestine) .Tues [DATE] .After pt has Dialysis . The Clinical Notes dated [DATE] at 5:49 AM, documented, .res (resident) is LOA (leave of absence) to dialysis via wheelchair van . The Clinical Notes dated [DATE] at 10:05 PM, documented, .nurse from (name of hospital) called this evening giving report on resident stating that O2 (oxygen) levels were low coming out of surgery but as soon as they were stable resident would be on way with new orders for ABT (antibiotic) and clear liquids . The Clinical Notes dated [DATE] at 1:55 PM, documented, .resident returned from hospital . Review of the Nursing Admission/Readmission Form dated [DATE] revealed a fall risk assessment score of 14, indicating Resident #58 was at moderate risk (score ,[DATE]) for falls. The physician's orders [REDACTED].PT clarification order for 5 to 7 x a week include there (therapeutic) ex (exercise), there act (activity) . Review of the Transfer To Dialysis Form dated [DATE] revealed Resident #58 was transported without an escort via wheelchair van to the dialysis clinic. The facility was unable to provide documentation an assessment was conducted for Resident #58, who was blind in both eyes and a bilateral amputee, to determine the resident's ability to participate safely in transportation via wheelchair van without an escort to dialysis after the change in condition which required a surgical procedure with an overnight hospital stay, with return to the facility on [DATE]. Review of the Clinical Notes dated [DATE] at 10:35 PM, documented, .received new order from md (medical doctor) office to send to ER (emergency room ) to tx (treatment) and evaluation due to recent episodes of confusion .prior to transfer resident's O2 % (percent) was 83 (normal range ,[DATE]%). Oxygen .was applied by this nurse. ems (emergency medical services) came and was taken by ems to hospital around 4pm . The Hospital History and Physical dated [DATE] documented, .was transferred from nursing home with confusion and hypoxia (low oxygen level) to the 80s (Normal range is ,[DATE] percent) on room air .also .right upper extremity swelling .Impression Metabolic [DIAGNOSES REDACTED] (Temporary or permanent damage to the brain that happens when the body's metabolic processes are seriously impaired) .Acute hypoxemic respiratory failure (Fluid build-up in the air sacs in the lungs) .Thrombocytopenic disorder (A low number of platelets in the blood) .End stage renal disease . The Clinical Notes dated [DATE] at 5:42 PM, documented, .Resident returned to facility after dialysis, pt discharged from hospital this am . Review of the Nursing Admission/Readmission Form dated [DATE] revealed a fall risk assessment score of 16, indicating Resident #58 was at moderate risk (score ,[DATE]) for falls. Review of the Transfer To Dialysis Form dated [DATE] revealed Resident #58 was transported without an escort via wheelchair van to the dialysis clinic. The facility was unable to provide documentation an assessment was conducted for Resident #58, who was blind in both eyes and a bilateral amputee (surgical removal of both legs), to determine the resident's ability to participate safely in transportation via wheelchair van without an escort to dialysis after the change in condition which required an overnight hospital stay, with return to the facility on [DATE] with [DIAGNOSES REDACTED]. The Clinical Notes Report dated [DATE] at 5:41 AM, documented, .Res LOA to dialysis via w/c van . The Clinical Notes Report dated [DATE] at 11:06 AM, documented, .received call from (name of clinic) dialysis that resident was in the process of being picked up by (name of company) transportation and w/c tipped backwards (off the lift gate on the van) with resident in it; this nurse was informed that resident hit head during fall, but was alert and oriented at time of transport to ER (emergency room ); resident currently at ER for eval and tx (treatment) . Hospital #1's Emergency Department (ED) Nurse Documentation dated [DATE] documented, .Presenting complaint: Patient states: was getting in van the driver was lifting his wheelchair and fell out of wheelchair backward (from the lift gate on the van) and hit his head on concrete . Hospital #1's ED Physician Documentation dated [DATE] documented, .The patient sustained injury to the head, patient was at dialysis and they were getting him into there (their) van and there chir (their chair) flipped (off the lift gate of the van) and hit .(Resident #58's) head .Differential Diagnoses: [REDACTED].Fairly extensive bilateral temporal subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain), greater on the right .Disposition: [DATE] 13:52 Transfer ordered to (Name of Hospital #2 for a higher level of care). [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON) on [DATE] at 10:31 AM, in the conference room, the DON was asked how it was determined the resident could safely travel in the transport van without an escort. The DON stated, You're going to have to read the PT note .There's no assessment to see if he was safe to go in the van . The DON was asked how the facility assessed Resident #58 for safety to travel in the wheelchair van without an escort after he was readmitted from having the second lower extremity amputation [DATE], after he fell during transport on [DATE], and after his changes in condition and return from hospitalization s [DATE] and [DATE]. The DON stated, We don't do an assessment to say he can travel .when therapy picked him up, if he wasn't safe to be up in the chair, they would have told us. There was one little period he got weak . The DON was asked how was it determined whether residents need an escort to ride with them during transport in the wheelchair van. The DON stated, .people just don't go with them .you're not going to see that documented . The DON was asked whether she would expect the residents to be assessed/reassessed for traveling to appointments or treatments alone or without escorts after change in status, hospitalization s, or falls. The DON stated, .I would expect therapy to re-evaluate him. When we call to make the transportation and all of that, they would not go out there and assess him to put him on the van. If they felt like he was not safe to ride the van, they would let us know . The DON was asked to explain the process to determine what type of transportation the residents need for transport. The DON stated, .It goes more by the certification and necessity . Resident #58 was not receiving therapy (PT) at the time of the second fall [DATE]. The PT Discharge Summary dated [DATE] documented, .Pt currently with max (maximum) potential established with mod (moderate) A (assist) for bed mobility with use of handrails, transfer with use of hoyer lift with max A x ,[DATE]. PT services have been DC to restorative care . Interview with the Rehabilitation (Rehab) Manager on [DATE] at 11:36 AM, in the conference room, the Rehab Manager was asked how residents were assessed to safely travel without an escort in the wheelchair van. The Rehab Manager stated, .We don't assess them getting on the van because it is a lift. They don't transfer them. He never leaves that wheelchair. He gets on the lift, and they strap him in . The facility was unable to provide documentation that Resident #58, a vulnerable resident who was blind in both eyes and had bilateral lower extremity amputations (surgical removal of both legs), received a safety assessment to travel without an escort to dialysis after the following: a. after a significant change in status when Resident #58 returned to the facility [DATE] after a Left above the Knee Amputation, changing his status to a bilateral amputee (surgical removal of both legs); b. after Resident #58 sustained a fall while traveling in the transportation van on [DATE]; c. after a change in condition when Resident #58 returned from an overnight hospital stay on [DATE] after a surgical procedure and hypoxia (low oxygen level); d. after a change in condition when Resident #58 returned from an overnight hospital stay on [DATE] after episodes of confusion and hypoxia. The failure of the facility to ensure safe conditions were provided for transport, failure to assess a resident for ability to participate in transport, and failure to provide a plan for safe transport to and return from dialysis treatments for Resident #58, a resident who was blind in both eyes, and a bilateral lower extremity amputee (surgical removal of both legs), resulted in IJ for Resident #58 when the resident sustained [REDACTED]. During the resident's hospitalization , Resident #58 declined, became comatose and expired on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS assessment dated [DATE] revealed a BIMS score of 14, which indicated no cognitive impairment, required extensive assistance with transfers, was unsteady with walking and transfers, and had 2 or more falls since prior assessment. The care plan dated [DATE] documented, .Risk For Falls R/T spasmodic [DIAGNOSES REDACTED]/sudden abnormal movements; very determined to be independent-avoids asking for help . Review of the Nurse's Event Notes revealed Resident #14 fell on [DATE], [DATE], and [DATE], with no injuries. The facility was unable to provide documentation that a fall risk assessment was completed after the falls on [DATE] or [DATE]. Interview with Nurse Consultant #3 on [DATE] at 6:40 PM, in the DON's Office, Nurse Consultant #3 confirmed that Resident #14 was not assessed for fall risk after the falls on [DATE] and [DATE]. Medical record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 30 day MDS dated [DATE] revealed Resident #41 had a BIMS score of 5, indicating severe cognitive impairment, required total dependence of 2 for transfers, walking was unsteady, was only able to stabilize with assistance from staff for moving from seated to standing position and surface to surface transfers, had impairment on one side to upper and lower extremities, and used a wheelchair for mobility. The care plan dated [DATE] documented, .Has history of falls prior admission . Review of the nurses' notes revealed Resident #41 had a witnessed fall in her room on [DATE] with no injury. The quarterly fall risk assessment dated [DATE] was incomplete, with no documentation to address Resident #41's balance, vision, health conditions and risk scale. Interview with the DON on [DATE] at 9:36 AM, in the conference room, the DON was asked if the quarterly fall risk assessment for Resident #41 should have been completed. The DON stated, Yes. Medical record review revealed Resident #127 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the annual MDS assessment dated [DATE] revealed Resident #127 had a BIMS score of 15, indicating no cognitive impairment, required extensive assistance of 2 with transfers, walking was not steady, was only able to stabilize with staff assistance, used walker and wheelchair for mobility, and had no falls since prior assessment. The care plan dated [DATE] documented, .history of Falls Prior r/t (related to) advancing Parkinson's Disease, sudden abnormal involuntary movements; periods of confusion/delirium at onset of UTI (Urinary Tract Infection) . Review of the physician's orders [REDACTED].) every 12 hours, Lisinopril (an antihypertensive medication) daily, Ropinirole (a Parkinson's medication) three times daily, and Seroquel (an antipsychotic medication) every night at bedtime. Review of the Nurse's Event Note(s) revealed Resident #127 fell on [DATE] and [DATE]. Review of the post fall Fall Risk Assessment completed [DATE] revealed inaccurate documentation that Resident #127 only received ,[DATE] high risk medications. The post fall risk assessment documented a total score of 8, with a score between 1 and 10 indicating the resident was at low risk for falls. The Fall Risk Assessment did not accurately reflect Resident #127's medication use. Observations in the Dining Room on [DATE] at 11:46 AM, and in Resident #127's room on [DATE] at 4:36 PM, [DATE] at 7:57 AM and 5:12 PM, [DATE] at 7:59 AM, and [DATE] at 8:20 AM, revealed Resident #127 sitting in a wheelchair. Interview with MDS Coordinator #1 on [DATE] at 1:00 PM, in the Skilled MDS Office, the MDS Coordinator confirmed that the [DATE] Fall Risk Assessment was incorrect, and should have reflected Resident #127 was a moderate risk for falls. Medical record review revealed Resident #142 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed age of [AGE] years, a BIMS score of 6, indicating severe cognitive impairment, required extensive staff assistance for activities of daily living, and walking did not occur. The MDS documented Resident #142's balance was not steady, was only able to stabilize herself with staff assistance, had range of motion impairment on one side of lower extremities, and had 1 fall with a fracture in the past month prior to admission. Review of the care plan with an effective date of [DATE] revealed Resident #142 was at risk for falls, and had a history of [REDACTED]. Review of the physician's orders [REDACTED].#142 required furosemide (a diuretic medication), metformin (a hypoglycemic medication), trazodone (an antidepressant medication), buspirone (an antianxiety medication), lactulose (a laxative medication), metoprolol tartrate (an antihypertensive medication), lisinopril (an antihypertensive medication), hydralazine (an antihypertensive medication), risperidone (an antipsychotic medication), cetirizine (an antihistamine medication), and docusate sodium (a laxative medication) at least daily. Review of the (MONTH) Medication Administration Record (MAR) revealed Resident #142 received furosemide, metformin, trazodone, buspirone, lactulose, metoprolol tartrate, lisinopril, hydralazine, risperidone, cetirizine, and docusate sodium at least daily from [DATE]-[DATE]. Review of the admission Fall Risk Assessment completed [DATE] revealed inaccurate documentation that Resident #142 only received ,[DATE] high risk medications. The admission risk assessment documented a total score of 14, with a score between 11 and 19 indicating the resident was at moderate risk for falls. The Fall Risk Assessment did not accurately reflect Resident #142's medication use. A NURSE'S EVENT NOTE dated [DATE] documented, .Unobserved Fall . Review of the post fall Fall Risk Assessment completed [DATE] revealed inaccurate documentation that Resident #142 had no falls in the past 90 days, and only received ,[DATE] high risk medications. The post fall risk assessment documented a total score of 7, with a score between 1 and 10 indicating the resident was at low risk for falls. The Fall Risk Assessment did not accurately reflect Resident #142's fall history or medication use. Interview with the DON on [DATE] at 9:44 AM, in the conference room, the DON was asked whether Resident #142's fall risk assessment should have gone from moderate to low after she sustained a fall on [DATE], the day after the admission fall risk was completed. The DON stated, It's inaccurate. Medical record review revealed Resident #167 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment, required limited to extensive staff assistance for activities of daily living, was unsteady, and was only able to stabilize with staff assistance for moving from seated to standing position, walking, turning around, moving on and off toilet, and surface to surface transfers, had 1 fall in the last month prior to admission, and 1 fracture related to a fall in the past 6 months prior to admission. Review of the care plan with an effective date of [DATE] revealed Resident #167 was at risk for falls and had a history of [REDACTED]. The admission fall risk assessment dated [DATE] was incomplete. Interview with Registered Nurse (RN) #2 on [DATE] at 8:49 AM, at the ,[DATE] Nurses' Station, RN #2 was asked what the fall risk assessments determined. RN #2 stated, How much assistance the patient needs when transferring .whether they're able to ambulate with or without assistance, are they visually impaired at all .if they have any verbal impairment, like are they able to call out for help. Those type of things cause them to score higher, if they have any physical impairment, like swelling, any type of braces. RN #2 was asked whether the fall risk assessments were used to determine the level of care the resident needs. RN#2 stated, Yes. We fill out a care plan . RN #2 was asked whether it was important to ensure the fall risk assessments were done and were accurate. RN #2 stated, Yes. It's of high importance. Interview with the Director of Nursing (DON) on [DATE] at 9:36 AM, in the conference room, the DON was asked about Resident #167's incomplete admission fall risk assessment dated [DATE]. The DON stated, This is when the computer went crazy . The DON was asked what should have been done if the computer was not functioning. The DON stated, You can print a form. The facility was unable to provide the completed admission fall risk assessment for Resident #167 for [DATE]. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the discharge MDS dated [DATE] revealed Resident #1 had a BIMS score of 15, indicating no cognitive impairment, and received dialysis while a resident at the facility. The Care Plan Report dated [DATE] documented, .Dialysis on Tues, Thurs, Sat .goes by community van in her w/c: BE AWARE she occasionally needs extra day of dialysis . The Physician order [REDACTED].Dialysis Tuesday-Thursday-Saturday . The facility was unable to provide documentation that Resident #1 was assessed for the ability to safely participate in transportation via wheelchair van without an escort to dialysis. Medical record review revealed Resident #240 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed a BIMS score of 5, indicating severe cognitive impairment and received dialysis. The physician's orders [REDACTED].Dialysis",2020-09-01
2724,AHC DYERSBURG,445446,1900 PARR AVENUE,DYERSBURG,TN,38024,2017-10-06,309,K,1,1,DRLB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of The Lippincott Manual of Nursing Practice, 10th Edition, policy review, observation, and interview, the facility failed to ensure a comprehensive approach to all care and services provided to facility residents and ensure communication between the [MEDICAL TREATMENT] center and the facility for 3 of 5 (Resident #58, #1, and #93) sampled residents reviewed receiving outpatient [MEDICAL TREATMENT]. The facility failed to ensure safety assessments and plans were completed and implemented prior to residents being transported by a transportation van service for medical services for 4 of 4 (Resident #58, #1, #240, and #242) sampled residents reviewed who were receiving outpatient [MEDICAL TREATMENT] and using a transportation van service. The failure of the facility to provide the appropriate safety assessment/reassessment and plans resulted in Immediate Jeopardy for Resident #58, a resident who was blind in both eyes, and a bilateral lower extremity [MEDICAL CONDITION] (surgical removal of both legs), when the resident sustained [REDACTED]. The resident was hospitalized as a result of the fall, declined during hospitalization , and expired in the hospital on [DATE]. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Regional Nurse Consultant (NC), and the Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 4:48 PM, in the conference room. The facility was cited an Immediate Jeopardy at F309-K which is Substandard Quality of Care. An extended survey was completed on [DATE]. An acceptable allegation of compliance (A[NAME]), which removed the IJ, was received on [DATE] at 6:57 PM. Corrective actions were validated onsite by the surveyors on [DATE] and [DATE]. The Immediate Jeopardy was effective [DATE], and continued until an allegation of compliance (A[NAME]) was received on [DATE] at 6:57 PM, and validated on [DATE] and [DATE]. The immediacy was removed [DATE]. The noncompliance continues at F309-E for monitoring of effectiveness of the corrective actions to ensure sustained compliance. The findings included: The Lippincott Manual of Nursing Practice, 10th Edition documented, .Nursing Practice And The Nursing Process .Ensuring Safety .Continually assess safety .particularly if the patient is very ill and the care plan is complex .Assess for the patient's personal safety issues-sensory deficits (a defect in the function of one or more of the senses, such as [MEDICAL CONDITION]) . Review of the [MEDICAL TREATMENT] Services Agreement documented, .Operator (Long Term Care Facility) shall be responsible for making arrangements to transport the patient to Provider's ([MEDICAL TREATMENT]) Clinic and any costs related to such transportation. If the patient needs to be accompanied .Operator shall be responsible for making such arrangements. Operator shall also be responsible for ensuring that the patient is medically stable to be transported . Review of the facility's [MEDICAL TREATMENT] Patient Services policy dated (MONTH) 2014, documented, At times, we will have patients with [MEDICAL TREATMENT] orders. There are several special interventions to be implemented with a patient receiving [MEDICAL TREATMENT] .Nursing documentation required: Pre and Post [MEDICAL TREATMENT] weights . The facility's Fall Risk/Fall Prevention Guidelines policy dated (MONTH) 2014, documented, .An assessment is the initial step in preventing avoidable falls. The completing of a fall risk assessment can be useful in identifying and managing risk factors. A Fall Risk Assessment .will be completed by a licensed nurse indicating the patient's risk factors .After a fall .Significant change in medical status .The licensed nurse completing the assessment will address the identified risk category, developing a plan of care, and the implementation of appropriate interventions to assist with fall prevention .Review of medications; eliminate unnecessary medications to reduce the risk of falls; patients receiving high risk medications .will be observed during routine care for possible adverse side effects .Post Fall Management is an opportunity to conduct a root cause analysis of a patients (patient's) fall, identifying specific factors that contributed to the fall. The fall determination will assist care givers in implementing interventions that are cause specific, possibly reducing future falls .Licensed Staff .Will complete the Nurse Event Note, detailing with as much information as possible, how/why the occurrence occurred .Attempt to determine the cause of the event, update the Fall Risk Assessment Tool, gather statements from staff members, resident, family and/or other witnesses; implement/modify the patient's current plan of care with intervention(s) associated with the cause of the fall .Nursing Administration .Will review all occurrences during the morning QA (Quality Assurance) meeting .The Interdisciplinary Team .will initiate a thorough investigation of the incident and discuss findings and potential interventions during the morning QA meeting .Finalize the Occurrence Investigation report, ensuring that all contributing factors have been identified, and the appropriate intervention has been implemented .Modify the patient's plan of care as needed .The DON or designee will input all fall data into the Facility's Monthly Fall Tracking Report .Fall Analysis .The Interdisciplinary Team will discuss falls in their morning QA meeting and perform a root cause analysis for each fall in order to identify why the fall occurred. The purpose of this process is to assist the clinician in implementing appropriate interventions that will reduce the occurrence of falls for the patient .The facility will share fall reporting data with the Medical Director, discussing any identified trends that may require further investigation and/or revision of the facility's procedures .Develop Corrective Action Plans as needed for identified trend(s) that may require further monitoring to achieve the optimum goal for fall reductions within the facility . Closed medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #58 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#58 being a bilateral lower extremity [MEDICAL CONDITION] (surgical removal of both legs). Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] and the quarterly MDS assessment dated [DATE] revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment, had severely impaired vision, required extensive staff assistance x 2 staff for transfers and extensive staff assist x 1 for locomotion, walking did not occur, and was not steady for surface to surface transfers, was only able to stabilize with human assistance. No use of mobility device was documented. The physician's orders [REDACTED].[MEDICAL TREATMENT] Tuesday-Thursday-Saturday continuous (name of [MEDICAL TREATMENT] clinic) . Review of the Nursing Admission/Readmission Form dated [DATE] revealed a fall risk assessment score of 13, indicating Resident #58 was moderate risk (score of ,[DATE]) for falls. Review of the Transfer to [MEDICAL TREATMENT] Form dated [DATE] revealed Resident #58 was transported without an escort via wheel chair van to the [MEDICAL TREATMENT] clinic. The current care plan dated [DATE] documented, .[MEDICAL TREATMENT] on 3 days/week (verify schedule) is still Tu (Tuesday) /Th (Thursday) /Sa (Saturday) at .(Name of [MEDICAL TREATMENT] Clinic); transported by w/c (wheel chair) van . The facility was unable to provide documentation an assessment was conducted for Resident #58, who was blind in both eyes and a bilateral [MEDICAL CONDITION] (surgical removal of both legs), to determine the resident's ability to participate safely in transportation via wheelchair van without an escort to [MEDICAL TREATMENT] after the recent significant change of condition of a left above the knee amputation (surgical removal of the left leg above the knee) on [DATE]. There was no documentation of collaboration with the [MEDICAL TREATMENT] facility and transportation van services to determine any safety issues with transporting Resident #58. The Physical Therapy (PT) progress notes dated [DATE] at 8:44 AM documented, .Pt (patient) presents with increased swelling with RUE (right upper extremity) which is limiting use and support required . The Physical Therapy (PT) progress notes dated [DATE] at 2:23 PM documented, .Comments: Pt demonstrates fair participation with poor to fair tolerance to therapy sessions. Pt has [MEDICAL TREATMENT] Tue (Tuesday), Thurs (Thursday), and Sat (Saturday) in the am. Treatment on those days cont (continue) to be performed post treatment in the pm in which pt demonstrates increased fatigue/weakness post [MEDICAL TREATMENT] treatments and tolerance/participation is limited. Pt presents with increased swelling with RUE (right upper extremity) which is limiting use and support required . The Clinical Notes Report dated [DATE] at 1:51 PM, documented, .resident returned from access center .he stated he slid out of chair on wheelchair van .No new orders noted .Wheelchair van driver came and told this nurse that he did slide out of wheelchair . The facility was unable to provide documentation a fall investigation was completed after the fall during transport on [DATE]. The facility was unable to provide documentation a post-fall risk assessment was conducted after the fall from the wheelchair during transport on [DATE] per the facility's Fall Risk/Fall Prevention Guidelines policy. Interview with the Director of Nursing (DON) on [DATE] at 4:50 PM, in the DON's Office, the DON was asked for the Nurse Event note for Resident #58's fall on [DATE] on the wheelchair van. The DON stated, .nurse didn't make one .It didn't happen here . Review of the care plan dated [DATE] revealed no revisions to Resident #58's care plan with interventions(s) associated with the cause of the fall on [DATE] while riding in the wheelchair van. The physician's orders [REDACTED].PT service at this time to restorative care. Interview with PT #1, on [DATE] at 1:15 PM, in the conference room, PT #1 was asked when Resident #58 was discharged from therapy. PT #1 stated on [DATE] Resident #58 was reaching a plateau, and was more fatigued. PT #1 stated Resident #58 was discharged to restorative nursing for that week. Review of the Transfer To [MEDICAL TREATMENT] Form dated [DATE] revealed Resident #58 was transported without an escort via wheelchair van to the [MEDICAL TREATMENT] clinic. The facility was unable to provide documentation an assessment was conducted for Resident #58, who was blind in both eyes and a bilateral [MEDICAL CONDITION] (surgical removal of both legs) resident, to determine the resident's ability to participate safely in transportation via wheelchair van without an escort to [MEDICAL TREATMENT] after the fall from the wheelchair during transport on [DATE]. There was no documentation of collaboration with the [MEDICAL TREATMENT] facility and transportation van services to determine any safety issues with transporting Resident #58. The physician's office history and physical dated [DATE] documented, .Assessment .Common bile duct stone .Discussion/Summary .Pt (patient) was scheduled for an ERCP (Endoscopic Retrograde Cholangiopancreatography, a procedure that enables your physician to examine the pancreatic and bile ducts using a bendable lighted tube inserted through the mouth into the stomach and the small intestine) .Tues [DATE] .After pt has [MEDICAL TREATMENT] . The facility's Clinical Notes dated [DATE] at 5:49 AM, documented, .res (resident) is LOA (leave of absence) to [MEDICAL TREATMENT] via wheelchair van . The facility's Clinical Notes dated [DATE] at 10:05 PM, documented, .nurse from (name of hospital) called this evening giving report on resident stating that O2 (oxygen) levels were low coming out of surgery but as soon as they were stable resident would be on way with new orders for ABT (antibiotic) and clear liquids . The facility's Clinical Notes dated [DATE] at 1:55 PM, documented, .resident returned from hospital . Review of the Nursing Admission/Readmission Form dated [DATE] revealed a fall risk assessment score of 14, indicating Resident #58 was at moderate risk (score of ,[DATE]) for falls. The physician's orders [REDACTED].PT clarification order for 5 to 7 x a week include there (therapeutic) ex (exercise), there act (activity) . Review of the Transfer To [MEDICAL TREATMENT] Form dated [DATE] revealed Resident #58 was transported without an escort via wheelchair van to the [MEDICAL TREATMENT] clinic. The facility was unable to provide documentation an assessment was conducted for Resident #58, who was blind in both eyes and a bilateral [MEDICAL CONDITION] (surgical removal of both legs), to determine the resident's ability to participate safely in transportation via wheelchair van without an escort to [MEDICAL TREATMENT] after the change in condition which required a surgical procedure with an overnight hospital stay, with return to the facility on [DATE]. There was no documentation of collaboration with the [MEDICAL TREATMENT] facility and transportation van services to determine any safety issues with transporting Resident #58. The PT DC (Discharge) Summary dated [DATE] documented, .Pt (patient) currently with max (maximum) potential established with mod (moderate) A (assist) for bed mobility with use of handrails, transfer with use of Hoyer lift with max A x ,[DATE]. PT services have been DC (discontinued) to restorative care (Therapies provided by nursing staff) . The Clinical Notes dated [DATE] at 10:35 PM documented, received new order from md (medical doctor) office to send to ER (emergency room ) to tx (treatment) and evaluation due to recent episodes of confusion .prior to transfer resident's O2 % (percent) was 83 (normal range ,[DATE]%). Oxygen .was applied by this nurse. ems (emergency medical services) came and was taken by ems to hospital (Hospital #1) around 4pm . Hospital #1's History and Physical dated [DATE] documented, .was transferred from nursing home with confusion and [MEDICAL CONDITION] (low oxygen levels) to the 80s (normal range ,[DATE]%) on room air .also .right upper extremity swelling .Impression Metabolic [MEDICAL CONDITION] (Temporary or permanent damage to the brain that happens when the body's metabolic processes are seriously impaired) .Acute hypoxemic [MEDICAL CONDITION] (Fluid build-up in the air sacs in the lungs) .[MEDICAL CONDITION] disorder (A low number of platelets in the blood) .End stage [MEDICAL CONDITION] . The facility's Clinical Notes dated [DATE] at 5:42 PM, documented, Resident returned to facility after [MEDICAL TREATMENT], pt discharged from hospital this am . Review of the Nursing Admission/Readmission Form dated [DATE] revealed a fall risk assessment score of 16, indicating Resident #58 was at moderate risk (score ,[DATE]) for falls. Review of the Transfer To [MEDICAL TREATMENT] Form dated [DATE] revealed Resident #58 was transported without an escort via wheelchair van to the [MEDICAL TREATMENT] clinic. The facility was unable to provide documentation an assessment was conducted for Resident #58, who was blind in both eyes and a bilateral [MEDICAL CONDITION] (surgical removal of both legs), to determine the resident's ability to participate safely in transportation via wheelchair van without an escort to [MEDICAL TREATMENT] after the change in condition which required an overnight hospital stay, with return to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no documentation of collaboration with the [MEDICAL TREATMENT] facility and transportation van services to determine any safety issues with transporting Resident #58. The facility's Clinical Notes Report dated [DATE] at 5:41 AM, documented, .Res (resident) LOA to [MEDICAL TREATMENT] via w/c van . The facility's Clinical Notes Report dated [DATE] at 11:06 AM, documented, .received call from (name of clinic) [MEDICAL TREATMENT] that resident was in the process of being picked up by (name of company) transportation and w/c tipped backwards (off of the lift gate) with resident in it; this nurse was informed that resident hit head (on concrete) during fall, but was alert and oriented at time of transport to ER (emergency room ); resident currently at ER for eval and tx . Hospital #1's Emergency Department (ED) Nurse Documentation dated [DATE] documented, .Presenting complaint: Patient states: was getting in van the driver was lifting his wheelchair (on the lift gate) and (Resident #58) fell out of wheelchair backward and hit his head on concrete . Hospital #1's ED Physician Documentation dated [DATE] documented, .The patient sustained injury to the head, patient was at [MEDICAL TREATMENT] and they were getting him into there (their) van and there chir (their chair) flipped (off the lift gate on the van) and (Resident #58) hit .head .Differential Diagnoses: [REDACTED].Fairly extensive bilateral temporal subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain), greater on the right .Disposition: [DATE] 13:52 Transfer ordered to (Name of Hospital #2 for a higher level of care). [DIAGNOSES REDACTED]. Review of the PT DC Summary dated [DATE] revealed Resident #58 was not receiving PT services at the time of the last fall on [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 10:31 AM, in the conference room, the DON was asked how it was determined the resident could safely travel in the transport van without an escort. The DON stated, You're going to have to read the PT (Physical Therapy) note .There's no assessment to see if he was safe to go in the van . The DON was asked how the facility assessed Resident #58 for safety to travel in the wheelchair van without an escort after he was readmitted from having the second lower extremity amputation [DATE], after he fell during transport on [DATE], and after his changes in condition and return from hospitalization s [DATE] and [DATE]. The DON stated, We don't do an assessment to say he can travel .when therapy picked him up, if he wasn't safe to be up in the chair, they would have told us. There was one little period he got weak .Restorative (Restorative Nursing Services, therapies provided by nursing staff) picked him up at that time . The DON was asked how was it determined whether residents need an escort to ride with them during transport in the wheelchair van. The DON stated, .people just don't go with them .you're not going to see that documented . The DON was asked whether she would expect the residents to be assessed/reassessed for traveling to appointments or treatments alone or without escorts after a change is status, hospitalization s or falls. The DON stated, .I would expect therapy to re-evaluate him. When we call to make the transportation and all of that, they would not go out there and assess him to put him on the van. If they felt like he was not safe to ride the van, they would let us know . The DON was asked to explain the process to determine what type of transportation the residents need for transport. The DON stated, .It goes more by the certification and necessity . Interview with the Rehab Manager on [DATE] at 11:36 AM, in the conference room, the Rehab Manager was asked how residents were assessed to safely travel without an escort in the wheelchair van. The Rehab Manager stated, .We don't assess them getting on the van because it is a lift. They don't transfer them. He never leaves that wheelchair. He gets on the lift, and they strap him in . The facility was unable to provide documentation that Resident #58 received a safety assessment to travel without an escort to [MEDICAL TREATMENT] after the following: a. after a significant change in status when Resident #58 returned to the facility [DATE] after a Left above the Knee Amputation (surgical removal of the left leg above the knee), changing his status to a bilateral [MEDICAL CONDITION] (surgical removal of both legs); b. after Resident #58 sustained a fall while traveling in the transportation van on [DATE]; c. after a change in condition when Resident #58 returned from the hospital on [DATE] after a surgical procedure and [MEDICAL CONDITION] (low levels of oxygen); d. after a change in condition when Resident #58 returned from the hospital on [DATE] after episodes of confusion and [MEDICAL CONDITION]. The failure of the facility to ensure safe conditions were provided for transport, failure to assess a resident for ability to participate in transport, and failure to provide a plan for safe transport to and return from [MEDICAL TREATMENT] treatments for Resident #58, a resident who was blind in both eyes, and a bilateral lower extremity [MEDICAL CONDITION] (surgical removal of both legs), resulted in IJ for Resident #58 when the resident sustained [REDACTED]. Review of the [MEDICAL TREATMENT] communication sheets revealed there was no [MEDICAL TREATMENT] communication between facility and [MEDICAL TREATMENT] for Resident #58 on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the discharge MDS dated [DATE] revealed Resident #1 had a BIMS score of 15, indicating no cognitive impairment, and received [MEDICAL TREATMENT] while a resident at the facility. The Care Plan Report dated [DATE] documented, .[MEDICAL TREATMENT] on Tues, Thurs, Sat .goes by community van in her w/c: BE AWARE she occasionally needs extra day of [MEDICAL TREATMENT] . The Physician order [REDACTED].[MEDICAL TREATMENT] Tuesday-Thursday-Saturday . The facility was unable to provide documentation that Resident #1 was assessed for the ability to safely participate in transportation via wheelchair van without an escort to [MEDICAL TREATMENT]. Review of the [MEDICAL TREATMENT] communication sheets revealed no [MEDICAL TREATMENT] communication documented between the facility and [MEDICAL TREATMENT] for Resident #1 for the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Medical record review revealed Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 6, which indicated severe cognitive impairment, and [MEDICAL TREATMENT] treatments. The care plan dated [DATE] documented, .risk for complications of [MEDICAL CONDITION] .[MEDICAL CONDITION] requiring [MEDICAL TREATMENT] . A physician's orders [REDACTED].[MEDICAL TREATMENT] Tuesday-Thursday-Saturday . Review of the [MEDICAL TREATMENT] communication sheets revealed there was no [MEDICAL TREATMENT] communication documented between the facility and [MEDICAL TREATMENT] for Resident #93 on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Interview with Assistant Director of Nursing (ADON) #2 on [DATE] at 2:53 PM, in the conference room, ADON #2 was asked about the missing transfer forms. ADON #2 stated, .sometimes the sheet doesn't come back with them ADON #2 was asked what the nurses do if the [MEDICAL TREATMENT] sheet does not come back with the resident. ADON #2 stated, .They would call and they'd say they'd fax it and we didn't get it and that shift nurse would go off . Medical record review revealed Resident #240 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed a BIMS score of 5, which indicated severe cognitive impairment and received [MEDICAL TREATMENT]. The physician's orders [REDACTED].[MEDICAL TREATMENT] Tuesday-Thursday-Saturday . The nurses' notes dated [DATE], [DATE], and [DATE] documented Resident #240 went to [MEDICAL TREATMENT] via wheelchair van. Observations of Resident #240 on [DATE] at 8:51 AM, revealed him to bed alert, hard of hearing, and lying in bed with the head of bed up. The breakfast meal was on the overbed table in front of the resident, and Resident #240 was leaning to the left side in bed. Resident #240 was asked whether he needed assistance with positioning, and he nodded his head to confirm that he did. The facility was unable to provide documentation that Resident #240 was assessed for the ability to safely participate in transportation via wheelchair van without an escort to [MEDICAL TREATMENT]. Medical record review revealed Resident #242 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed a BIMS score of 13, indicating no cognitive impairment, and Resident #242 received [MEDICAL TREATMENT]. The physician's orders [REDACTED].[MEDICAL TREATMENT] Tuesday-Thursday-Saturday . Review of the TRANSFER TO [MEDICAL TREATMENT] forms dated [DATE] and [DATE], revealed Resident #242 was transported to [MEDICAL TREATMENT] via wheelchair van. The facility was unable to provide documentation that Resident #242 was assessed for the ability to safely participate in transportation via wheelchair van without an escort to [MEDICAL TREATMENT]. The facility's failure to ensure a comprehensive approach to all care and services provided to facility residents and ensure communication between the [MEDICAL TREATMENT] center and the facility for Resident #58, #1, and #93; and the facility's failure to ensure safety assessments and plans were completed and implemented prior to residents being transported by a transportation van service for Resident #58, #1, #240, and #242 resulted in Immediate Jeopardy for Resident #58, a resident who was blind in both eyes, and a bilateral lower extremity [MEDICAL CONDITION] (surgical removal of both legs), when the resident sustained [REDACTED]. The resident was hospitalized as a result of the fall, declined during hospitalization , and expired in the hospital on [DATE]. An extended survey was completed on [DATE]. An acceptable allegation of compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on [DATE] at 6:57 PM. Corrective actions were validated onsite by the surveyors on [DATE] and [DATE]. Validation of the credible A[NAME] was accomplished onsite [DATE] and [DATE], through review of facility documents, review of in-service records, observations, and interviews with nursing staff. The surveyors validated the corrective actions stated in the A[NAME] were implemented which removed the immediate jeopardy. The facility provided evidence of in-service training with sign-in sheets for all charge nurses on completion of the Transfer Form to include the Safety Risk Assessment, including report to the transport driver, and signature of nurse, patient (if able), and driver, for every resident upon transfer off the facility premise; and to include an escort to accompany the resident in the event the driver refused to sign the Transfer Form. Interviews with the charge nurses conducted in the facility confirmed the nurses understood the transfer process was always to include the safety assessment with documentation. The noncompliance continues at F309-E for monitoring of effectiveness of the corrective actions to ensure sustained compliance. The facility is required to submit a plan of correction.",2020-09-01
2723,AHC DYERSBURG,445446,1900 PARR AVENUE,DYERSBURG,TN,38024,2017-10-06,281,K,1,1,DRLB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of The Lippincott Manual of Nursing Practice, 10th Edition, review of Snell, M. [NAME] (1999). Guidelines For Safely Transporting Wheelchair Users. OT Practice. 4(5) ,[DATE], policy review, observation, and interview, the facility failed to ensure the implementation of professional standards of practice for 4 of 4 (Resident #58, #1, #240, and #242) sampled residents reviewed who were being transported to and from [MEDICAL TREATMENT] by a transportation wheelchair van service. The facility failed to ensure residents' safety by conducting resident safety risk assessments in order to determine the residents' abilities to independently travel in a transportation van service to and return from [MEDICAL TREATMENT] treatments; and ensure a safety plan was developed and implemented for residents' safe transportation to and return from [MEDICAL TREATMENT] treatments. The failure of the facility to develop and implement a safety plan for residents using a transportation van service resulted in Immediate Jeopardy (IJ) for Resident #58, who was blind in both eyes and a bilateral lower extremity [MEDICAL CONDITION] (surgical removal of both legs), when the resident sustained [REDACTED]. The resident was hospitalized as a result of the fall, declined during hospitalization , and expired in the hospital on [DATE]. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The facility was cited an Immediate Jeopardy at F281-K. The Administrator, the Regional Nurse Consultant (NC), and the Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 4:48 PM, in the conference room. An extended survey was completed on [DATE]. An acceptable allegation of compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on [DATE] at 6:57 PM. Corrective actions were validated onsite by the surveyors on [DATE] and [DATE]. The Immediate Jeopardy was effective [DATE]. The immediacy was removed [DATE]. The noncompliance continues at F281-E for monitoring of effectiveness of the corrective actions to ensure sustained compliance. The findings included: The Lippincott Manual of Nursing Practice, 10th Edition documented, .Nursing Practice And The Nursing Process .Ensuring Safety .Continually assess safety .particularly if the patient is very ill and the care plan is complex .Assess for the patient's personal safety issues-sensory deficits (a defect in the function of one or more of the senses, such as [MEDICAL CONDITION]) . The Guidelines For Safely Transporting Wheelchair Users. OT Practice article documented, .Each person's wheelchair and seating system is a specialized unit designed to fit and provide unique postural control to him or her. When someone is to be transported in his or her wheelchair, the therapist, in conjunction with the client, family and rehabilitation supply dealer, needs to recommend and provide equipment that takes the transportation information into consideration. Additional equipment recommendations may be necessary to establish the highest possible safety level during transportation . The [MEDICAL TREATMENT] Services Agreement documented, .Operator (Long Term Care Facility) shall be responsible for making arrangements to transport the patient to Provider's ([MEDICAL TREATMENT]) Clinic .If the patient needs to be accompanied .Operator shall be responsible for making such arrangements. Operator shall also be responsible for ensuring that the patient is medically stable to be transported . The facility's Fall Risk/Fall Prevention Guidelines policy dated (MONTH) 2014, documented, .An assessment is the initial step in preventing avoidable falls. The completing of a fall risk assessment can be useful in identifying and managing risk factors. A Fall Risk Assessment .will be completed by a licensed nurse indicating the patient's risk factors .Upon admission/readmission to the facility .After a fall .Significant change in medical status .Quarterly .The licensed nurse completing the assessment will address the identified risk category, developing a plan of care, and the implementation of appropriate interventions to assist with fall prevention .Review of medications; eliminate unnecessary medications to reduce the risk of falls; patients receiving high risk medications .will be observed during routine care for possible adverse side effects .Post Fall Management is an opportunity to conduct a root cause analysis of a patients (patient's) fall, identifying specific factors that contributed to the fall. The fall determination will assist care givers in implementing interventions that are cause specific, possibly reducing future falls .Licensed Staff .Will complete the Nurse Event Note, detailing with as much information as possible, how/why the occurrence occurred .Attempt to determine the cause of the event, update the Fall Risk Assessment Tool, gather statements from staff members, resident, family and/or other witnesses; implement/modify the patient's current plan of care with intervention(s) associated with the cause of the fall .Nursing Administration .Will review all occurrences during the morning QA (Quality Assurance) meeting .The Interdisciplinary Team .will initiate a thorough investigation of the incident and discuss findings and potential interventions during the morning QA meeting .Finalize the Occurrence Investigation report, ensuring that all contributing factors have been identified, and the appropriate intervention has been implemented .Modify the patient's plan of care as needed .The DON or designee will input all fall data into the Facility's Monthly Fall Tracking Report .Fall Analysis .The Interdisciplinary Team will discuss falls in their morning QA meeting and perform a root cause analysis for each fall in order to identify why the fall occurred. The purpose of this process is to assist the clinician in implementing appropriate interventions that will reduce the occurrence of falls for the patient .The facility will share fall reporting data with the Medical Director, discussing any identified trends that may require further investigation and/or revision of the facility's procedures .Develop Corrective Action Plans as needed for identified trend(s) that may require further monitoring to achieve the optimum goal for fall reductions within the facility . Closed medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #58 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#58's status to a bilateral lower extremity [MEDICAL CONDITION] (surgical removal of both legs). Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], and the quarterly MDS dated [DATE], revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment, had severely impaired vision, required extensive staff assistance x (of) 2 for transfers and extensive staff assist x 1 for locomotion, walking did not occur, was not steady for surface to surface transfers, and was only able to stabilize with human assistance. No use of mobility device was documented. The physician's orders [REDACTED].[MEDICAL TREATMENT] Tuesday-Thursday-Saturday continuous (name of [MEDICAL TREATMENT] clinic) . The current care plan dated [DATE] documented, .[MEDICAL TREATMENT] on 3 days/week .is still Tu (Tuesday) /Th (Thursday) /Sa (Saturday) at .(Name of [MEDICAL TREATMENT] Clinic); transported by w/c (wheelchair) van . Review of the Nursing Admission/Readmission Form dated [DATE] revealed a fall risk assessment score of 13, which indicated Resident #58 was at moderate risk (score of ,[DATE]) for falls. Review of the Transfer to [MEDICAL TREATMENT] Form dated [DATE] revealed Resident #58 was transported without an escort via wheel chair van to the [MEDICAL TREATMENT] clinic. The facility was unable to provide any documentation that an assessment was conducted for Resident #58, who was blind in both eyes and a bilateral [MEDICAL CONDITION] (surgical removal of both legs), to determine the resident's ability to independently and safely transport via wheelchair van without an escort to [MEDICAL TREATMENT] after the recent significant change of condition of a left above the knee amputation on [DATE]. The Clinical Notes Report dated [DATE] at 1:51 PM documented, .resident (Resident #58) returned from access center (outpatient surgery center) .he stated he slid out of chair on wheelchair van .No new orders noted .Wheelchair van driver came and told this nurse that he did slide out of wheelchair . The facility was unable to provide documentation a fall investigation or a Post Fall risk assessment was performed after the fall during transport on [DATE]. Review of the current care plan dated [DATE] revealed no revisions to Resident #58's care plan with safety interventions being developed and implemented to ensure the patient's safety while being transported by the transportation van services for medical purposes. Review of the Transfer To [MEDICAL TREATMENT] Form dated [DATE] revealed Resident #58 was transported without an escort via wheelchair van to the [MEDICAL TREATMENT] clinic. Interview with the Director of Nursing (DON) on [DATE] at 4:50 PM, in the DON's Office, the DON was asked for the Nurse Event note for Resident #58's fall on [DATE] on the wheelchair van. The DON stated, .nurse didn't make one .It didn't happen here . The physician's office History and Physical dated [DATE] documented, .Pt (patient) was scheduled for an ERCP (Endoscopic Retrograde Cholangiopancreatography, a procedure that enables the physician to examine the pancreatic and bile ducts using a bendable lighted tube inserted through the mouth into the stomach and the small intestine) .Tues [DATE] .After pt has [MEDICAL TREATMENT] . The facility's clinical notes dated [DATE] at 5:49 AM, documented, .res (resident) is LOA to [MEDICAL TREATMENT] via wheelchair van . On [DATE] at 10:05 PM the facility's clinical notes documented, .nurse from (name of hospital) called this evening giving report on resident stating that O2 (oxygen) levels were low coming out of surgery but as soon as they were stable resident would be on way with new orders for ABT (antibiotic) and clear liquids . On [DATE] at 1:55 PM the facility's clinical notes documented, .resident returned from hospital . Review of the Nursing Admission/Readmission Form dated [DATE] revealed a fall risk assessment score of 14, indicating Resident #58 was at moderate risk (score of ,[DATE]) for falls. Review of the Transfer To [MEDICAL TREATMENT] Form dated [DATE] revealed Resident #58 was transported without an escort via wheelchair van to the [MEDICAL TREATMENT] clinic. The facility was unable to provide documentation an assessment was conducted and a transportation safety plan was implemented for Resident #58, who was blind in both eyes and a bilateral [MEDICAL CONDITION], to determine the resident's ability to participate safely in transportation via wheelchair van without an escort to [MEDICAL TREATMENT] after the change in condition which required a surgical procedure with an overnight hospital stay, with return to the facility on [DATE]. The facility's clinical notes dated [DATE] at 10:35 PM documented, .received new order from md (medical doctor) office to send (Patient #58) to ER (emergency room ) to tx (treatment) and evaluation due to recent episodes of confusion .prior to transfer resident's O2 % (percent) was 83 (normal range ,[DATE]%). Oxygen .was applied by this nurse. ems (emergency medical services) came and (Resident #58) was taken by ems to hospital around 4pm . The Hospital History and Physical dated [DATE] documented, .was transferred from nursing home with confusion and [MEDICAL CONDITION] to the 80s on room air .also .right upper extremity swelling .Impression Metabolic [MEDICAL CONDITION] (Temporary or permanent damage to the brain that happens when the body's metabolic processes are seriously impaired) .Acute hypoxemic [MEDICAL CONDITION] (Fluid build-up in the air sacs in the lungs) .[MEDICAL CONDITION] disorder (A low number of platelets in the blood) .End stage [MEDICAL CONDITION] . The facility's clinical notes dated [DATE] at 5:42 PM, documented, .Resident returned to facility after [MEDICAL TREATMENT], pt discharged from hospital this am . Review of the Nursing Admission/Readmission Form dated [DATE] revealed a fall risk assessment score of 16, indicating Resident #58 was at moderate risk (score of ,[DATE]) for falls. Review of the Transfer To [MEDICAL TREATMENT] Form dated [DATE] revealed Resident #58, who was blind in both eyes and a bilateral lower extremity [MEDICAL CONDITION] (surgical removal of both legs), was transported without an escort via wheelchair van to the [MEDICAL TREATMENT] clinic. The facility was unable to provide documentation an assessment and safety plan for transportation was implemented for Resident #58, who was blind in both eyes and a bilateral [MEDICAL CONDITION] (surgical removal of both legs), to determine the resident's ability to participate safely in transportation via wheelchair van without an escort to [MEDICAL TREATMENT] after the change in condition which required an overnight hospital stay, with return to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's clinical notes dated [DATE] at 5:41 AM, documented, .Res (resident) LOA (Leave of Absence) to [MEDICAL TREATMENT] via w/c van . On [DATE] at 11:06 AM the facility's clinical notes documented, .received call from (name of clinic) [MEDICAL TREATMENT] that resident was in the process of being picked up by (name of company) transportation and w/c tipped backwards (off the lift gate of the van) with resident (#58) in it; this nurse was informed that resident hit head (on concrete) during fall, but was alert and oriented at time of transport to ER (emergency room ); resident currently at ER for eval (evaluation) and tx (treatment) . Hospital #1's Emergency Department (ED) Nurse Documentation dated [DATE] documented, .Presenting complaint: Patient states: was getting in van the driver was lifting his wheelchair and (Resident #58) fell out of wheelchair backward (off the lift gate of the van) and hit .head on concrete . Hospital #1's ED Physician Documentation dated [DATE] documented, .The patient sustained injury to the head, patient was at [MEDICAL TREATMENT] and they were getting him into there (their) van and there chir (their chair) flipped (off the lift gate of the van) and hit .head (on concrete) .Differential Diagnoses: [REDACTED].Fairly extensive bilateral temporal Subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain), greater on the right .Disposition: [DATE] 13:52 Transfer ordered to (Name of Hospital #2 for higher level of care). [DIAGNOSES REDACTED]. Interview with the DON on [DATE] at 10:25 AM, in the conference room, the DON was asked if the facility had a transport safety assessment and plan for residents to travel without an escort via wheelchair van to [MEDICAL TREATMENT]. The DON stated, .It does not specifically ask that question . The DON verified there was no specific policy related to completion of assessment for safety for residents traveling in the wheelchair van without an escort. The facility was unable to provide documentation that Resident #58, a vulnerable resident with [MEDICAL CONDITION] and bilateral lower extremity amputations, received a safety assessment to determine his ability to safely participate in travel without an escort to [MEDICAL TREATMENT] after the changes in status as follows: a. after a significant change in status when Resident #58 returned to the facility [DATE] after a Left above the Knee Amputation, changing his status to a bilateral [MEDICAL CONDITION]; b. after Resident #58 sustained a fall out of the wheelchair while traveling in the transportation van on [DATE]; c. after a change in condition when Resident #58 returned from an overnight hospital stay on [DATE] after a surgical procedure and [MEDICAL CONDITION] (low oxygen levels); d. after a change in condition when Resident #58 returned from an overnight hospital stay on [DATE] after episodes of confusion and [MEDICAL CONDITION]. The failure of the facility to ensure a safety plan was developed or implemented for residents who used a transportation van service for medical reasons resulted in an IJ for Resident #58, a resident who was blind in both eyes, and a bilateral lower extremity [MEDICAL CONDITION] (surgical removal of both legs), when the resident sustained [REDACTED]. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the discharge MDS dated [DATE] revealed Resident #1 had a BIMS score of 15, indicating no cognitive impairment, and received [MEDICAL TREATMENT] while a resident at the facility. The facility's Care Plan Report dated [DATE] documented, .[MEDICAL TREATMENT] on Tues, Thurs, Sat .goes by community van in her w/c . The facility's Physician order [REDACTED].[MEDICAL TREATMENT] Tuesday-Thursday-Saturday . The facility was unable to provide documentation that Resident #1 was assessed for the ability to safely participate in transportation via wheelchair van without an escort to [MEDICAL TREATMENT]. Medical record review revealed Resident #240 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed Resident #240 had a BIMS score of 5, indicating severe cognitive impairment, and received [MEDICAL TREATMENT]. The physician's orders [REDACTED].[MEDICAL TREATMENT] Tuesday-Thursday-Saturday . Review of the nurses' notes dated [DATE], [DATE], and [DATE] revealed Resident #240 went to [MEDICAL TREATMENT] via wheelchair van. Observations of Resident #240 on [DATE] at 8:51 AM, in Resident #240's room, revealed he was alert, hard of hearing, and lying in bed with the head of bed up. The breakfast meal was on the overbed table, and Resident #240 was leaning to the left side in bed. Resident #240 was asked whether he needed assistance with positioning, and he nodded his head to confirm that he did. The facility was unable to provide documentation that Resident #240 was assessed for the ability to safely participate in transportation via wheelchair van without an escort to [MEDICAL TREATMENT]. Medical record review revealed Resident #242 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed Resident #242 had a BIMS score of 13, indicating no cognitive impairment, and received [MEDICAL TREATMENT]. The physician's orders [REDACTED].[MEDICAL TREATMENT] Tuesday-Thursday-Saturday . Review of the Transfer To [MEDICAL TREATMENT] Form dated [DATE] and [DATE] revealed Resident #242 was transported to [MEDICAL TREATMENT] via wheelchair van. The facility was unable to provide documentation that Resident #242 was assessed for the ability to safely participate in transportation via wheelchair van without an escort to [MEDICAL TREATMENT]. An extended survey was completed on [DATE]. An acceptable allegation of compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on [DATE] at 6:57 PM. Corrective actions were validated onsite by the surveyors on [DATE] and [DATE]. Validation of the credible A[NAME] was accomplished onsite [DATE] and [DATE], through review of facility documents, review of in-service records, observations, and interviews with nursing staff. The surveyors validated the corrective actions stated in the A[NAME] were implemented which removed the immediate jeopardy. The facility provided evidence of in-service training with sign-in sheets for all charge nurses on completion of the Transfer Form to include the Safety Risk Assessment, including report to the transport driver, and signature of nurse, patient (if able), and driver, for every resident upon transfer off the facility premise; and to include an escort to accompany the resident in the event the driver refused to sign the Transfer Form. Interviews with the charge nurses conducted in the facility confirmed the nurses understood the transfer process was always to include the safety assessment with documentation. The facility was cited an Immediate Jeopardy at F281-K. The noncompliance continues at F281-E for monitoring of the corrective actions to ensure sustained compliance. The facility is required to submit a plan of correction.",2020-09-01
2354,SIGNATURE HEALTHCARE OF MONTEAGLE REHAB & WELLNESS,445393,26 SECOND STREET,MONTEAGLE,TN,37356,2020-01-23,744,D,1,0,C1QB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of a facility document, medical record review, observations, and interviews, the facility failed to provide dementia care to prevent escalation of behaviors for 1 resident (#5) of 6 residents with dementia reviewed. The findings included: Review of a facility document dated 12/19/2019 showed .Resident altercation .Resident (Resident #5) struck another resident (Resident #4) in the face .(Resident #5) Agitated .Staff heard yelling and responded promptly .Resident was placed under 1:1 and other resident was evaluated . Medical record review showed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly MDS dated [DATE] showed Resident #5 had short and long term memory loss. Medical record review of Resident # 5's Comprehensive Care Plan dated 2/29/2019 showed .Impaired cognitive skills .[MEDICAL CONDITIONS] type . Review of the revised care plan dated 11/6/2019 showed .At risk and/or active behavior problems .Socially Inappropriate .Verbally Abusive .slamming doors, anxious at times, yelling out, not allowing staff to clean room, getting into others personal space .Reduce the following stressors that may be contributing to the resident's inappropriate behavior loud surroundings, overstimulation . Medical record review of a Nurse's note dated 11/20/2019 showed .(Resident #5) has been slamming door to his room throughout the shift today . Medical record review of a Nurse's note dated 11/25/2019 showed .(Resident #5) has been slamming doors and yelling out this shift . Medical record review of a Nurse's note dated 12/1/2019 showed .(Resident #5) has had several verbal outbursts this shift. Resident has been getting close to other resident's and yelling at them .Resident began to slam to door (door to) his room after lunch . Medical record review of a Nurse's note dated 12/3/2019 showed .(Resident #5) has been yelling out this shift. Resident will come out of his room begin yelling and return to his room and slam his door . Medical record review of a Nurse's note dated 12/7/2019 showed .(Resident #5) did slam his room door once or twice early in the shift before going to sleep . Medical record review of a Nurse's note dated 12/12/2019 showed .(Resident #5) has not had any verbal outbursts this shift. Resident has slammed the door to his room multiple times . Medical record review of a Social Services Note dated 12/20/2019 showed .Late entry: SSD (Social Service Director) was still in the building late yesterday afternoon when .(Resident #5) was involved in an altercation with another Elder which resulted in the other Elder being hit in the nose by . Medical record review of a Behavioral Health Physician's Progress Note for Resident #5 dated 12/26/2019 showed .nsg (nursing) reports recent resident altercation where (Resident #5) was the aggressor .some periods of labile mood, agitation .noted periods of increased agitation .anxiety . Medical record review showed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's Significant Change Minimum Data Set ((MDS) dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 12 indicating the resident had moderate cognitive impairment. Medical record review of Resident #4's Behavioral Medicine Progress note dated 12/26/2019 revealed .nsg (nursing) reports resident altercation where pt. (patient) was the non-aggressor .Per exam patient is alert with no noted anxiety or agitation .Noted confusion consistent with dementia .No noted clinical evidence of any psychological harm per exam . Interview with Certified Nursing Assistant (CNA) #4 on 1/21/2020 at 12:30 PM revealed .I was walking out of the breakroom .I heard some yelling .heard (Resident #4) say get away from me. I turned around and looked in front of the dining room and saw him (Resident #4) sitting in his wheel chair in front of the dining room. I saw a little blood on the side of his nose .I asked him what happened he pointed at (Resident #5) and said he hit me .(Resident #5) slams his room door sometimes he doesn't like loud noises and sometimes the activities get loud . Observation of Resident #5 on 1/21/2020 at 1:15 PM revealed the resident ambulated down the hall toward his room, entered his room and then slammed the door. Interview with the Occupational Therapist on 1/21/2020 at 1:35 PM revealed .I was in the therapy room, I heard a commotion .(Resident #5) yelling . both (Resident #4) and (Resident #5) were in the hallway they were about 10 feet apart. I didn't see anything happen, I saw .(Resident #4) had some blood on his face and .(Resident #5) was in distress. That is what made me think an incident had occurred between them .(Resident #5) isn't an aggressive type person but he does have strong emotions about his situation and can get defensive if someone yells or loud noises . Interview with Licensed Practical Nurse (LPN) # 4 on 1/21/2020 at 2:00 PM revealed .(CNA #4) brought .(Resident #4) to the nurses' station she said she didn't see anything but she had heard yelling and saw .(Resident #4) and (Resident #5) in the hallway and (Resident #4's) nose was bleeding. It was a superficial laceration .there was a little swelling to the area. I cleaned him up .applied an ice pack to the area and within an hour it was much improved .I asked him (Resident #4) what happened and he said that young boy (Resident #5) hit me in the face .that was all I could get out of him .We do behavior charting on him (Resident #5) daily for any aggressive behaviors, or yelling and slamming of doors .Slamming doors is a daily occurrence, and he does yell at other residents but nothing physical . Interview with CNA #5 on 1/21/2020 at 4:30 PM revealed .loud noises seem to set him (Resident #5) off and he will yell but I can't understand what he is saying .One day he was in the dining room and he started out low saying 'bastard' then he kept getting louder so we asked him if he wanted to eat in his room and he said 'yeah.' He can get upset very quickly. About the only words he says that you can understand are yeah and bastard . Observation and interview with Resident #5 in his room on 1/22/2020 at 12:10 PM revealed the resident lying on the bed awake and alert. The resident laughed and mumbled a few unidentifiable words. Observation and interview with Resident #4 in his room on 1/22/2020 at 12:25 PM showed the resident was awake and was lying on the bed. No anxious or fearful behaviors were observed. Interview with the resident revealed .well I was watching him (Resident #5) and another fell ow talking. When (Resident #5) was getting ready to leave the dining room he just walked up to me and popped me on the side of my nose. It didn't .hurt .just stunned me. I hadn't done anything and I hadn't said a word to him .I don't know why he did that . Interview with the Director of Nursing (DON) on 1/23/2020 at 10:35 AM confirmed the facility failed to supervise Resident #5 while the resident was in an environment known to escalate the resident's behaviors.",2020-09-01
1554,TENNESSEE VETERANS HOME,445270,PO BOX 10299,MURFREESBORO,TN,37129,2018-04-26,609,D,1,0,F2N711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of a facility investigation and interview the facility failed to report timely one abuse investagation of 5 abuse investigations reviewed. Findings Include: Review of a facility investigation dated 4/8/18 revealed on the evening of 4/7/18 Resident #11 reported to Certified Nurse Aide (CNA) #1 he was missing a large sum of money from his room. Continued review revealed CNA #1 approached Nurse #1 around 9:00 PM on 4/7/18 and told her she had something to tell her but as Nurse #1 was busy passing medications, CNT #1 told Nurse #1 she would tell her later. Further review revealed around midnight on 4/8/18 CNT #1 reported to Nurse #1 Resident #11 had told her he was missing money. Continued review revealed Nurse #1 did not report the allegation of abuse to the facility administration. Nurse #1 reported the allegation to the oncoming nurse supervisor around 7:00 AM on 4/8/18. Resident # 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS) revealed a score of 15/15 indicative of the resident was cognitively intact. Resident #11 required minimal assistance with activities of daily living (ADL) and used a wheelchair to self propel for mobility. Resident #11 has left sided paralysis and continent of bowel and bladder. Interview with Resident #11 on 4/25/18 at 10:57 AM in his room revealed Resident #11 stated he had gone to the bank on 3/28/18 and withdrew the $1200.00 and showed surveyor the receipt. Continued interview revealed Resident #11 stated he kept his wallet in his pants pocket when he was out of his room and at night when he sleeps he locks his wallet in his drawer in the cabinet next to his bed and he keeps the key in his pillow case. Continued interview revealed on the morning of 4/2/18 when he awoke around 6:00 AM, he noticed the key to the drawer was almost hanging out of the pillow case and his money was gone. When asked why he waited until 4/7/18 to report the missing money, Resident #11 stated he was setting a trap with cans to try to catch someone trying to get into his drawer. Resident #11 stated he removed all the items from his drawer to look for his money and his room was observed to have numerous boxes of various sizes, stacked along 3 walls of the room, and the closet door had a large amount of clothing hanging from a hook on the door. Resident #11 is in a private room close to the West Unit Nurse Station. Resident #11 also stated that he now keeps his wallet in the back of the drawer and underneath the other articles in the drawer. Interview with the Director of Nursing (DON) revealed Resident #11 had not been consistent in his reporting of what happened with the missing money. Continued interview with the DON revealed Resident #11 told her he had withdrew the money for a trip to Hawaii to see his grandchildren, but he ended up using it to buy someone a car. Further interview with the DON revealed Resident #11 stated he ordered a pizza on 4/2/18 and video footage showed the pizza to be delivered on 4/1/18. Resident #11 also stated he dropped a large sum of money on the floor while paying for the pizza and the pizza delivery man offered to help him pick it up in which he declined the help. Resident #11 also stated he was alone when the pizza was delivered, however; video footage showed Licensed Practical Nurse (LPN) #7 exiting the room after the pizza delivery. Witness statement by LPN #7 dated 4/8/18 revealed she was in the room when the pizza was delivered and did not see Resident #11 drop a large sum of money when paying for the pizza. LPN #7 worked a shift on 4/1/18, 4/2/18 and 4/3/18 and Resident #11 did not report any missing money to her. Interview with the Administrator revealed he had cautioned Resident #11 in the past about keeping large sums of money in his room and offered to keep money in Resident Account Fund and Resident #11 declined. Continued interview with the Administrator revealed he interviewed the Resident on 4/9/18 and was told by Resident #11 he realized the money was missing when he was going to pay down on his private room bill. Resident #11 told the Administrator he had planned to pay the facility $1,000.00 on 4/2/18 and his money was taken sometime between 8:30 PM on 04/01/18 and 10:30AM on 4/2/18. Review of a Police Report dated 4/8/18, revealed Resident #11 reported to the police officer he had $1300.00 in $100 dollar bills in his wallet, locked in his dressser. Continued review of the Police Report revealed Resident #11 reported last seeing the money at 9:00AM on 4/1/18 before he left for church and realized it was missing on 4/2/18 when he was paying for his pizza. Further review of the Police Report revealed Resident #11 lock on his dresser only worked part time and he was unsure of who would have of come into his room and taken his money. Telephone intervie conducted with a Detective from the local Police Department on 4/25/18 at 1:25 PM revealed he had watched video footage from the facility and had questioned Resident #11, facility staff, and two of Resident #11 friends who frequently took him out on outings. Continued interview with Police Dectective revealed Resident #11 had changed his story several times and one of his friends had stated Resident#11 often carries large sums of money. Further interview with Resident #11 friend revealed he had taken Resident #11 on an outing on 4/1/18 and did not know how much money Resident #11 had that day but Resident #11 had given money in church and after church and he took him to buy lottery tickets. Review of Resident #11's leave of absence sheet documented he had signed out on 4/1/18 at 10:45 AM and no documented time of his return. Review of facility videos of Resident #11's hallway revealed on 4/1/18 at 8:25 PM pizza delivery man entered the room and exited 8:28 PM. LPN #7 exited at 8:31 PM. Two other staff entered and exited the room at 9:07 PM and 9:12 PM. Resident #11's call light was answered around 10:40 PM and ice was brought to him. LPN #7 entered the room at 11:08 PM to administer night time medications and exited the room at 11:14 PM. Resident's call light was answered around 12:50 AM on 4/2/18 and again around 4:50 AM. His call light was again answered at around 6:25 AM. Resident #11 had stated to this surveyor the money had to have been taken between the times he went to sleep, after midnight until he was awakened around 6:00- 6:30 AM. No one was seen on the video entering his room after answering his call light at 12:50 AM until his call light was answered at 4:50 AM (staff exited at 4:52 AM), and then again at 6:25 AM. Review of the Resident Council meeting minutes were reviewed for the past year with no concerns documented from residents about missing money or items. Telephone interview with CNA #1 on 4/26/18 at 10:15 AM confirmed she did not immediately report the allegation of misappropriation to her supervisor or Abuse Coordinator. Telephone interview with Nurse #1 on 4/25/18 at 3:58 PM revealed she did not immediately report the allegation of abuse to the Abuse Coordinator and had failed to comply with the reporting of abuse allegations to the State Agency within the required 2 hour time frame.",2020-09-01
2162,SIGNATURE HEALTHCARE OF FENTRESS COUNTY,445362,208 DUNCAN ST N,JAMESTOWN,TN,38556,2018-06-13,684,D,1,1,1BIR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of a facility job description, review of medical records, review of personnel records and interview, the facility failed to ensure 1 resident (#450) received transportation to a physician's follow-up appointment, of 3 residents reviewed for resident/facility transportation. The findings included: Review of the facility job description Transportation Aide (CNA) (Certified Nursing Assistant) revealed .transport residents to appointments and perform direct resident care duties under the supervision of licensed nursing personnel .notify family of arrangements in regards to appointments .report changes in condition to Charge Nurse . Medical record review revealed Resident #450 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician/Prescriber Order dated 4/16/18 revealed .F/u (follow-up) .5-14-18 .facility to transport . Telephone interview with the husband of Resident #450 on 6/11/18 at 1:15 PM revealed the facility did not transport the resident to her follow-up orthopedic appointment on 5/14/18. He revealed he was called on the phone by a staff member (could not recall name) and informed the facility was too busy . could not take her to the appointment. Interview with CNA #1 on 6/11/18 at 4:00 PM, in the Station 3 breakroom, confirmed she was scheduled to transport Resident #450 for a follow-up appointment with an orthopedic surgeon on 5/14/18 in the facility van. Further interview confirmed CNA #1 canceled the physician appointment .she had to go to the bathroom, she is a 2 person assist .I had to find help .it took her a long time to go .we would have been 10 minutes late . Continued interview confirmed CNA #1 did not notify the nurse or the family prior to canceling the appointment. Review of the personnel file for CNA #1, Coaching & Counseling Session, dated 5/14/18 revealed .insubordination, non performance of .duties or assignments .cancelled/rescheduled a resident's previously scheduled appointment without due cause .failed to properly notify family of the cancellation/rescheduling of the resident's appointment . Interview with the Director of Nursing (DON) on 6/12/18 at 10:50 AM, in the DON office, confirmed the facility failed to ensure Resident #450 was transported to a scheduled outside physician appointment; and failed to to notify the assigned nurse and family prior to the appointment cancellation.",2020-09-01
493,"THE WATERS OF WINCHESTER, LLC",445145,1360 BYPASS ROAD,WINCHESTER,TN,37398,2019-06-11,609,D,1,0,MC9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of a facility policy, medical record review, and interviews, the facility failed to report an injury of unknown injury involving bodily injury for 1 resident (#1) of 3 residents reviewed for injuries of unknown origin. The findings include: Review of facility policy Abuse Prevention Policy Updated 1/19/17 revealed .All personnel must promptly report any incident of resident abuse, mistreatment or neglect, including injuries of unknown origin .when the source of the injury was not observed or known by any person . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 14 day Minimum (MDS) data set [DATE] revealed Resident #1 scored a 4 (severe cognitive impairment) on the Brief Interview for Mental Status. Medical record review of a nursing progress note dated 5/27/19 at 3:16 PM revealed .c/o (complains of) increased pain to right hip .(named physician) informed .received a new order to obtain right hip x-ray . Medical record review of a Mobile Radiology Report dated 5/27/19 revealed .There is a right hip hemiarthroplasty in normal position. A moderately displaced [MEDICAL CONDITION] trochanter is present. Surgical staples are present in the proximal right thigh laterally. No other fracture dislocation or other abnormalities of the right hip are present .Conclusion .Displaced [MEDICAL CONDITION] trochanter, new . Interview with Licensed Practical Nurse (LPN) #2 on 6/10/19 at 4:20 PM, in the conference room, revealed .on 5/27/19 she (Resident #1) started having some hip pain even with her PRN (as needed) medication .she had started to complain of pain in her hip, her medication was not as effective as it had been. I called the doctor and told him and he ordered a right hip x-ray .I am not aware of anything out of the ordinary occurring, the only thing different was an increased complaint of pain. No one reported anything from any shift (increased pain or injury) . Telephone interview with LPN #2 on 6/11/19 at 9:40 AM revealed .when I came in on the 27th around 6:30 PM .(LPN #1) reported .(Resident #1) had complained of increased pain and the x-ray technician was here .I picked up the x-ray results off the fax early on the 28th and passed them to the day shift nurse .during the night she never complained of pain .and there weren't any non-verbal signs of pain or any discomfort .I am not aware of anything happening, any incidents or a fall that would have attributed to the fracture. I know now I should have checked the fax machine and reported the results immediately . Interview with the Director of Nursing (DON) on 6/11/19 at 11:25 AM, in the conference room, revealed .on Tuesday morning about 10:30 AM, I was notified of the x-ray results of a lesser trochanter fracture on (Resident #1's) right side. I immediately started an investigation .during the interviews with staff no one was aware of any incidents or occurrences that would have attributed to a fracture. I was not able to identify anything indicating abuse/neglect or concerns related to quality of care . Continued interview confirmed the x-ray was obtained at approximately 6:30 PM on 5/27/19 and the x-ray report was faxed to the facility on [DATE] at approximately 7:00 AM. Further interview revealed the DON was notified of the results at approximately 10:30 AM and .I should have been notified immediately when the results were reviewed by the nurse at 7:00 AM . Continued interview confirmed the facility failed to report an injury of unknown origin timely to the State survey agency and the facility failed to follow facility policy.",2020-09-01
1097,RENAISSANCE TERRACE,445223,257 PATTON LANE,HARRIMAN,TN,37748,2018-09-25,689,D,1,0,V9FH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of a facility policy, medical record review, documentation review and interviews the facility failed to follow the facility's Fall Risk Management Policy for 1 resident (#1) of 3 residents reviewed for falls. The findings include: Review of a facility policy Fall Risk Management dated 2/12, revealed .A fall risk assessment needs to be completed on admission, after each fall .The fall risk care plan is to be updated after each fall . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and discharged on [DATE], with [DIAGNOSES REDACTED]. Review of a 14 day Minimum (MDS) data set [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment, further review revealed the resident required extensive assistance with toilet use, personal hygiene, and was frequently incontinent of both bowel and bladder. Review of a care plan dated 8/29/18 revealed .I am at moderate risk for falls r/t (related to) Confusion, Unaware of safety needs . Further review revealed no new fall precaution interventions for the fall occurring on 9/3/18. Review of an Incident Note dated 9/4/17 10:57 AM, revealed Late Entry: .assessed resident due to resident stating she had a fall .daughter in law present UA (Urine Analysis) with C &S (Culture and Sensitivity) ordered .C/O (complained of) her left knee being bruised observed left knee being swollen with some mild pale colored purple discoloration. Resident rubs this knee frequently possible arthritis per daughter in law. Left forearm observed to have various stages and colors of Ecchymosis. Actually on both arms. Next c/o headache states a pain goes to the crown of her head from her neck. Observed residents head .no discoloration or raised areas seen or felt. Daughter in law in agreement for series of x-rays on lateral skull, left forearm, left knee, order was placed stat . Review of a facility document Risk Management dated 9/3/18, revealed Resident #1 slid from her wheelchair head to toe assessment completed ROM (range of motion), pain assessed no injuries noted .Action .Falls Risk Evaluation .not created .IDT (interdisciplinary team): Therapy notified. Therapy to screen for positioning while up in wheelchair due to decreased safety awareness . Interview with the Registerd Nurse Supervisor on 9/24/18 at 6:15 PM, in the conference room confirmed Resident #1 had a documented fall on 9/3/18 at 6:12 AM. Continued interview confirmed the facility failed to follow their Fall Risk Management policy and did not complete a Falls Risk Assessment after a documented fall, and failed to update the fall risk care plan.",2020-09-01
3570,BLEDSOE COUNTY NURSING HOME,4.4e+233,107 WHEELERTOWN AVENUE,PIKEVILLE,TN,37367,2019-11-25,677,E,1,0,YOOH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of a facility policy, medical record review, observations, and interviews, the facility failed to provide nail care as needed for 11 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) dependent residents of 41 residents reviewed for Activities of Daily Living (ADL) care. The findings included: Review of a facility policy Nails, Care of (Finger and Toe), not dated, revealed .Purpose .to provide cleanliness .Procedure .scrub nails gently with brush .Trim and clean nails; file smoothly . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's Annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment. Continued review revealed the resident was dependent on the staff for Bed Mobility, Transfer, Dressing, Eating, Toilet Use, and Personal Hygiene. Medical record review of Resident #1's Comprehensive Care Plan last reviewed on 10/31/19 revealed .the Resident Has an ADL performance deficit .The resident is totally dependent on 1 staff for personal hygiene and oral care . Observation with Resident #1 on 11/25/19 at 6:05 AM, in her room, revealed the resident lying in bed awake and alert. Continued observation revealed the resident was lying on her back with her head on a pillow, covered with a sheet and a blanket. Continued observation revealed the resident's nails were approximately 3/8 inch in length from the tip of her finger, and dark debris was observed underneath the second, third, fourth and fifth fingernails on both of the resident's hands. Observation of Resident #1 with Licensed Practical Nurse (LPN) #1 on 11/25/19 at 7:00 AM, in her room, revealed the resident had dark debris underneath her second, third, fourth, and fifth fingernails on her right and left hands. Continued observation revealed a foul odor was detected from the resident's hands. Interview with LPN #1 on 11/25/19 at 12:00 PM, in the conference room, revealed .she (Resident #1) does play in her feces, and likely the dark odorous material underneath her fingernails is just that . Continued interview confirmed the resident had not received needed personal hygiene and nail care. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's Quarterly MDS dated [DATE] revealed the resident had short and long term memory problems. Continued review revealed the resident was dependent for Personal Hygiene. Medical record review of Resident #2's Comprehensive Care Plan last reviewed on 11/14/19 revealed .the resident has an ADL self-care deficit . Observation of Resident #2 with LPN #1 on 11/25/19 at 7:09 AM, in her room, revealed dark debris under her left second, third fingers and her right second finger. Interview with LPN #1 continued interview confirmed the resident had not received needed personal hygiene and nail care. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #3's Quarterly MDS dated [DATE] revealed a BIMS score of 7 indicating severe cognitive impairment. Continued review revealed the resident required limited assistance with personal hygiene. Medical record review of Resident #3's Comprehensive Care Plan last reviewed on 9/4/19 revealed .the resident needs assistance with ADL's as required during the activity . Observation of Resident #3 with LPN #1 on 11/25/19 at 7:20 AM, in his room, revealed the resident's left third fingernail was cracked and had zagged edges, and the resident's first, second, and third fingernails on the right hand had dark debris under the nails. Interview with LPN #1 confirmed the resident had not received needed personal hygiene and nail care. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #4's Quarterly MDS dated [DATE] revealed a BIMS score of 1 indicating severe cognitive impairment. Continued review revealed the resident required limited assistance with personal hygiene. Medical record review of Resident #4's Comprehensive Care Plan last reviewed on 10/18/19 revealed .the resident requires assist by 1 staff with personal hygiene . Observation of Resident #4 with LPN #1 on 11/25/19 at 7:25 AM, in her room, revealed the resident had dark odorless debris under her left second and third fingernails. Interview with LPN #1 confirmed the resident had not received needed personal hygiene and nail care. Medical record review revealed Resident #5 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #5's Annual MDS dated [DATE] revealed the resident had short and long term memory problems. Continued review revealed the resident required extensive assistance with personal hygiene. Medical record review of Resident #5's Comprehensive Care Plan last reviewed on 11/21/19 revealed .the resident requires extensive assistance by 1 staff with personal hygiene . Observation of Resident #5 with LPN #1 on 11/25/19 at 7:30 AM, in her room, revealed dark odorless debris under the residents left second, third, fourth, and fifth fingernails. Interview with LPN #1 confirmed the resident had not received needed personal hygiene and nail care. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #6's Quarterly MDS dated [DATE] revealed a BIMS score of 0 indicating severe cognitive impairment. Continued review revealed the resident was dependent on staff for personal hygiene. Review of Resident #6's Comprehensive Care Plan last reviewed on 10/12/19 revealed .the resident is total dependent on 1 staff for personal hygiene . Observation of Resident #6 with LPN #1 on 11/25/19 at 7:37 AM, in his room, revealed the resident had dark odorless debris underneath his left first, third, and 4th fingernails. Interview with LPN #1 confirmed the resident had not received needed personal hygiene and nail care. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #7's MDS dated [DATE] revealed a BIMS score of 0 indicating severe cognitive impairment. Continued review revealed the resident was dependent on staff for personal hygiene. Medical record review of Resident #7's Comprehensive Care Plan dated 10/15/19 revealed .the resident is totally dependent on 1 staff for personal hygiene . Observation of Resident #7 with LPN #1 on 11/25/19 at 7:42 AM, in her room, revealed the resident had dark odorless debris underneath her left third, fourth, and fifth fingernails. Interview with LPN #1 confirmed the resident had not received needed personal hygiene and nail care. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #8's Annual MDS dated [DATE] revealed a BIMS score of 0 indicating severe cognitive impairment. Continued review revealed the resident was dependent on staff for personal hygiene. Review of Resident #8's Comprehensive Care Plan last reviewed on 11/1/19 revealed .the resident requires total assistant 1 - 2 staff for all personal hygiene . Observation of Resident #8 with LPN #1 on 11/25/19 at 7:50 AM, in his room, revealed the resident had dark debris underneath his right first, second, third, fourth, and fifth fingernails. Further observation revealed the resident's hand had a foul odor. Interview with LPN #1 confirmed the resident had not received needed personal hygiene and nail care. Medical record review revealed Resident #9 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #9's Quarterly MDS dated [DATE] revealed a BIMS score of 0 indicating severe cognitive impairment. Continued review revealed the resident was dependent for personal hygiene. Medical record review of Resident #9's Comprehensive Care Plan last reviewed on 9/3/19 revealed .the resident requires assist by 1 staff with personal hygiene . Observation of Resident #9 with LPN #1 on 11/25/19 at 7:57 AM, in his room, revealed the resident had odorless dark debris underneath his left second and third fingernails and his right second and third fingernails. Interview with LPN #1 room confirmed the resident had not received needed personal hygiene and nail care. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #10's Quarterly MDS dated [DATE] revealed a BIMS score of 2 indicating severe cognitive impairment. Continued review revealed the resident was dependent on staff for personal hygiene. Medical record review of Resident #10's Comprehensive Care Plan last reviewed on 11/14/19 revealed .the resident is dependent on staff to meet all personal hygiene . Observation of Resident #10 with LPN #1 on 11/25/19 at 7:59 AM, in her room, revealed the resident had dark odorless debris underneath her left third and fourth fingernails and her right third, and fourth fingernails. Interview with LPN #1 confirmed the resident had not received needed personal hygiene and nail care. Medical record review revealed Resident #11 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #11's Quarterly MDS dated [DATE] revealed the resident had short and long term memory problems. Continued review revealed the resident was dependent on staff for personal hygiene. Medical record review of Resident #11's Comprehensive Care Plan last reviewed on 11/1/19 revealed .the resident is totally dependent on 1 staff for personal hygiene . Observation of Resident #11 with LPN #1 on 11/25/19 at 8:03 AM, in his room, revealed thick dark odorless debris underneath his right fourth finger. Interview with LPN #1 confirmed the resident had not received needed personal hygiene and nail care. Interview with Certified Nursing Assistant (CNA) #1 at 8:15 AM, at the nurses' station, confirmed nail care was to be done during the residents shower and daily as needed. Interview with CNA #2 on 11/25/19 at 8:20 AM, at the nurses' station, confirmed nail care was to be done during the residents shower and every time it was needed. Interview with the Director of Nursing (DON) on 11/25/19 at 12:40 PM, in the conference room, confirmed .nail care is to be done with every shower and on an as needed basis . Interview with LPN #1 on 11/25/19 at 12:50 PM, in the conference room, confirmed the facility failed to provide ADL care for Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11.",2020-09-01
2164,SIGNATURE HEALTHCARE OF FENTRESS COUNTY,445362,208 DUNCAN ST N,JAMESTOWN,TN,38556,2019-10-23,755,D,1,0,5D2K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of a facility policy, medical record review, review of a facility investigation, and interview, the facility failed to ensure medications were obtained from the facility pharmacy for 1 resident (#2) of 4 residents reviewed for medication administration. The findings included: Review of a facility policy, Medication Ordering and Receiving From Pharmacy - Provider Emergency Pharmacy Service and Emergency Kits (E-Kits) dated 5/2016, revealed .Emergency pharmaceutical service is available on a 24-hour basis .Medications are not borrowed from other residents. The ordered medication is obtained either from the emergency kit or from the provider pharmacy . Medical record review revealed Resident #2 was admitted to the facility on [DATE] at 7:17 PM with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].Eliquis (anticoagulant) tablet 2.5 mg (milligram) oral (by mouth) twice a day . Continued review revealed the medication was to be administered the morning of 8/30/19. Review of a facility investigation dated 9/3/19 revealed on 8/30/19 the facility had not received the Eliquis from the facility pharmacy for the patient. Continued review revealed Licensed Practical Nurse (LPN) #1 borrowed the Eliquis from another resident and administered it to Resident #2. Telephone interview with LPN #1 on 10/23/19 at 7:15 AM revealed .the Administrator came to me he had gotten a phone call from (Resident #2's)'s wife .she was upset the resident had not received his medications .I got his antibiotic from the E-Kit, but the Eliquis wasn't in the E-Kit .this was about 9:00 AM .told him (Administrator) it (Eliquis) wasn't in E-Kit .he was livid. He said 'make it happen .didn't care how' .He (Administrator) didn't specifically tell me to borrow from another resident he just said make it happen . Continued interview revealed .(Resident #2) was admitted after the cut off time for the pharmacy delivery so his medicine wouldn't normally arrive until after 3 (PM) the next day. I took the Eliquis from (another resident) and administered it to (Resident #2) .I could have gotten the medication though a local pharmacy .I just went the wrong way about getting the medicine .I knew what I did was against nursing protocol . Interview with the Administrator on 10/23/19 at 8:00 AM, in the conference room, revealed .(Resident #2) was admitted to the building late on Thursday and on Friday morning I got a call from his family .(Resident #2's spouse) reported he (Resident #2) had not received his medications . Continued interview revealed .After I talked to his wife I went to his room he was upset .I came out of the room .(LPN #1) was at the desk. I said let's check all the E-Kits .we were not able to locate (Eliquis) .I asked if we could borrow some and replace it .I did feel the urgency to obtain the medication so I did say we need to find the medicine and give it to the resident . Further interview revealed .we do have a backup pharmacy but I don't know if they were contacted . Interview with the Director of Nursing (DON) on 10/23/19 at 1:45 PM, in the conference room, revealed LPN #1 reported to the DON that .(Resident #2's) family had notified the Administrator that he (Resident #2) had not received his medications yet .the Administrator demanded she (LPN #1) get the medication for the resident and to borrow it from another resident .I asked her .did she borrow the medication and she said yes she borrowed the medication from (another resident) . Further interview confirmed the facility failed to follow facility policy for obtaining medications. Telephone interview with the Pharmacy Consultant on 10/24/19 at 9:05 AM revealed .if a facility has a late admission it is hard to get the medication out for the night delivery .when this happens the facility is to use the medications available in the E-Kit and get the others from the back up pharmacy . Further interview confirmed .if someone admits after cut off time, the facility needs to call the back-up pharmacy and get a 3 day supply .",2020-09-01
2167,STANDING STONE CARE AND REHAB,445363,410 W CRAWFORD AVENUE,MONTEREY,TN,38574,2020-02-18,689,D,1,0,NCXV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of a facility policy, review of a facility document, medical record review, and interviews, the facility failed to report a fall timely for 1 resident (Resident #1) of 3 residents reviewed for falls. The findings included: Review of the facility's policy titled, Falls, last reviewed on 11/6/2019 showed .If a fall occurs the following actions will be taken: .Evaluate resident including neuro checks, pain, Range of Motion, skin, joints, extremities vital signs .Evaluate resident each shift for 72 hours .Neuro Checks will be completed on residents that experience an unwitnessed fall or a fall that results in head trauma .Pain will be evaluated every shift for 72 hours .Notify physician and family and document notification in the Electronic Medical Record . Review of a facility document Occurrence Investigation dated 1/20/2020 showed .Resident had swelling of left knee and complaints of pain .Upon investigation it was determined that resident had a fall on 1/15/2020 sometime during the night and staff assisted back to bed .Due to miscommunication between staff the fall was not reported to the charge nurse and not documented .On night of 1/15/2020 2 CNAs (Certified Nursing Assistants) entered room resident noted on R (right) side of bed by the window on her knees, holding on to SR (side rail) with both hands 3 CNAs assisted resident back up into bed .Upon staff interview noted resident had a fall from bed on night of 1/15/2020. Resident had no complaints at that time. CNAs did not report to nurse . Resident #1 was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 11 indicating the resident had moderately impaired cognition. The resident required extensive assistance with bed mobility, dressing, personal hygiene, and required total assistance with toilet use. Medical record review of Resident #1's Resident Progress Note dated 1/18/2020 at 12:14 PM, showed .Elder complaining of left leg pain. On assessment left knee is swollen . Medical record review of Resident #1's radiology report dated 1/18/2020 showed .Results: Fracture distal femoral metaphysis, acute. It is new from (MONTH) 4, (YEAR). Bones are osteoporotic. Fracture not significantly displaced .Conclusion: Acute nondisplaced fracture distal femoral metaphysis. Marked [MEDICAL CONDITION] . During an interview on 2/14/2020 at 1:25 PM Licensed Practical Nurse (LPN) #1 stated .when I came in on (2/16/2020) the reporting nurse told me .(Resident #1) had her legs off the bed which was very odd for her because she didn't really move. She would move her arms but not legs. She just didn't move her lower extremities, she could she just didn't . During an interview on 2/18/2020 at 5:45 AM, CNA #1stated .I was with (CNA #2) and we heard .(Resident #1) screaming and .(CNA #3) ran to her room. I was right behind her .(Resident #1) was not in her bed she had her knees on the floor and she was holding on to the rail .She wasn't yelling anymore and we asked her if she was okay and she said yes .I didn't report the fall . During an interview with on 2/18/2020 at 6:05 AM CNA #2 stated .I heard .(Resident #1) yell out which wasn't unusual when I entered the room .(CNA #3) and (CNA #1) were already in the room .(Resident #1) was a little bit slid off the right side of the bed with both of her legs out of the bed .So I helped them situate her .I told (LPN #4) what I had seen . During an interview with on 2/18/2020 at 6:20 AM CNA #3 stated .(CNA #1) and I were making our rounds I heard her (Resident #1) scream so I went running to her room, I saw her on her knees and she was holding on to the bed rail .we got her on the bed. We should have gotten the nurse before we got her up but we didn't we were just focused on what was going on .I didn't tell anyone about the fall . During an interview with on 2/18/2020 at 6:35 AM LPN #4 stated .my first knowledge of her (Resident #1's) fall was after she was sent out. I was the nurse for the first half of the shift when the fall was supposed to have occurred . During an interview with the on 2/18/2020 at 2:30 PM the Director of Nursing (DON) stated .it was reported on Monday morning the 20th during morning meeting that she had a fracture .They (staff) notify the on call nursing manager of all falls, but we weren't aware of a fall until the 21st after she (Resident #1) was discharged . It was reported by (CNA #2) .When we did interviews with the 3 CNA's that were aware something had occurred both .(CNA #1) and (CNA #3) reported they had found her (Resident #1) on the floor on her knees holding on to the bed rail .(CNA #2) reported she had only seen her sitting on the side of the bed with her legs dangling .(CNA #2) was her (Resident #1's) assigned CNA .(CNA #2) said she did not report a fall because she was unaware of a fall but she did report observing her legs off the bed .(CNA #1 and CNA #3) assisted getting (Resident #1) off of the floor .they had not reported it because they thought .(CNA #2) would . During an interview on 2/18/2020 at 3:00 PM the DON confirmed the facility failed to report a fall for Resident #1 timely.",2020-09-01
2628,WOODBURY HEALTH AND REHABILITATION CENTER,445435,119 WEST HIGH STREET,WOODBURY,TN,37190,2020-01-27,600,D,1,0,EW7611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of a facility policy, review of a facility investigation, medical record review, observations, and interviews, the facility failed protect 4 residents from abuse (#1, #2, #3, and #6) of 16 residents reviewed for abuse. The findings included: Review of a facility policy titled Abuse Prevention Policy & (and) Procedure dated 2/26/2018, showed .This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual,, physical and/or mental abuse .Verbal Abuse: Any use of oral, written or gestured language that willfully includes the disparaging and derogatory terms to residents, their families or within hearing distance, regardless of their age, ability to comprehend or infirmities . Review of a facility investigation dated 11/20/2019 showed the facility received an anonymous report on the Corporate Compliance Hotline that Certified Nursing Assistant (CNA) #6 had used inappropriate language toward residents. The facility validated that the CNA used inappropriate language in patient care areas and terminated the employee on 11/25/2019. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set ((MDS) dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 3 indicating Resident #1 had severe cognitive impairment. Observation in the resident's room on 1/27/2020 at 8:50 AM showed Resident #1 seated in a wheelchair with no anxious or fearful behaviors observed. The resident was pleasantly confused. During an interview on 1/27/2020 at 3:10 PM, CNA #5 stated .it has been several months ago .(Resident #1) was in the hall .she was talking loud .(CNA #6) turned around and looked at .(Resident #1) and said 'shut the hell up' .I did feel like that was verbal abuse .I did not report it .I should have reported it but I didn't . Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly MDS dated [DATE] showed a BIMS score of 7 indicating Resident #2 had severe cognitive impairment. Observation in the resident's room on 1/27/2020 at 9:10 AM showed Resident #2 was lying in bed awake and alert with no fearful or anxious behaviors observed. The resident was pleasantly confused. During an interview on 1/27/2020 at 3:10 PM, CNA #5 stated .(Resident #2's) call light was on .I went in to answer the call light (CNA #6) followed me into the room (the resident) was coming out of the bed. (CNA #6) told him (Resident #2) to 'keep his ass in the bed' .I did think that was a little verbally abusive .I did not report it to anybody . Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly MDS dated [DATE] showed Resident #3 had short and long term memory loss. During an interview on 1/27/2020 at 10:30 AM, CNA #3 stated .I was in .(Resident #3's) room .getting her out of bed. We (CNA #3 and CNA #6) had .(Resident #3) in her wheel chair and .(Resident #3's) oxygen was all messed up .She (CNA #6) was aggregated and said something along the lines of hell, dammit. I can't specifically remember what she said she was just cursing under her breath .just basic cursing . During an interview with on 1/27/2020 at 11:15 AM, Licensed Practical Nurse (LPN) #1 stated .it was just her (CNA #6's) demeanor .would come in the door cursing .one day I was standing at my cart and she was in .(Resident #3's) room with other CNA (CNA #3) .something to do with oxygen .she (CNA #6) was fussing and carrying on that second shift had not put the 02 (oxygen) up right .she (CNA #6) was using .GD (expletive) and dammit stuff like that .I guess I should have reported it but I didn't . Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly MDS dated [DATE] showed a BIMS score of 5 indicating Resident #6 had severe cognitive impairment. Observation in the resident's room on 1/27/2020 at 9:00 AM, in her room, showed Resident #6 was lying in bed awake and alert with no fearful or anxious behaviors observed. The resident was pleasantly confused. During an interview on 1/27/2020 at 9:20 AM, CNA #1 stated .(Resident #6) was up in the hall and she was talking and talking and getting loud .(CNA #6) looked at her and said 'shut the [***] up' .it was a few months ago .I didn't report it to anyone until . During an interview on 1/27/2020 at 9:40 AM, CNA #2 stated .I was working with .(CNA #6) she was in the room with .(Resident #6) .I heard her say keep your God Damn legs in the bed' . I did feel like it was an abusive situation .verbal abuse. I came out and looked at the nurse and she looked at me. I didn't say anything to anyone I thought the nurse had heard her but I don't remember who the nurse was . During an interview on 1/27/2020 at 10:00 AM, CNA #3 stated .I was walking to clock out she (CNA #6) was in the TV room with .(Resident #6) .She (CNA #6) was saying .'shut the [***] up' .mumbling rude stuff .I have no ideal exactly when it was but it was last year maybe the middle of the year. I didn't report it to anybody I thought it was mean . Interview on 1/27/2020 at 6:25 PM, the Administrator stated '' .prior to receiving the call on our corporate hot line we were unaware of any allegations of verbal abuse against (CNA #6) .we immediately called (CNA #6) . DON (Director of Nursing) and I interviewed her .based on staff interviews during our investigation we did identify she (CNA #6) did use inappropriate and unprofessional language in patient care areas and we terminated her for unprofessional conduct . Interview with the Administrator confirmed the facility failed prevent verbal abuse to the residents and .if the facility had been made aware of the allegations when they initially occurred there would have been no further occurrences .",2020-09-01
2072,SIGNATURE HEALTHCARE OF SOUTH PITTSBURG REHAB & WE,445343,201 EAST 10TH STREET,SOUTH PITTSBURG,TN,37380,2020-02-20,600,D,1,0,95YR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of a facility policy, review of a facility investigation, medical record review, observations, and interviews, the facility failed to prevent abuse for 1 resident (Resident #1) of 4 residents reviewed for abuse, resulting in Resident #1 being hit on the nose by another resident. The findings included: Review of the facility's policy titled, Abuse, Neglect and Misappropriation of Property, last revised 5/8/2019 showed .It is this organization's intention to prevent the occurrence of abuse.This policy applies to all residents without respect to the resident's cognitive condition, awareness, or ability to understand the event at issue.Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting physical harm.willful means non-accidental.Willful as used in the definition of 'abuse' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of a facility investigation dated 2/18/2020 showed .Certified Nursing Assistant (CNA) #2 was cleaning the dining room and heard yelling.found (Resident #2) in (Resident #1's) room yelling at him to get out of his room. (Resident #1) was yelling that it wasn't his (Resident #2's) room. (CNA #2) was able to get (Resident #2) out of the room. Resident #1 told (CNA #2) that (Resident #2) hit him in the nose hard.reported the same thing to the nurse. When the nurse asked (Resident #2) if he had hit (Resident #1) he said 'Yes I hit him'. Actions taken to protect the resident: aggressor (Resident #2) placed 1:1 (one on one). 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 scored a 14 (cognitively intact) on the Brief Interview of Mental Status (BI[CONDITION]). The resident had not exhibited any behaviors during the assessment look back period. Observation and interview in Resident #1's room on 2/20/2020 at 11:55 AM showed the resident lying in bed awake and alert. No fearful or anxious behaviors were observed. The resident stated .that person (Resident #2) hit me in the nose that happened 2 or 3 days ago.my nose is okay now. Resident #2 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Comprehensive Care Plan dated 12/16/2019 showed .Elder has a history of behavior problems such as wandering, exit seeking, disrobing, being verbally abusive and sexually inappropriate with staff. At risk for causing harm to himself and/or others.Administer medications as ordered by the physician and monitor effectiveness/response to meds, Approach elder at a later time if he is agitated, Attempt to explain to elder why behavior is unacceptable, Discuss what types of music elder prefers to listen to when exhibiting behaviors, Talk to elder about baseball when exhibiting behaviors. Revision to the Care Plan on [DATE]20 showed .Behavioral elder placed on 1:1 awaiting transfer to Geri-psych.Stay 1:1 until transfer to Geri-psych. Review of the quarterly MDS dated [DATE] showed Resident #2 scored an 8 (moderate cognitive impairment) on the BI[CONDITION]. The resident had no signs or symptoms of [MEDICAL CONDITION] and no behaviors had been observed during the look back period. Medical record review of a Nurse's Progress Note for Resident #2 dated 1/20/20 showed .Elder continues to be inappropriate with staff. Told another resident he was going to kick her butt. Refused to take medication. Gave writer the finger and ask me to give him one, he said if I did he would break it. Medical record review of a Nurse's Progress Note for Resident #2 dated 1/31/2020 showed .Elder started on new med without adverse reactions noted. Elder continues to be verbally aggressive with staff, making derogatory remarks to staff. Medical record review of a Nurse's Progress Note for Resident #2 dated [DATE]20 at 3:27 AM showed .Elder has been up at nurses station several times this shift, cursing staff and trying to hit staff with fist. Elder went to back door and was kicking at back door. Medical record review of a Nurse's Progress Note for Resident #2 dated 2/8/2020 at 10:53 PM showed .Elder cussing at staff banging on the door and kicking the door going outside. Charging at staff with fist balled up, threatening to hit us. Called.(Psychiatric Nurse Practitioner) gave order for.[MEDICATION NAME] (antipsychotic). Medical record review of a Nurse's Progress Note for Resident #2 dated [DATE]20 showed .No adverse reaction noted from med (medication) changes. Elder continues to yell/scream/curse/ threaten staff. Medical record review of a Nurse's Progress Note for Resident #2 dated [DATE]20 showed .Elder at nurses station several times throughout day, yelling threatening to knock nurses head off for keeping him here. Medical record review of a Nurse's Progress Note for Resident #2 dated 2/18/2020 11:13 PM showed .Elder has been pacing in and out of his room since evening shift began. Elder has admitted to this nurse that he entered another resident's (Resident #1's) room and struck him in the nose. During an interview on 2/20/2020 at 1:00 PM Licensed Practical Nurse (LPN) #1 stated .(CNA #2) reported she heard some yelling and went to (Resident #1's) room.(Resident #1) had told her (CNA #2) that man (Resident #2) had hit him in the nose. I asked.(Resident #2) if he hit (Resident #1) he said 'yes'.(Resident #1) said it happened.(Resident #2) had actually been really good that night he had been pacing the floor but that was his normal. He has never been bad about going into other resident's room that is why it was so bazar he did that. During an interview on 2/20/2020 at 1:30 PM CNA #1 stated .(Resident #2) wasn't too bad that night he was just pacing the hall.(LPN #1) and I were in another resident's room and when we came out.(CNA #1) told us he (Resident #2) had gone in (Resident #1's)'s room and hit him in the nose.(LPN #1) asked (Resident #2) if he hit (Resident #1) and he said 'yes'. During an interview on 2/20/2020 at 2:20 PM the Director of Nursing stated Resident #2 did have ongoing behaviors of cursing and threatening the staff, but he had never hit any other resident. The DON confirmed the facility failed to prevent abuse to Resident #1.",2020-09-01
2629,WOODBURY HEALTH AND REHABILITATION CENTER,445435,119 WEST HIGH STREET,WOODBURY,TN,37190,2020-01-27,609,D,1,0,EW7611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of a facility policy, review of a facility investigation, medical record review, observations, and interviews, the facility failed to report allegations of abuse for 4 residents (#1, #2, #3, and #6) of 16 residents reviewed for abuse. The findings included: Review of a facility policy titled Abuse Prevention Policy & (and) Procedure dated 2/26/2018 showed .This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual,, physical and/or mental abuse .All allegations involving abuse, neglect, exploitation or mistreatment .are reported immediately to the state survey agency .Immediately means as soon as possible, but not later than 2 hours after the allegation is made .Verbal Abuse Any use or oral, written or gestured language that willfully includes the disparaging and derogatory terms to residents, their families or within hearing distance, regardless of their age, ability to comprehend or infirmities . Review of a facility investigation dated 11/20/2019 showed the facility received an anonymous report on the Corporate Compliance Hotline that Certified Nursing Assistant (CNA) #6 had used inappropriate language toward residents. The facility validated that the CNA used inappropriate language in patient care areas and terminated the employee on 11/25/2019. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set ((MDS) dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 3 indicating Resident #1 had severe cognitive impairment. During an interview on 1/27/2020 at 3:10 PM, CNA #5 stated .it has been several months ago .(Resident #1) was in the hall .she was talking loud .(CNA #6) turned around and looked at .(Resident #1) and said 'shut the hell up' .I did feel like that was verbal abuse .I did not report it .I should have reported it but I didn't . Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly MDS dated [DATE] showed a BIMS score of 7 indicating Resident #2 had severe cognitive impairment. During an interview on 1/27/2020 at 3:10 PM, CNA #5 stated .(Resident #2's) call light was on .I went in to answer the call light (CNA #6) followed me into the room (the resident) was coming out of the bed. (CNA #6) told him (Resident #2) to 'keep his ass in the bed' .I did think that was a little verbally abusive .I did not report it to anybody . Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly MDS dated [DATE] showed Resident #3 had short and long term memory loss. During an interview on 1/27/2020 at 10:30 AM, CNA #3 stated .I was in .(Resident #3's) room .getting her out of bed. We (CNA #3 and CNA #6) had .(Resident #3) in her wheel chair and .(Resident #3's) oxygen was all messed up .She (CNA #6) was aggregated and said something along the lines of hell, dammit. I can't specifically remember what she said she was just cursing under her breath .just basic cursing . During an interview with on 1/27/2020 at 11:15 AM, Licensed Practical Nurse (LPN) #1 stated .it was just her (CNA #6's) demeanor .would come in the door cursing .one day I was standing at my cart and she was in .(Resident #3's) room with other CNA (CNA #3) .something to do with oxygen .she (CNA #6) was fussing and carrying on that second shift had not put the 02 (oxygen) up right .she (CNA #6) was using .GD (expletive) and dammit stuff like that .I guess I should have reported it but I didn't . Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly MDS dated [DATE] showed a BIMS score of 5 indicating Resident #6 had severe cognitive impairment. During an interview on 1/27/2020 at 9:20 AM, CNA #1 stated .(Resident #6) was up in the hall and she was talking and talking and getting loud .(CNA #6) looked at her and said 'shut the [***] up' .it was a few months ago .I didn't report it to anyone until . During an interview on 1/27/2020 at 9:40 AM, CNA #2 stated .I was working with .(CNA #6) she was in the room with .(Resident #6) .I heard her say keep your God Damn legs in the bed' . I did feel like it was an abusive situation .verbal abuse. I came out and looked at the nurse and she looked at me. I didn't say anything to anyone I thought the nurse had heard her but I don't remember who the nurse was . During an interview on 1/27/2020 at 10:00 AM, CNA #3 stated .I was walking to clock out she (CNA #6) was in the TV room with .(Resident #6) .She (CNA #6) was saying .'shut the [***] up' .mumbling rude stuff .I have no ideal exactly when it was but it was last year maybe the middle of the year. I didn't report it to anybody I thought it was mean . Interview on 1/27/2020 at 6:25 PM, the Administrator stated '' .prior to receiving the call on our corporate hot line we were unaware of any allegations of verbal abuse against (CNA #6) .we immediately called (CNA #6) . DON (Director of Nursing) and I interviewed her .based on staff interviews during our investigation we did identify she (CNA #6) did use inappropriate and unprofessional language in patient care areas and we terminated her for unprofessional conduct . The Administrator confirmed the facility failed to follow facility policy and failed to report allegations of verbal abuse until 11/20/2020. Refer to F-600.",2020-09-01
1616,CUMBERLAND VILLAGE CARE,445276,136 DAVIS LANE,LAFOLLETTE,TN,37766,2019-11-13,600,D,1,0,9LJZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of a facility policy,medical record review, review of facility documentation, observations, and interviews, the facility failed to prevent abuse for 2 residents (#2 and #3) of 8 residents reviewed for abuse. The findings include: Review of the facility policy Abuse Prohibition, revised 7/1/19 revealed .(Facility) prohibits abuse .Abuse is defined as the willful infliction of injury .Actions to prevent abuse .will include .identifying, correcting, and intervening in situations in which abuse .more likely to occur .Anyone who witnesses an incident of suspected abuse .report the incident to his/her supervisor immediately .The notified supervisor will report the suspected abuse to the Center Executive Director (CED) or designee and other officials in accordance with state law .If the suspected abuse is resident to resident, the resident who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed .The Center is responsible for identifying residents who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's Comprehensive Care Plan dated 11/8/18 revealed the resident required placement on the locked unit for exit seeking behavior, exhibits psychosocial distress with own well-being and/or social relationship related to frequent conflict with personal relationships with other residents and staff, and has verbal and physical behaviors. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Continued review revealed the resident exhibited verbal and other behaviors directed toward others. Further review revealed the resident was independent for bed mobility, walking in the room, toileting and personal hygiene and required supervision and set up for walking in the corridor, and supervision with assist of 1 staff for transfers and locomotion on the unit. Medical record review of a Nurse's Note by Registered Nurse (RN) #1 dated 4/30/19, revealed .Heard resident yelling, when entered room observed resident's roommate (Resident #3) lying in his bed with this resident (Resident #1) on top of him hitting him in the face. Removed resident and questioned why he was hitting his roommate and he stated 'he was trying to steal my stuff, so I hit him' Told him he couldn't be hitting other residents, and he states 'I will if he doesn't leave my stuff alone' . Medical record review of Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #3's Quarterly MDS dated [DATE], revealed a BIMS score of 3, indicating the resident was severely cognitively impaired, was independent in activities of daily living (ADLs), except locomotion on unit which required supervision with 1 staff member, and exhibited no behaviors. Medical record review revealed Resident #3 Comprehensive Care Plan dated 6/25/14 revealed the resident required placement on the locked unit for need of higher level of supervision related to Dementia, and decreased safety awareness. Medical record review of a Nurse Practitioner (NP) note dated 4/30/19, revealed .Resident (#3) seen today r/t (related to) altercation with another resident. Nursing reports resident was hit in the face by another resident .Resident is sitting on side of his bed, reports his face hurts, and states 'but it's not bad'. Resident's eyes are bleeding, his nose is bleeding .Resident is alert, oriented to person, no noted change in mental status, denies headache or dizziness .Facial Bones x-ray . Medical record review of Resident #3's x-ray report dated 4/30/19, revealed .no fracture, destructive lesion, or other abnormalities of the facial bones present .the paranasal sinuses and orbits are normal. Observation of Resident #3 on 11/12/19 at 3:45 PM, in the resident's room revealed the resident was pleasantly confused, smiling, and without anxious or fearful behaviors. Interview with RN #1 on 11/13/19 at 11:30 AM, in the conference room confirmed .I was walking down the hall .I seen (Resident #1) on top of (Resident #3) .I seen him punch (Resident #3) .I immediately separated the residents .assessed them both .removed (Resident #1) from the room .notified the nurse practitioner . Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's Comprehensive Care Plan dated 4/29/19 revealed the resident was at risk for elopement and required placement on locked unit, required extensive assistance for ADLs. Medical record review of the Quarterly MDS dated [DATE] revealed the resident was severely cognitively impaired, exhibited wandering, physical, verbal, and other behaviors daily. Continued review revealed the resident required extensive assist of 1 staff for all ADLs except eating, which required set up help. Review of facility documentation revealed on 11/6/19 Resident #1 was observed yelling at Resident #2 .get out of my way . then kicked Resident #2 in the leg and Resident #2 fell to the ground and hit her head. Medical record review of hospital documentation dated 11/6/19 revealed Resident #2 had no major injuries, negative x-ray and negative MRI, and condition was stable. Observation of Resident #2 on 11/13/19 at 10:25 AM, revealed the resident ambulating with staff after activity, resident smiling and pleasant, no anxious or fearful behaviors, visible injuries, or distress noted. Interview with the Administrator on 11/13/19 at 5:10 PM, in the conference room confirmed the facility failed to prevent abuse for Resident #3 and Resident #2.",2020-09-01
5258,SIGNATURE HEALTHCARE OF MEMPHIS,445241,1150 DOVECREST RD,MEMPHIS,TN,38134,2016-04-19,323,D,1,0,J25F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of a resident investigation tool, policy review, observation and interview, the facility failed to ensure the residents were as free from accident hazards as possible as evidenced by the facility's failure to follow policy for 1 of 3 (resident #1) sampled resident's reviewed with accidents. The findings included: An investigation tool dated 3/24/16 documented, .Summary of investigator's findings . Resident was transferred to the gerichair from the bed without using a mechanical lift . The facility's Safe Lifting & (and) Movement of Resident policy documented, .In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents . The facility's SWAT (safety with all transfers) - Standards for all Lifts Tool policy documented, .It is the intent of this facility to provide a safe resident lifting program which promotes quality care in a manner that supports safety, comfort and dignity for the resident . There must always be at least two (2) staff . present each time a mechanical lift transfer is performed . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #1's room on 4/18/16 at 9:30 AM, revealed Resident #1 in bed on her back with an immobilizer on her right upper arm. Resident #1 was pulling and hitting the left side of her face and chin with her left hand. Observations in Resident #1's room on 4/18/16 at 12:30 AM, revealed 2 staff members getting Resident #1 up to the gerichair with the lift. Resident #1 began kicking her left leg, her left leg made her right leg flop and slide while in the sling of the lift and her head was moving up and down and around on the top of the geri chair. Interview with certified nursing assistants (CNA) #1 and #2 on 4/18/16 at 12:30 PM, in Resident #1's room, CNA #1 and #2 were asked if the resident's knees could possibly bump the post of the lift. CNA #1 and #2 stated, Shouldn't because that is why we have 2 persons to ensure a safe transfer. Interview with Registered Nurse (RN) #1 on 4/18/16 at 12:30 PM, in Resident #1's room, RN #1 stated, It's policy for 2 people during transfer with the lift. Interview with CNA #3 on 4/18/16 at 3:25 PM, in the conference room, CNA #3 was asked to explain the way he transferred Resident #1 on 3/17/16. CNA #3 stated, I sat her on the side of the bed and slid her to the chair. The facility staff did not follow policy of using a mechanical lift when transferring Resident #1 from the bed to the gerichair.",2019-04-01
1636,COUNTRYSIDE HEALTHCARE AND REHABILITATION,445280,3051 BUFFALO ROAD,LAWRENCEBURG,TN,38464,2017-07-20,278,D,1,0,4V9N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of an incident report, medical record review, and interview, the facility failed to ensure the assessment was accurate for 1 of 3 (Resident #5) sampled residents reviewed for falls. The findings included: 1. Medical record review revealed Resident #5 was admitted to the facility 3/14/16 with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Incident Report dated 3/6/17 revealed the resident was being assisted into the facility van when his legs twisted and he lost his balance. The Certified Nursing Assistant (CNA) assisted the resident to the ground outside the wound care center. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment, and required staff assistance for activities of daily living. There were no falls recorded on his MDS since previous assessment. Interview with the Admission Director on 7/20/17 at 8:38 AM, in the quiet room, she reviewed the fall assessment on the MDS dated [DATE]. She was asked if it was appropriate to not code for the fall on the MDS. The Admission Director stated, No. Interview with the Director of Nursing (DON) on 7/20/17 at 11:11 AM, at the East nursing station, the DON was asked if it was appropriate to not code for falls on the MDS. The DON stated, No.",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
375,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2019-09-18,600,D,1,1,QLQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility abuse policy, medical record review, review of facility documentation, observation and interview, the facility failed to prevent verbal abuse of 1 resident (#17) of 26 residents reviewed for abuse. The findings include: Review of the facility policy Abuse Prevention Policy and Procedure, dated 2/26/18, revealed .The purpose of this written .Prevention Program is to outline the preventive steps taken by the facility to reduce the potential for the mistreatment, neglect and abuse of residents . Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set, dated dated [DATE], revealed Resident #17 scored an 8 on the Brief Interview for Mental Status, indicating severe cognitive impairment, with short and long term memory deficits, and was totally dependent on 2 persons to transfer. Review of the facility's documentation, dated 9/5/19, revealed 2 Certified Nursing Assistants (CNA #1 and #2) were providing care to Resident #17 when CNA #1 became upset with the resident and spoke harshly to him, using foul language. Further review revealed CNA #1 was removed from resident care. Continued review revealed CNA #1 confirmed she became upset with the resident and used the F word. Review of the Director of Nursing's (DON) summary statement revealed, Two CNA's were getting (Resident #17) up and the resident became agitated. He started to flail his arms and (CNA #1) said 'Don't you f***ing hit me.' .(CNA #1) admits to saying F***ing in front of the resident and was terminated . Observation of Resident #17 on 9/16/19 from 2:35 PM until 3:15 PM revealed he was in his wheel chair, using his arms to propel himself through the front halls of his unit. Interview with the Charge Nurse on 9/16/19 at 3:15 PM, at the nursing station, revealed .(Resident #17) is normally in the hall .always mild mannered .doesn't normally resist care . Further interview revealed Resident #17 was diagnosed with [REDACTED]. Continued interview revealed the Charge Nurse had not encountered any problems with CNA #1 prior to 9/5/19 and stated .they (referring to the facility administration) don't tolerate foul language . Interview with CNA #2 on 9/18/19 at 11:40 AM, in the conference room, revealed the facility's documentation of the events on 9/5/19 was correct. Interview with the DON on 9/18/19 at 11:50 AM, in the conference room, confirmed the verbal abuse had occurred and he stated his observation and interview of Resident #17 two hours after the incident, revealed the resident had no memory of the verbal abuse.",2020-09-01
3268,WEST HILLS HEALTH AND REHAB,445501,6801 MIDDLEBROOK PIKE,KNOXVILLE,TN,37919,2019-11-26,600,D,1,0,H7OL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility documents, medical record review and interview, the facility failed to prevent physical abuse of 1 resident (#2) from a second resident (#1) of 3 residents reviewed for abuse. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the initial Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 had severe cognitive impairment and required limited assist of 1 person for transfer and ambulation. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the initial Minimum Data Set ((MDS) dated [DATE], revealed Resident #2 had severe cognitive impairment and required assist of 2 persons for transfer and was non-ambulatory. Review of facility documents revealed on 10/30/19, at 9:45 AM, in the dining room, Resident #1 stepped to Resident #2's seat and slapped Resident #2. Continued review revealed 1 staff member was in the dining room, witnessed the slap and stated, prior to the incident, there was no indication Resident #1 and Resident #2 were interacting. Further review of the documents revealed neither resident had displayed any physical aggression toward others prior to this incident. Interview with the Administrator on 11/25/19, at 2:00 PM, in the conference room, as facility documents were reviewed, revealed Resident #1 was observed 1:1 until the resident was able to be transferred the same day of the incident to a gero-psych unit. Continued interview and review of the documentation of Resident #2's physical assessment the day of the incident, confirmed the resident did not have any mark on her face from receiving the slap and also did not remember the incident.",2020-09-01
1745,BEECH TREE HEALTH AND REHABILITATION,445292,"240 HOSPITAL LANE, PO BOX 300",JELLICO,TN,37762,2018-03-07,842,E,1,0,1FZ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility incidents, medical record review, and interview, the facility failed to ensure the medical records for were complete with possible abuse incidents, including the outcome and impact of the incidents to the residents involved, and actions taken in response to the incidents for 4 (#3, #6, #7, and #10) of 11 sampled residents. The findings included: Review of a facility Incident with a date of occurrence of 10/13/17, at 8:15 PM, revealed, (On) 9/9/17, (Resident #10) and (Resident #6) were noted to be sitting in the alcove on 200 Unit on public sofa out of line of sight from nurse station. (Resident #10) had her blouse raised to her neck. Residents were not touching. Residents were separated, redirected, placed on 1-minute checks for 24 hours and continued to only be permitted to visit in common areas for increased supervision. (On) 10/9/17, (Resident #6) and (Resident #10) were noted to be sitting in the alcove on 200 Unit on public sofa out direct line of sight from nurse's station. (Resident #6) had his pant unzipped and his hand in his pants. (Resident #10) was leaning against (Resident #6) but she did not have her hands in his pants. Residents were immediately separated and the sofa was removed from the common area and replaced with two single person chairs. Both residents were placed on 15-minute checks. Continue to allow residents to only visit in common (high traffic, public) areas for increased supervision, staff encourage resident to visit in Day Room as much as possible, which is direct line of sight from Nurses Station .(Resident #6) was on 15-minute checks due to exit seeking behaviors, at 8 p.m. Resident was in the day room according to staff. At 8:15 p.m. resident was not in in the day room, nor in his room, staff found (Resident #6) in (Resident #10) bed undressed engaging in sexual activity. Both residents are confused. (Resident #6) has a BIMS (Brief Interview for Mental Status) of 5 (severe cognitive impairment). (Resident #10) has a BIMS of 7 (severe cognitive impairment). Both residents requested staff to leave them alone, but staff separated the residents. Physical assessment was completed with no injuries noted. (Resident #10) was moved to the locked unit to prevent any further interaction between the residents. Psych services met with both residents .Social services interviewed both residents, neither acknowledge clear recollection of events. (Resident #6) has [DIAGNOSES REDACTED]. (Resident #10) has [DIAGNOSES REDACTED]. Review of Resident #10's medical record from 10/1/17 through 3/5/18, revealed no entries in Social Service Progress Notes regarding the sexual incidents or follow up between Resident #6 and Resident #10. The first note following the 10/13/17 incident, was a 10/16/17 Social Service Progress Note, stating SS (social services) spoke with (Resident #10) she has concerns of her new room and roommate she asked to be moved. Moved her to room .and all her belongings all departments notified. No subsequent notes addressed the incidents or behaviors that occurred between Resident #6 and Resident #10. Review of Resident #6's medical record from 10/1/17 through 3/5/18 revealed no entries in Social Service Progress Notes regarding the sexual incidents between Resident #6 and Resident #10. The first note following the 10/13/17 incident, was a 10/16/17 Social Service Progress Note, stating SS visited with (Resident #6) he is very confused up amb (ambulating) thru (sic) out the unit. Pleasant, talking about his house and his family. His daughter has been to visit today. No problems or concerns at this time. SS will continue to visit and monitor. No subsequent notes addressed the incidents or behaviors that occurred between Resident #6 and Resident #10. Interview with the social worker (SW) on 3/7/18 at 10:52 PM, in her office, confirmed the residents engaged in sexual intercourse, and that they both asked staff to leave them alone and continued to have sex after the staff entered the room. The SW stated the residents were separated by staff and Resident #10 was moved to the secured unit where she continued to reside as a measure of safety. The SW stated the residents were not able to consent to have sexual relations due to their levels of cognition. The SW stated she was very involved in the 10/13/17 incident, having interviewed both residents, and was involved in monitoring them afterward. The SW stated she spent time with Resident #10 following her admission to the secured unit to help her adjust. The SW reviewed the Social Service Progress Notes for Resident #6 and Resident #10 and confirmed there was no social service documentation in either record regarding the incidents or follow up. The SW stated she needed to do a better job documenting. Review of a facility incident with a date of occurrence of 12/12/17 at 5:45 PM revealed, (MONTH) 12, (YEAR) (Tuesday) at 5:45 p.m. Employee # 8, RN (Registered Nurse), received a phone call from (Resident #7) daughter stating that her mother called her this evening stating that a man came into her room over the weekend and was touching and kissing her. (Resident #7) described (Resident #2) and knew him by his first name. Daughter stated, 'It made mother uncomfortable.' Employee # 8, RN, interviewed (Resident #7) about the incident. (Resident #7) stated, I know (Resident #2's) first name from therapy. I invited him into my room over the weekend because we are good friends from therapy. But he got too close and tried to kiss me. But it was a dry kiss because I shoved him off and told him he was married. I am alright and I am not hurt. That is all that happened. It just shook me up a little bit. (Resident #2) did not attempt further advances after (Resident #7) pushed him away and refused him. No advances have been made since the weekend. (Resident #7) has a BIMS of 9 (moderate cognitive impairment) with a [DIAGNOSES REDACTED]. She can make her wants and needs known and is able to verbalize fears and concerns. Social Services interviewed (Resident #7) with no psychosocial distress noted related to the event .Social services interviewed various residents with Resident #1528 (Resident #3) reporting that (Resident #2) came into her room on (MONTH) 10, (YEAR) and kissed her on the cheek. She asked him to leave and he left and never returned. (Resident #3) stated she is not afraid and feels safe. (Resident #3) has a BIMS of 11 (moderate cognitive impairment). All other residents interviewed did not have any concerns or complaints to report. (Resident #2) has a BIMS of 15 (no cognitive impairment) but does exhibit intermittent moderate confusion. He has [DIAGNOSES REDACTED]. Review of Resident #2's medical record from 12/1/17 through 3/5/18, revealed no entries in Social Service Progress Notes regarding the allegation/incidents in which Resident #2 went into Resident #7's room and Resident #3's room and kissed these residents. The first note following the 12/10/17 incident with Resident #3 and the 12/12/17 incident with Resident #7, was a 12/18/17 Social Service Progress Note, stating Myself, Administrator, Nurse Practitioner, and several managers met with (Resident #2's family member) this am to discuss some concerns he has had about his dad and communication between himself and staff. All concerns were discussed and resolved. No subsequent notes addressed the incidents of sexually inappropriate behaviors or psychosocial outcome to Resident #7 or Resident #3. Review of Resident #3's medical record from 12/1/17 through 3/5/18, showed no entries in Social Service Progress Notes regarding the incident in which Resident #2 allegedly kissed Resident #3. The first note following the 12/10/17 incident, a 2/1/18 Social Service Progress Note, stating Quarterly review (Resident #3) is alert and has some confusion. Up daily in w/c (wheelchair) she continues to go out for [MEDICAL TREATMENT] three times a week. She likes to play games on her iPad and talk on her phone attends some group activities. Pleasant to visit with. Has good family support. No problems or concerns at this time. SS will continue to visit and monitor. There were no notes that addressed the incident, or psychosocial well-being of Resident #3 following the incident on 12/10/17. Interview with the SW on 3/7/18 at 11:28 AM, in her office, revealed Resident #2 was trying to make friends and he acted inappropriately towards the female residents within a limited period. The SW reported Resident #2 did not have inappropriate sexual behaviors prior to (MONTH) or following December. The SW stated Resident #2's wife resided in the facility and he spent most of his time with her. The SW reported there were medication changes for Resident #2 following these incidents. The SW stated she and the administrator talked with Resident #2 following the incidents and reported Resident #2 may have understood to a certain extent regarding not going into female residents' rooms and being sexually inappropriate. The SW reviewed the social service notes for Resident #2 and Resident #3 and confirmed there were no entries regarding the incidents, her involvement, or the outcome. The SW stated she needed to do a better job documenting in the social service notes. Interview with the Administrator and Director of Nursing (DON) on 3/7/18 at 2:23 PM, in the SW office, confirmed the incidents between the residents #3, #6, #7, and #10, as well as the outcome and follow up from social services, should be documented by social services in the medical records.",2020-09-01
4647,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2016-08-18,431,D,1,0,43T011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policies, medical record review, review of pharmacy documentation, review of facility incident documentation, review of narcotic count sheets and narcotic audit sheets, and interview, the facility failed to implement its written policies and procedures to account of all controlled drugs for 1 Resident (#7) of 10 sampled residents. The findings included: Review of the facility Acceptance of Controlled Drugs Policy dated 11/30/14 revealed the following: Policy: To ensure controlled substances are properly accounted for in accordance with Federal Regulations. Controlled drugs will be delivered to the facility by the pharmacy and 2 nurses will sign the medications into the facility on the pharmacy delivery slip. Procedure: The pharmacy will deliver controlled drugs to the facility. Two nurses will sign the medications into the facility on the pharmacy delivery sheet and ensure the correct medication, dosage, and amounts are correct. The medications will be placed into the medication cart by the nurses that received the medications from the pharmacy. The controlled drug declining inventory sheet from the pharmacy will be placed in the MAR indicated [REDACTED]. It will be kept with the declining inventory sheet in the MAR indicated [REDACTED] Review of the Controlled Drug Count Policy revised 6/1/2015 revealed: Policy: To ensure controlled substances are properly accounted for in accordance with Federal and State Regulations. The oncoming and the off going nurses assigned to the medication cart will be responsible for ensuring the accuracy of controlled drug count. Procedure: A new controlled drug count sheet will be utilized each month. One controlled drug count sheet per medication cart. Enter the month, Cart (hall), and Year. The 2 nurses will count the number of individual controlled drugs: Look at each medication and verify that the number of individual controlled drugs matches the number on the declining inventory sheet. If the number does not match, STOP - do not sign the controlled drug count sheet, no one is to leave the unit, determine the discrepancy, call the Director of Clinical Services, when the DCS arrives she/he will begin an investigation to determine the reason for the discrepancy, it is the responsibility of the off going nurse who has been the custodian of the medication cart keys for any missing medications . The two nurses will count the number of declining inventory sheet and boxes/cards/etc. Verify that the number of individual boxes/cards/etc matches the number on the Controlled Drug count sheet. If the number does not match, STOP do not sign the controlled drug count sheet, no one is to leave the unit, determine the discrepancy, call the Director of Clinical Services, when the DCS arrives she/he will begin an investigation to determine the reason for the discrepancy, it is the responsibility of the off going nurse who has been the custodian of the medication cart keys for any missing medications . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Medical record review of the (MONTH) (YEAR) physician's orders [REDACTED]. Review of pharmacy documentation of medications delivered on 4/15/16 revealed an order of 30 Hydrocodone-Acetaminophen tablets 5 milligram/325 milligram (mg) for Resident #7. The pharmacy delivery slip was not signed by any nursing staff. Review of a facility incident for Resident #7 revealed on 4/19/16, the resident requested a pain pill that was ordered as needed. When the staff nurse went to retrieve the Lortab 5/325 mg, she noted that none were available. The nurse called the pharmacy to request a refill and was told a card of 30 was delivered on 4/15/16. The nurse immediately informed the Registered Nurse and the Assistant Director of Clinical Services (ADCS). The medication cart and narcotic drawer were again searched with nomedication available. Resident #7 was given pain medication out of the emergency backup box. Medication rooms on both halls were searched and the remaining 2 carts on the other hall were also searched. The medication card and narcotic sign out sheet were not located. Review of the (MONTH) (YEAR) Narcotic Count Sheet for the West I medication cart revealed nursing staff failed to document reconciliation of medications with two staff members for the following dates: 4/1/16, 4/2/16, 4/3/16, 4/4/16, 4/5/16, 4/6/16, 4/9/16, 4/12/16, 4/17/16, 4/20/16, 4/21/16. Review of the Narcotic Audit forms provided by the Director of Clinical Services on 8/18/16 revealed documentation written for the following dates: 4/26/16, 5/4/16, 5/18/16, 5/24/16, 6/1/16, and 6/7/16. The audits failed to identify which medication cart was checked, what staff was working the cart, and if blank spaces on count sheets were found, what action was taken. Interview with Director of Clinical Services (DCS) on 8/18/16 at 8:54 AM revealed she did an in-service with nursing staff after the incident of missing medication on 4/19/16. Further interview at 10:48 AM revealed she reported she performed a narcotic audit for 2 months after the incident. Further interview at 1:17 PM confirmed the DCS did not know what she did with the in-service documentation for the nursing staff and was unable to indicate which medication carts were checked for each audit completed. The facility failed to follow facility policy and procedure for completing an accurate account of all controlled drugs.",2019-08-01
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
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
2813,MADISONVILLE HEALTH AND REHAB CENTER,445457,465 ISBILL RD,MADISONVILLE,TN,37354,2019-05-20,842,C,1,0,HYGS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policies, medical record reviews, observations, and interviews, the facility failed to store medical record documents designated for destruction in secure containers to prevent unauthorized access or use, for 3 Residents, (Residents #1, #2 and #3) of 3 residents reviewed for privacy, on 2 of 2 units. The findings included: Review of the facility policy, Retention of Records, revised 2006, revealed .inactive records .will be destroyed Review of the facility policy Protected Health Information (PHI), Management and Protection, revised (MONTH) 2014, revealed .it is the responsibility of all personnel who have access to resident and facility information .to ensure .information is managed and protected .to prevent unauthorized .disclosure . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations made throughout the facility during the initial tour revealed a lack of secure document destruction containers. Observations of the DON office and interview with the DON on 5/20/19 at 1:00 PM, revealed 18 card board boxes, with tops folded closed stored along the walls. All 18 boxes contained paper documents with protected health information for facility residents designated to be destroyed. The DON reported her office was locked when she was out of the building, but acknowledged the documents were not secured as stored, if her office door was left open while she was in the facility. The DON reported she had stored records awaiting destruction in her office since (MONTH) of 2019. Observation of the outside storage building and interview with the maintenance director on 5/20/19 at 1:20 PM, revealed 64 cardboard boxes of varying sizes stored there. Examinations of the boxes stored in the most accessible areas, revealed all were filled with medical record documents which contained protected health information, awaiting destruction. The maintenance director reported prior to (MONTH) 2019, the facility did not store medical records of any type there. The maintenance director confirmed the records as stored, could be accessed by unauthorized persons. Observations of the nursing station on 5/20/19 at 2:45 PM, revealed a large, open topped, cardboard box was in use beneath the desk, in which were stored various medical record documents slated for destruction. The box was not secured, and documents inside it, could be viewed or withdrawn by anyone behind the desk. Documents pulled from the box included admission orders [REDACTED]#3. Interview with the Administrator on 5/20/19 at 3:00 PM, in the conference room, revealed the Administrator reported the facility document destruction provider had terminated its' contract with the facility corporate office sometime in early (MONTH) 2019. The document destruction provider had repossessed its' locked shred boxes at the facility and since (MONTH) 2019, no alternate provider had been contracted to provide secure document destruction for the facility. The Administrator reported she had made multiple requests to the Corporate Nurse and Corporate Vice President of Operations related to the matter, and was informed by her supervisors, the requests had been forwarded to the Corporate Office for resolution, but confirmed as of 5/20/19, no action had been taken by the Corporate Ownership to resolve the matter. The Administrator confirmed surveyor observations of unsecured documents awaiting destruction in the DON office, storage building and behind the nursing station were not in accordance with corporate policies and the facility had failed to secure medial record documents with protected health information in a fashion to prevent access by unauthorized persons.",2020-09-01
2326,GENERATIONS CENTER OF SPENCER,445388,87 GENERATIONS DRIVE,SPENCER,TN,38585,2019-07-29,609,D,1,0,Z3WT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policies, review of a facility document, medical record review, 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 Reporting Abuse to State Agencies and Other Entities/Individual Policy dated 1/1/19 revealed .The facility shall ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident are reported immediately, but not later than 2 hours after the allegation is made . Review of facility document Alleged Incident/Accident Report dated 7/24/19 at 7:15 PM revealed .(Resident #1) informed this nurse that (Resident #2) inappropriately touched her breast .Assessment reveals no scratches, redness, discolorations or injuries/impairment noted. Resident is without emotional distress, tremors or anxiety at this time . Medical record review revealed Resident #1 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) for Resident #1 dated 7/1/19 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of a Quarterly MDS for Resident #2 dated 5/20/19 revealed a BIMS score of 6, indicating severe cognitive impairment. Interview with Resident #1 on 7/29/19 at 10:45 AM, in her room, revealed .I had been talking about watching a movie all that day .(Resident #2) rolled me back to my room, he had helped me once before .I thought we were going to watch a movie .he grabbed my breast inside my shirt and put them in his mouth. He pulled his penis out and placed my hand on his penis .I got away from him .rolled out of the room to the nurses' station .I pushed my call light before I left the room, I saw .(Licensed Practical Nurse #1) at the end of the hall and I asked the nurse to remove (Resident #2) and he made him leave . Interview with Registered Nurse (RN) #1 on 7/29/19 at 12:05 PM, in the conference room, revealed .(Resident #1) was going down the hall heading to .(LPN #1) and saw the janitor first .(Resident #1) reported the incident to (the Janitor) then she went on down the hall and reported it to (LPN #1). (LPN #1) called the Administrator and (Administrator) called me and I came in and started the investigation and .(Administrator) reported the incident (to the State Survey Agency) the next day . Interview with Resident #2 on 7/29/19 at 1:10 PM, in his room, revealed the resident recalled the incident and stated .well it was after supper and I pushed her (Resident #1) back to her room .I sat there for about 15 minutes .I touched her breasts .underneath her shirt .(Resident #1) touched me in the penis area, but then she got to thinking about her ole man and stopped and she just talked about him .we hadn't ever done anything before . Interview with the Administrator on 7/29/19 at 5:20 PM, in the conference room, revealed .it appeared to be consensual, and it was a he said she said .(Resident #1) reported the incident on (7/24/19) and I did not report the allegation until the next morning . Continued interview confirmed the facility failed report an allegation of abuse timely to the State Survey Agency and failed to follow facility policy.",2020-09-01
1215,LIFE CARE CENTER OF TULLAHOMA,445238,1715 N JACKSON ST,TULLAHOMA,TN,37388,2019-03-06,583,D,1,0,YLBX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policies, review of a facility investigation, medical record review, observation, and interviews, the facility failed to ensure privacy was maintained during a shower for 2 residents (#7and #8) of 11 residents reviewed for privacy. The findings included: Review of facility policy, Preservation of Resident Rights revised 11/19/16, revealed .All associates are responsible for the preservation of resident's rights .Privacy during medical treatments and personal care . Review of facility policy, Protecting Patient Privacy and Prohibiting Mental Abuse: Photography and Social Media dated 8/30/16, revealed .This facility will ensure that an environment as home-like as possible will be provided to all patients .treats each resident with respect and dignity. All forms of abuse are prohibited .Taking photographs with camera-equipped cell phones or any other photographic device .is strictly prohibited anywhere in the facility without the express permission of the Executive Director .Associates are prohibited from taking photographs or recordings on any personal electronic devices .when working with or near residents . Review of facility policy, Social Media revised on 9/1/16, revealed .social media policy is designed to protect .patients (residents) .This prohibition includes photos and video where the patient is not easily identifiable (e.g. a close-up photo of any part of a patient's body) .It also includes photos or video where the patient is easily identifiable . Review of a facility investigation dated 2/13/19 at 10:50 AM, revealed the police department notified the Human Resource Director of an incident which occurred on 2/12/19. Further review revealed .an employee (Certified Nursing Assistant (CNA) #1) had participated in a video chat with an incarcerated male in a patient care area (shower room) and breached the privacy of the resident (residents) . Continued review of a witness statement from CNA #2 revealed .(CNA #2) walked in the shower room where .(CNA #1) was doing showers she was facetiming her boyfriend .I do not remember if a patient was in the room at the time . Further review of a witness statement from Licensed Practical Nurse (LPN) #3 revealed .Shower Tech-yelled out for a CNA to assist .I went to the shower room to help .entered to help .I did know (CNA #1) had the phone over by the sink .I was not aware that someone could actually see the resident . Further review of a witness statement from CNA #3 revealed .I walked into the shower room on west wing .(CNA #1) was on the phone. I did advise her to hang up the phone numerous times and let her know .(Interim DON) was down the hall .hoping she (CNA #1) would hang up the phone . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Medical record review of Resident #7's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5 (severe cognitive impairment). Continued review revealed the resident required extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and was always incontinent of both bowel and bladder. Observation of Resident #7 on 2/21/19 at 12:05 PM, in the dining room, revealed the resident was seated at a dining room table with three other residents. Continued observation revealed the resident was feeding herself without difficulty and no signs of anxiety or fearful behavior were observed. Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Medical record review of Resident #8's Quarterly MDS dated [DATE] revealed a BIMS score of 6 (severe cognitive impairment). Continued review revealed the resident required extensive assistance with bed mobility, transfer, dressing toilet use, personal hygiene, and was frequently incontinent of both bowel and bladder. Observation of Resident #8 on 2/21/19 at 12:10 PM, in the dining room, revealed the resident was seated at a dining room table with two other residents. Continued observation revealed the resident was feeding herself and no signs of anxiety or fearful behavior were observed. Interview with the Interim Director of Nursing (DON) on 2/21/19 at 10:10 AM, in the conference room, revealed .the police detective contacted the facility .to inquire about employment of a CNA .They (police detective) had viewed a video chat involving an inmate at the county jail and a health care employee. They were attempting to identify what nursing facility the employee was employed by. She (employee) was identified as one of our CNA's (CNA #1) .we (DON and Human Resources Manager) went to the police station and viewed the video .we were able to identify two residents (Resident #7 and Resident #8) .We were able to see the inmate .two screens were viewable one was of him (inmate) and the other was of the patient care area .at this point we were only able to identify one resident (Resident #7) .(Resident #7) is seen seated on a shower chair draped with a sheet .(CNA #1) goes to the door and asked the nurse to send another CNA in to assist her. The next view I see of the patient (Resident #7) is a side view .the sheet has been removed .I was able to see her (Resident #7's) right breast .(LPN #3) and (CNA #2) both enter the patient care area, I could see .(LPN #3) and (CNA #3) lift the patient (Resident #7) up and the brief (adult undergarment) slide out, but I was not able to see her bottom or full view of her buttocks area .(CNA #3) is viewed entering the patient care area with the second resident (Resident #8) .(Resident #8) .has her own personal gown on .(CNA #1) is back at the counter top (where phone was lying) talking to him (inmate) .I am able to view .(Resident #8) .(CNA #3) removed her (Resident #8's) gown .It wasn't until she was being dried and dressed that I was able to see a full front view of her breast, her abdominal fold, and umbilicus area. I was not able to see her peri (perineal) area . Interview with the Interim DON on 2/22/19 at 2:30 PM, in the conference room, confirmed the facility failed to ensure privacy during personal care for Resident #7 and Resident #8 and the facility failed to follow facility policy. Refer to F-600",2020-09-01
1216,LIFE CARE CENTER OF TULLAHOMA,445238,1715 N JACKSON ST,TULLAHOMA,TN,37388,2019-03-06,600,D,1,0,YLBX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policies, review of a facility investigation, review of a police report, medical record review, observation, and interviews, the facility failed to prevent abuse for 2 residents (#7and #8) of 11 residents reviewed for abuse. The findings included: Review of facility policy, Protecting Patient Privacy and Prohibiting Mental Abuse: Photography and Social Media dated 8/30/16, revealed .This facility will ensure that an environment as home-like as possible will be provided to all patients which will include an environment that treats each resident with respect and dignity. All forms of abuse are prohibited .Taking photographs with camera-equipped cell phones or any other photographic device .is strictly prohibited anywhere in the facility without the express permission of the Executive Director .Associates are prohibited from taking photographs or recordings on any personal electronic devices .when working with or near residents . Review of facility policy, Social Media revised on 9/1/16, revealed .social media policy is designed to protect .patients (residents) .This prohibition includes photos and video where the patient is not easily identifiable (e.g. a close-up photo of any part of a patient's body) .It also includes photos or video where the patient is easily identifiable . Review of a facility investigation dated 2/13/19 at 10:50 AM, revealed the police department notified the Human Resource Director of an incident which occurred on 2/12/19. Further review revealed .an employee (Certified Nursing Assistant (CNA) #1) had participated in a video chat with an incarcerated male in a patient care area (shower room) and breached the privacy of the resident (residents) . Continued review of a witness statement from CNA #2 revealed .(CNA #2) walked in the shower room where .(CNA #1) was doing showers she was facetiming her boyfriend .I do not remember if a patient was in the room at the time . Further review of a witness statement from Licensed Practical Nurse (LPN) #3 revealed .Shower Tech-yelled out for a CNA to assist .I went to the shower room to help .entered to help .I did know (CNA #1) had the phone over by the sink .I was not aware that someone could actually see the resident . Further review of a witness statement from CNA #3 revealed .I walked into the shower room on west wing .(CNA #1) was on the phone. I did advise her to hang up the phone numerous times and let her know .(Interim DON) was down the hall .hoping she (CNA #1) would hang up the phone . Review of a Police Department Incident Report dated 2/13/19 revealed .On (MONTH) 12, 2019 I was monitoring video visitations (video chat) made from .(named) County Jail when I observed a recording which was made by inmate The recording showed the female recipient of the video chat appearing to be working .I did observe the phone was placed on a sink or counter allowing the video chat to continue I observed an older female (residents) in a wheel chair in the room which appeared to be a bathroom. The video which lasted twenty-five minutes, showed the female in the wheelchair being undressed and dressed and several times completely naked. When the video chat was terminated due to time .(inmate) initiated another video chat call to the same recipient as the first. In this recording, the recipient is talking with .(inmate) and there is another older female in the video chat completely naked. The recipient did place the phone on the counter by the sink again and allowed the video chat to continue. Several times in both recordings the recipient states I am working or I am trying to work but continues to allow the video chat call to proceed. This recording is approximately thirty minutes long .I discovered the name of video chat recipient was (CNA #1) .discovered .(CNA#1) is currently working at .(the facility). I contacted the facility and spoke with Director of Human Resources (HR) .who confirmed that .(CNA #1) is employed .(HR Director) assured me they have Zero Tolerance for the usage of cell in the work area .(HR Director) and Interim Director of Nursing .came to the .Police Department to view the video. Upon viewing the video .(CNA #1) was identified as the recipient of the video chat .(Interim DON) also stated the room where the video chat occurred is called the shower room and .(CNA #1)'s responsibility that day was Shower Tech .(Interim DON) recognized three other employees .(Interim DON) did provide me with information on the female victims (Resident #7 and Resident #8) that were in the shower room . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Medical record review of Resident #7's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5 (severe cognitive impairment). Continued review revealed the resident required extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and was always incontinent of both bowel and bladder. Observation of Resident #7 on 2/21/19 at 12:05 PM, in the dining room, revealed the resident was seated at a dining room table with three other residents. Continued observation revealed the resident was feeding herself without difficulty and no signs of anxiety or fearful behavior were observed. Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Medical record review of Resident #8's Quarterly MDS dated [DATE] revealed a BIMS score of 6 (severe cognitive impairment). Continued review revealed the resident required extensive assistance with bed mobility, transfer, dressing toilet use, personal hygiene, and was frequently incontinent of both bowel and bladder. Observation of Resident #8 on 2/21/19 at 12:10 PM, in the dining room, revealed the resident was seated at a dining room table with two other residents. Continued observation revealed the resident was feeding herself and no signs of anxiety or fearful behavior were observed. Interview with the Interim Director of Nursing (DON) on 2/21/19 at 10:10 AM, in the conference room, revealed .the police detective contacted the facility .they (police detective) had viewed a video chat involving an inmate at the county jail and a health care employee. They were attempting to identify what nursing facility the employee was employed by. She (employee) was identified as one of our CNA's (CNA #1) .we (DON and Human Resources Manager went to the police station and viewed the video .we were able to identify two residents (Resident #7 and Resident #8) .it was identified there were two calls from the inmate .one lasted 25 minutes and then he called back and the conversation was approximately 30 minutes .we were able to see the inmate .two screens were viewable one was of him and the other was of the patient care area .at this point we were only able to identify one resident (Resident #7). The patient is seen seated on a shower chair draped with a sheet .(CNA #1) goes to the door and asked the nurse to send another CNA in to assist her. The next view I see of the patient (Resident #7) is a side view .the sheet has been removed, I was able to see her (Resident #7's) right breast .(LPN #3) and (CNA #2) both enter the patient care area, I could see .(LPN #3) and (CNA 3) lift the patient (Resident #7) up and the brief (adult undergarment) slide out, but I was not able to see her bottom or full view of her buttocks area .(CNA #3) is viewed entering the patient care area with the second resident (Resident #8) .(Resident #8) has her own personal gown on .(CNA #3) comes back in the patient care area with the sit to stand lift .(CNA #1) is back at the counter top talking to him (inmate) I am able to view .(Resident #8) .(CNA #3) removed her (Resident #8's) gown .It wasn't until she was being dried and dressed that I was able to see a full front view of her breast, her abdominal fold, and umbilicus area. I was not able to see her peri (perineal) area .the screen is blank and we were not able to see any patient care, when the video came back on .(CNA #1) said take her (Resident #7) out so I can argue some more. The resident was taken out of the patient care area .and the video is ended . Telephone interview with the Police Detective on 2/21/19 at 1:00 PM revealed .I saw the actual video chat .the inmates know they are being taped. The way the video works is if a face is not in the screen the screen should go blank, if the recipient moves her face away they can still see for a few seconds before the screen goes blank. It is possible he (inmate) was able to view the resident . Interview with Resident #8 on 2/21/19 at 2:30 PM, in her room, revealed the resident was unable to recall the incident. Interview with Resident #7 on 2/22/19 at 8:35 AM, in her room, revealed the resident was unable to recall the incident. Interview with the Social Service Director on 2/22/19 at 10:30 AM, in the conference room, revealed .not seen any changes in the residents .no change in their emotional psychosocial wellbeing .neither of the residents have any recall of the incident . Interview with the Interim DON on 2/22/19 at 2:30 PM, in the conference room, confirmed the facility failed to prevent abuse to Resident #7 and Resident #8 and the facility failed to follow facility policy.",2020-09-01
1217,LIFE CARE CENTER OF TULLAHOMA,445238,1715 N JACKSON ST,TULLAHOMA,TN,37388,2019-03-06,609,D,1,0,YLBX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policies, review of a facility investigation, review of a police report, medical record review, observation, and interviews, the facility failed to report abuse timely for 2 residents (#7 and #8) of 11 residents reviewed for abuse. The findings included: Review of facility policy, Protection of Residents: Reducing the Threat of Abuse & Neglect revised 2/2018, revealed .To minimize the threat of abuse and/or neglect, nursing homes must incorporate clear-cut policies and practices that demonstrate a hardline, zero-tolerance approach to resident abuse .REPORTING AND RESPONSE .All associates are mandated to immediately report suspected resident abuse and/or neglect to their immediate supervisor and/or facility representative .All alleged or suspected violations involving mistreatment, abuse, neglect .will be immediately reported to the administrator and/or director of nursing .Facilities must 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 . Review of facility policy, Social Media revised on 9/1/16, revealed .social media policy is designed to protect .patients (residents) .This prohibition includes photos and video where the patient is not easily identifiable (e.g. a close-up photo of any part of a patient's body) .It also includes photos or video where the patient is easily identifiable . Review of a facility investigation dated 2/13/19 at 10:50 AM, revealed the police department notified the Human Resource Director of an incident which occurred on 2/12/19. Further review revealed .an employee (Certified Nursing Assistant (CNA) #1) had participated in a video chat with an incarcerated male in a patient care area (shower room) and breached the privacy of the resident (residents) . Continued review of a witness statement from CNA #2 revealed .(CNA #2) walked in the shower room where .(CNA #1) was doing showers she was facetiming her boyfriend .I do not remember if a patient was in the room at the time . Further review of a witness statement from Licensed Practical Nurse (LPN) #3 revealed .Shower Tech-yelled out for a CNA to assist .I went to the shower room to help .entered to help .I did know (CNA #1) had the phone over by the sink .I was not aware that someone could actually see the resident . Further review of a witness statement from CNA #3 revealed .I walked into the shower room on west wing .(CNA #1) was on the phone. I did advise her to hang up the phone numerous times and let her know .(Interim DON) was down the hall .hoping she (CNA #1) would hang up the phone . Review of a Police Department Incident Report dated 2/13/19 revealed .On (MONTH) 12, 2019 I was monitoring video visitations (video chat) made from .(named) County Jail when I observed a recording which was made by inmate The recording showed the female recipient of the video chat appearing to be working .I did observe the phone was placed on a sink or counter allowing the video chat to continue I observed an older female (residents) in a wheel chair in the room which appeared to be a bathroom. The video which lasted twenty-five minutes, showed the female in the wheelchair being undressed and dressed and several times completely naked. When the video chat was terminated due to time .(inmate) initiated another video chat call to the same recipient as the first. In this recording, the recipient is talking with .(inmate) and there is another older female in the video chat completely naked. The recipient did place the phone on the counter by the sink again and allowed the video chat to continue. Several times in both recordings the recipient states I am working or I am trying to work but continues to allow the video chat call to proceed. This recording is approximately thirty minutes long .I discovered the name of video chat recipient was (CNA #1) .discovered .(CNA#1) is currently working at .(the facility). I contacted the facility and spoke with Director of Human Resources (HR) .who confirmed that .(CNA #1) is employed .(HR Director) assured me they have Zero Tolerance for the usage of cell in the work area .(HR Director) and Interim Director of Nursing .came to the .Police Department to view the video. Upon viewing the video .(CNA #1) was identified as the recipient of the video chat .(Interim DON) also stated the room where the video chat occurred is called the shower room and .(CNA #1)'s responsibility that day was Shower Tech .(Interim DON) recognized three other employees .(Interim DON) did provide me with information on the female victims (Resident #7 and Resident #8) that were in the shower room . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Medical record review of Resident #7's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5 (severe cognitive impairment). Continued review revealed the resident required extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and was always incontinent of both bowel and bladder. Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Medical record review of Resident #8's Quarterly MDS dated [DATE] revealed a BIMS score of 6 (severe cognitive impairment). Continued review revealed the resident required extensive assistance with bed mobility, transfer, dressing toilet use, personal hygiene, and was frequently incontinent of both bowel and bladder. Interview with the Interim Director of Nursing (DON) on 2/21/19 at 10:10 AM, in the conference room, revealed .the police detective contacted the facility .to inquire about employment of a CNA .(police detective) viewed a video chat involving an inmate at the county jail and a health care employee .attempting to identify what nursing facility the employee was employed by. She was identified as one of our CNA's (CNA #1) .we (DON and Human Resources Manager) went to the police station and viewed the video .we were able to identify two residents (Resident #8 and Resident #9) .In addition to (CNA #1) two CNA's (CNA#2 and CNA #3) and a LPN (Licensed Practical Nurse #3) were viewed entering the patient care area during the video chat . Telephone interview with CNA #3 on 2/21/19 at 3:05 PM revealed .I walked in (the shower room) with a patient (resident) .I saw she (CNA #1) was on the phone .I didn't realize it was a video chat. I did tell her to get off the phone . Continued interview confirmed staff was not to have a cellphone in a resident care area and she failed to report the incident. Interview with the Interim DON on 2/22/19 at 2:30 PM, in the conference room, confirmed the facility failed to report an allegation of abuse timely for Resident #7 and Resident #8 and the facility failed to follow facility policy. Refer to F-600",2020-09-01
1495,LAUGHLIN HEALTH CARE CENTER,445264,801 E MCKEE ST,GREENEVILLE,TN,37743,2018-07-21,689,J,1,0,X9GP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policies, review of the wander guard manufacturer's recommendations, medical record review, review of a facility investigation, interview, and observation, the facility failed to provide adequate supervision to prevent an accident for 1 resident (#1) of 16 residents reviewed for elopement risk and failed to properly secure wander guards (device worn by residents that triggers an alarm when the resident attempts to exit the facility) to the ankle of 5 residents (#4, #5, #7, #11, and #14) of 16 residents reviewed for elopement risk. The facility's failure to provide supervision resulted in Resident #1 exiting the building, falling down an embankment, sustaining an injury, and placing Resident #1 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). 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 7/3/18 and is ongoing. The findings included: Review of facility policy Elopement of Resident last revised on 1/2007, revealed .locate as quickly as possible, prevent serious injury or exposure, to any resident that may have wandered away from the facility .Charge nurses and CNAs (Certified Nursing Assistants) on each station must be aware of those residents assigned to each (staff member) .notice that you haven't seen a resident for a while, start searching immediately in that area . Review of facility policy Incident/Accident Report dated 2/2008, revealed .Purpose: to document the events of an incident or accident . Review of Manufacturer's recommendations Compliance Information Statement (wander guards) dated 3/20/15, revealed .place the strap around the resident's ankle .to ensure proper operation of the Transmitter, it must be in an upright or vertical position on the ankle . 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, last updated 11/18/17, last reviewed on 11/22/17, revealed .Episodes of exit seeking. Episode of wandering when anxious .Wander guard to prevent from exiting building without anyone knowing . Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8 (moderate cognitive impairment). Further review revealed the resident needed supervision for transfers and personal hygiene with 1 person assist and was independent with ambulation. Medical record review of Resident #1's quarterly Elopement Risk evaluation dated 5/30/18 revealed the resident was at risk for elopement and required continued use of a wander guard alarm bracelet. Review of a facility investigation of an incident that occurred on 7/3/18 at 9:15 AM revealed Resident #1 exited the facility through the front entrance alongside contracted landscapers. Further review revealed the resident fell in the parking lot, got back up, proceeded to walk toward a wooded embankment area, and then fell down the embankment. Continued review of a hand written statement by the facility receptionist dated 7/3/18 revealed .around 9:20 AM I heard the alarm at the front door go off. I immediately went out and turned the alarm off and glanced out the doors. I did not see anyone outside so I returned to my desk. Within a couple of minutes two workers from (contracted landscaping company) came to the front window to report they thought a man was trying to get away .the workers proceeded to tell me the man went into the woods. I rushed to the edge of the woods and found (Resident #1) sitting on the ground . Further review of a hand written statement by Landscape Contract Worker #1 dated 7/3/18 at 9:30 AM revealed .I was leaving the nursing home after doing some landscaping work in the courtyard and a man followed me out the door before the door locked. He fell in the road next to the door. (He) got up went across the road almost fell again .got to the woods fell into the woods. Notified the (receptionist) . Continued review of a hand written statement by the facility Staffing Coordinator dated 7/3/18 revealed .Worker from (landscaping company) .stated there was a man that fell .the worker stated the resident fell off the curb .he helped him (Resident #1) up and watched him .(Resident #1) proceeded to woods on far side of parking lot .when we (Staffing Coordinator and Receptionist) got to edge of woods the (landscape) workers went down to resident, which had fallen down over bank .I proceeded down over the hill to assist . Medical record review of an acute care hospital Emergency Department (ED) physician's History and Physical dated 7/3/18 at 10:29 AM revealed .presents with a complaint of fall/right hand injuries .pt (patient) escaped from the NH (Nursing Home) and found in the woods in back .some scratches to hands and abrasion to rt (right) knee. No MS (Mental Status) changes .Physical Exam .Extremities .abrasions to rt hand and knee (bandage) dressed by EMS (Emergency Medical Services) .neurovasc (neurovascular) intact .Patient Disposition .Primary Impression: Hand Abrasion . Interview with the Receptionist on 7/11/18 at 10:30 AM, in the conference room, revealed .I saw a group of people pass by out of the corner of my eye .the alarm sounded .I walked around from my desk, out into the hallway, down to the doors. I looked through the doors and window and didn't see anyone so I reset the alarm .I did not go outside . Interview with Licensed Practical Nurse (LPN) #1 on 7/11/18 at 1:25PM, at the West Nurses' Station, revealed .(Resident #1) would go to the front door and it would lock and alarm .he would just walk up and look out the doors .would tell us he wanted to go home .(Resident #1) easy to redirect . Interview with LPN #2 on 7/11/18 at 1:35 PM, at the West Nurses' Station, revealed .(Resident #1) was oriented to some degree .he could find his way from his room to the dining room and back .he would talk about going home .I never had to go to the front and get him . Interview with CNA #5 on 7/11/18 at 2:05 PM, on the East Wing Hallway, revealed .if I responded to an alarm at the front door, I would go outside and look to see if I saw a resident .if I didn't see anyone I would report it to my nurse or the nearest one that could take care of it . Interview with Registered Nurse (RN) #3 on 7/11/18 at 2:15 PM, in the East Wing Nurses' Station, revealed .if someone reported the door alarm had sounded and no one was seen I would go outside and look for a resident myself and then I would page for both wings (units) to complete a head count of all residents . Interview with the Director of Nursing (DON) on 7/11/18 at 2:45 PM, in her office, revealed .talked to the workers (landscapers) they said they didn't hear the alarm .we have signs on the doors to always make sure the doors closed behind them (visitors) and not let anyone out they don't know .he (Resident #1) must have caught the door before it closed .really don't know what else we could have put in place . Interview with the Administrator on 7/11/18 at 3:00 PM, in the Administrator's office, revealed .we have annual in-services for our employees and contract workers .we try to get as many contract workers to come as possible .no I don't think the landscape workers attended .we have signs on the doors telling our visitors to not let anyone out they don't know .she (Receptionist) saw a few people pass by then the alarm went off .she looked around and didn't see anything .turned the alarm off .no she did not go outside .probably been better if she had . Interview with the Receptionist on 7/12/18 at 2:00 PM, in the front office, revealed .if the alarm sounds I respond .it's usually just a CNA pushing someone out or a family member, or therapy taking someone for a home evaluation, never had an elopement .no one ever told me to go outside and look around but looking back I should have . Observation and Interview with the Facility Maintenance Director and the Receptionist on 7/17/18 at 9:00 AM, in the facility parking lot, confirmed the distance from the facility entrance/exit doors to the beginning of the woods/embankment was 157 feet and the embankment drop off was 15.3 feet. Interview with the Administrator on 7/17/18 at 1:15 PM, in the conference room, revealed .not sure we have covered that (to check outside when alarm sounds) in the annual in-service .not sure if the annual in-service is for specific procedures for code orange (elopement) . 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 had a BIMS score of 9 (moderate cognitive impairment). Continued review revealed the resident required supervision for ambulation. Medical record review of Resident #4's annual Elopement Risk assessment dated [DATE] revealed the resident was identified at risk for elopement and required the continued use of a wander guard. Medical record review of Resident #4's care plan revised date 5/25/18 revealed .can become anxious/agitated .pace and wander in her wheelchair . Observation of Resident #4 on 7/11/18 at 12:15 PM, in the dining room, revealed a wander guard alarm was attached to Resident #4's wheelchair and was not on the resident's ankle. Interview with RN #2 on 7/17/18 at 10:15 AM, in the conference room, confirmed Resident #4 .is at risk for elopement .someone would need to hold the door for her, but she would go out . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual MDS dated [DATE] revealed the resident had a BIMS score of 11 (cognitively intact). Continued review revealed the resident required supervision for locomotion with the use of a wheelchair. Medical record review of Resident #5's care plan, last revised 6/6/18 revealed the resident was identified with wandering behaviors in the past and the wander guard alarm was implemented. Observation of Resident #5 on 7/12/18 at 12:15 PM, in her room, revealed a wander guard alarm was on the resident's wheelchair and was not attached to the resident's ankle. 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 the resident had short and long term memory loss, was severely impaired for daily decision making, and required limited assist for locomotion off the unit in a wheelchair with 1 person to assist. Medical record review of Resident #7's quarterly Elopement Risk assessment dated [DATE] revealed the resident was identified at risk for elopement and required the continued use of a wander guard alarm. Observation of Resident #7 on 7/17/18 at 8:15 AM, in his room, revealed the wander guard was attached to the resident's wheelchair and was not attached to the resident's ankle. Interview with RN #2 on 7/17/18 at 10:25 AM, in the conference room, revealed .he (Resident #7) could get out if someone opened the door for him . Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS for Resident #11 dated 7/1/18 revealed a BIMS score of 5 (severe cognitive impairment). Continued review revealed the resident required limited assistance for mobility with the use of a wheelchair and 1 person assist. Medical record review of Resident #11's comprehensive care plan dated 7/4/18 revealed Resident #11 was at risk for elopement and the intervention included the use of a wander guard. Observation of Resident #11 on 7/20/18 at 10:55 AM, in her room, revealed the wander guard was attached to the resident's wheelchair and was not attached to the resident's ankle. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #14's 14 day MDS dated [DATE] revealed the resident had a BIMS score of 4 (severe cognitive impairment). Continued review revealed the resident required extensive assist with locomotion using a wheelchair with 1 person physical assist. Medical record review of the Resident #14's Care Plan dated 6/4/18 revealed the use of a wander guard alarm. Observation of Resident #14 on 7/20/18 at 11:15 AM, in the front hallway, revealed the wander guard was attached to the resident's wheelchair and was not attached to the resident's ankle. Interview with Certified Nurse Assistant (CNA) #4 on 7/11/18 at 2:00 PM, on the East Wing Hallway, revealed . I have been working here since (MONTH) (YEAR) .I don't know if they (residents) have a wander guard bracelet unless I see it on the chair or their leg . Interview with the Director of Nursing on 7/21/18 at 11:30 AM, in the conference room, confirmed the facility failed to follow the manufacturer's recommendations for placement of the wander guards for Resident #4, #5, #7, #11, and #14.",2020-09-01
2359,SIGNATURE HEALTHCARE OF MONTEAGLE REHAB & WELLNESS,445393,26 SECOND STREET,MONTEAGLE,TN,37356,2018-02-21,867,E,1,0,Q3XO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy and interview, the facility failed to develop and implement plans of action to correct resident behaviors on 1 unit (secure unit) of 5 units reviewed. The findings included: Review of the facility's policy Abuse, Neglect, Exploitation, and Misappropriation of Property reviewed 8/24/17 revealed .14.Every substantiated allegation of abuse will be reviewed by the Facility's Quality Assurance and Performance Improvement Committee to detect potential patterns or trends, and for consideration of further interventions or training opportunities . Interview with the Director of Nursing (DON) on 2/21/18 at 9:40 AM, in the front office, revealed residents on the secure unit included a high number of individuals diagnosed with [REDACTED]. Continued interview revealed the Quality Assurance (QA) committee did not routinely perform QA activities on resident to resident behaviors and due to the nature of the resident population on the secure unit, the behaviors were considered commonplace and were expected occurrences. Further interview revealed the facility did not track and trend incidents related to resident behaviors on the secure unit and had not made any recommendations to the IDT team for improvements in clinical processes to reduce the frequency of behaviors on the secure unit. Continued interview revealed the IDT team had not forwarded any investigative findings relevant to behaviors or incidents on the secure unit to the QA committee for review. Further interview confirmed the QA committee had not evaluated staffing models or the lack of activities on the secure unit to the frequency of resident versus resident altercations. Interview with the Secure Unit Manager (SM) on 2/21/18 at 10:00 AM, in the front office, revealed the SM did not participate in the monthly QA meetings. Continued interview revealed the IDT team reviewed incidents on the secure unit, but had not identified any discernable trends relevant to resident behaviors or altercations on the secure unit. Further interview revealed the IDT team was responsible for investigation of resident incidents on the secure unit and the investigations were not routinely forwarded to the QA committee for formal evaluation. Continued interview revealed the QA committee had not forwarded any recommendations for improvement of clinical processes relevant to resident behaviors on the secure unit for implementation. Interview with the Corporate Consultant (CC) on 2/21/18 at 10:30 AM, in the front office, confirmed the QA committee was expected to examine resident incidents and behaviors and to track and trend data related to resident behaviors in an effort to identify areas for clinical improvement. Continued interview revealed the IDT team should forward findings relevant to resident altercations, incidents, and behaviors to the QA committee for evaluation routinely. Further interview confirmed the QA and IDT teams failed to share information or investigate trends relevant to resident to resident altercations and the facility failed to follow facility policy.",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
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
3748,WHARTON NURSING HOME,445510,878-880 WEST MAIN STREET,PLEASANT HILL,TN,38578,2017-03-22,323,D,1,0,PSV011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, facility incident report review, medical record review, and interview, the facility failed to implement immediate interventions post fall for 2 residents (#3 and #4) of 4 residents reviewed for accidents. The Findings included: Review of the facility policy Falls Clinical Protocol, undated, revealed .staff will try various relevant interventions .until falling reduces or stops .will re-evaluate the continued relevance of current interventions . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 had a Brief Interview Mental Status (BIMS) score of 3 (severe cognitive impairment). Continued review revealed the resident required oversight, encouragement or cueing for transfers and ambulation. Further review revealed the resident used a walker for mobility. Review of facility incident reports revealed the resident sustained [REDACTED]. Further review revealed the facility failed to identify or implement an intervention after resident's falls. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed Resident #4 had a BIMS score of 3 (severe cognitive impairment). Continued review revealed the resident required extensive assist with transfers, dressing, and personal hygiene with 2 person assist. Review of facility incident reports revealed the resident sustained [REDACTED]. Further review revealed the facility failed to identify or implement an intervention the resident's falls. Interview with the Director of Nursing on 3/8/17 at 12:15 PM, in the conference room, confirmed the facility had failed to identify or implement interventions after falls for Resident #3 and #4 and the facility failed to follow facility policy.",2020-03-01
1219,LIFE CARE CENTER OF MORGAN COUNTY,445239,419 SOUTH KINGSTON STREET,WARTBURG,TN,37887,2019-06-28,608,D,1,0,PXU111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, facility of a facility investigation, medical record review, and interviews, the facility failed to report a suspicion of a crime within 24 hours to the State Survey Agency for 1 resident (#1) of 4 residents reviewed for Abuse. The findings included: Review of facility policy Protection of Residents: Reducing the Threat of Abuse & Neglect, last revised 2/2018, revealed .Each resident has the right to be free from abuse .Residents must not be subjected to abuse by anyone .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 .or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction .TRAINING understanding behavioral symptoms of residents that may increase the risk of abuse and neglect .aggressive and/or catastrophic reactions of residents .outbursts of yelling out . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a significant change Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored a 14 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Continued review revealed the resident exhibited behavioral symptoms towards others (including threatening others, screaming, and cursing) 4 to 6 days per week. Review of a facility investigation dated 6/4/19 revealed a typed summary note dated 6/4/19 from a Nurse Practitioner (NP) to the facility regarding Registered Nurse (RN) #2. Further review revealed .In order to follow the law of our Duty to Warn, we must inform you of homicidal ideation with intent and plan expressed by your employee (RN #2) .to myself this morning toward a current inpatient (Resident #1) .(RN #2) expressed profound feelings of anger toward (Resident #1) and stated to myself and our (behavioral health counselor) .that this past weekend she had considered several ways in which to take the life of (Resident #1) specifically to use critical medications potassium (excessive amounts cause cardiac dysthymias) and insulin (excessive amounts can cause death) (two different plans) to do so. (RN #2) stated she had the potassium in her hand at one point at which (RN #2's sister), also a facility employee) saw her and she (RN #2) stopped and realized it was wrong. She (RN #2) expressed to us (NP) that she needed help because she knows these feelings are wrong and an act of harming a patient is wrong but that she is afraid she will harm the patient if she continues to have to work with her. We did contact inpatient psychiatric services which advised us to have our MD write a letter of non-voluntary committal to a psychiatric facility and to send her to the emergency room via the law enforcement . Continued review of a statement by the Business Office Manager (BOM) dated 6/4/19 revealed RN #2's sister (employed by the facility as a Certified Nursing Assistant) submitted a request for a leave of absence for RN #2 and advised the BOM that RN #2 was going to be admitted to a psychiatric unit. Further review revealed RN #2 had made comments regarding Resident #1. Continued review of a statement by the Director of Nursing (DON) dated 6/4/19 revealed the DON was informed by the BOM that RN #2 made statements regarding Resident #1 and that she wanted to harm the resident and voiced intent with a plan. Medical record review of a Psychiatric Progress Note for Resident #1 dated 6/13/19 revealed Resident #1 was demanding, attention-seeking, was generally unhappy and dissatisfied. Further review revealed the resident calls out on the call light with extreme frequency, often less than a minute of staff leaving the room, yells out frequently, was disruptive, and the resident's continual and near-constant behaviors often interfered with staff's ability to provide care to other residents. Continued review revealed the facility staff and administration explained to resident how her behaviors impacted the unit. Further review revealed .discussed with DON (Director of Nursing) various potential behavioral modifications which might help including parameters set on how often she should expect to call out along with frequent checks by staff. Moving her to a different room and/or having her room with a roommate was another option which may help decrease her need to call out since some of her behaviors may be driven by feelings of loneliness . Interview with the Administrator on 6/4/19 9:30 AM, in the Activities Office, revealed RN #2 had left the Administrator a voice mail .one time about doing something to (Resident #1) . and he went to talk with RN #2 and offered to move her to a different unit, but the RN refused. Interview with the Assistant Director of Nursing (ADON) on 6/20/19 at 12:10 PM, in the Activities Office, revealed on 6/4/19 Registered Nurse (RN) #2 went to her own Physician and reported .some things . which alerted the Physician there was a problem. Continued interview revealed RN #2 worked a 12 hour shift (7:00 PM to 7:00 AM) on 6/3/19. Further interview revealed the facility was told RN #2 stated she was on her way to Resident #1's room to do something and had potassium pills in her hand, but stopped when she saw her sister (CNA#1). Continued interview revealed Resident #1 used her call light often Interview with the Administrator and the ADON on 6/20/19 at 12:35 PM, in the Activities Office, confirmed the facility did not report the incident to the State Survey Agency. Interview with Licensed Practical Nurse (LPN) #1 on 6/27/19 at 10:15 AM, in the Activities Office, revealed Resident #1 would yell at times and had her call light on excessively. Interview with LPN #3 on 6/27/19 at 11:00 AM revealed Resident #1 yelled frequently and was on the call light all the time for things she could do for herself. Telephone interview with LPN #4 on 6/27/19 at 11:15 AM revealed the Resident #1 used the call light frequently and asked for things she could do for herself. Interview with the DON on 6/28/19 at 11:45 AM confirmed Resident #1 was on the called light frequently and the facility was working on getting 2 more nurses to help out with the morning medication pass to help the staff on the floor. Further interview confirmed RN #2 told the DON that Resident #1 was on the call light frequently and stated how much time it took just to go in and move something which was within the resident's reach. Telephone interview CNA #1 (RN #2's sister) on 6/28/19 at 12:05 PM revealed during one night Resident #1 had her call light on over 70 times during the 12 hour shift. In summary, RN #2 had a plan to harm Resident #1 by giving her excessive amounts of insulin or potassium because of the stress caused by the resident's overuse of the call light and demanding nature. The facility failed to report a suspicion of a crime to the State Survey Agency within 24 hours of being made aware by the RN's medical provider.",2020-09-01
3942,WYNDRIDGE HEALTH AND REHAB CTR,445304,456 WAYNE AVENUE,CROSSVILLE,TN,38555,2017-01-24,225,D,1,0,EVQC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, hospice contract, review of facility documents, medical record review, and interviews the facility failed to investigate and report an allegation of abuse for 1 resident (#1) of 3 residents reviewed for abuse. The findings included: Review of the facility policy Neglect, Misappropriation Protocol revised 6/14, revealed .2. Any Staff member or person affiliated with this facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report, or cause a report to be made of, the mistreatment or the offense. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information .3. Staff members and persons affiliated with this facility shall not knowingly: Attempt, with or without threats or promises of benefit, to induce another to fail to report an incident of mistreatment or other offense . Review of a Long Term Care Services Contract for Hospice dated 12/14 revealed .XIII. Grievances The Hospice and Nursing Facility hereby jointly agree to cooperate fully in resolving a Resident Patient's grievances related to the provision of the Hospice or Nursing Facility services. In this regard, the Hospice and Nursing Facility shall immediately bring to the attention of their respective senior managers all Resident Patient's complaints involving either Party . Medical record review revealed Resident #1 was admitted to the facility on [DATE] discharged on [DATE] to Geri Psych, readmitted on [DATE], discharged on [DATE] readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a Social Service note from the care plan meeting dated 12/22/16 revealed Resident #1's daughter stated the resident confided in her that he had been raped. The Social Service Worker informed the resident's daughter the Director of Nursing would be notified, and this would be a top priority. Review of the facility investigation dated 12/22/16 revealed .(Hospice) Administrator notified (Director of Nurses) on 12/22/16 the Hospice Chaplin was visiting (12/16/16) with Resident #1 and the resident reported to the chaplin that the 'Doctors' had raped him . Interview with Licensed Practical Nurse #1 (LPN) on 1/23/17 at 8:09 AM, in the 300 hall nurses station confirmed she and another LPN were instructed by the DON to complete a physical assessment of Resident #1. Continued interview confirmed a physical Assessment of the resident's rectal/anal area revealed no trauma, no scratches, or redness was present. Continued interview confirmed the resident had never reported to her any abuse or mistreatment from the staff or anyone else. Interview with Hospice Chaplin on 1/23/17 at 12:14 PM, via telephone confirmed he had been informed by Resident #1 on 12/16/16 of the alleged rape. Continued interview confirmed he did not follow up on the allegation and did not inform the facility or Hospice of the allegation. Interview with Director of Nursing 1/24/17 at 9:41 AM, in the conference room confirmed she would have expected the Hospice Chaplin to notify the facility immediately of the allegation of abuse. Continued interview confirmed the Hospice Chaplin failed to notify the facility immediately of the allegation of abuse, the facility failed to follow their abuse policy.",2020-01-01
4680,NORRIS HEALTH AND REHABILITATION CENTER,445303,3382 ANDERSONVILLE HIGHWAY,ANDERSONVILLE,TN,37705,2016-08-09,312,D,1,0,6ZST11,"**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 provide showers per the care plan for 1 Resident (#5), of 4 residents reviewed for Activities of Daily Living, of 5 residents reviewed. The findings included: Review of the facility policy, Routine Resident Care revised (MONTH) 2008, revealed .Residents receive necessary assistance to maintain good grooming and personal .hygiene .Showers, tub baths, and/or shampoos are scheduled at least twice weekly and more often as needed . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident with a Brief Interview of Mental Status Score of 15/15 (cognitively intact), had no symptoms of [MEDICAL CONDITION], and was dependent for transfers, bathing, and personal hygiene. Medical record review of the current Care Plan revealed Resident #5 was to receive showers twice weekly on Wednesdays and Saturdays. (An average of 8 showers monthly). Medical record review of the Activity of Daily Living (ADL) Flow Sheets dated 6/30/16 to 7/30/16 revealed the resident was not showered on Wednesdays and Saturdays in accordance with the Care Plan, and received only 3 showers in a 30 day period between 6/30/16 to 7/30/16. No showers were documented as performed between 7/16/16 and 7/30/16 (14 consecutive days). Observation and interview with Resident #5 on 8/9/16 at 5:00 PM, in the resident's room, revealed the resident was alert, oriented to place and circumstances. The resident reported he did not regularly receive showers on Wednesdays and Saturdays and reported he frequently was not offered showers on his appointed shower days. Continued observation and interview revealed a noticeable smell of body odor present. The resident also reported the facility frequently delayed his showers. Resident #5 stated he could not recall when he last showered. Interview with the DON on 8/9/16 at 5:30 PM, in the Administrator's Office, confirmed the facility had failed to shower the resident in accordance with the care plan and facility policy, and confirmed no evidence was present in the medical record which indicated the resident had refused showers on the scheduled shower days.",2019-08-01
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
2574,BETHESDA HEALTH CARE CENTER,445427,444 ONE ELEVEN PLACE,COOKEVILLE,TN,38501,2017-12-20,609,D,1,0,9D4B11,"**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 immediately report an allegation of abuse for 1 resident (#6) of 6 residents reviewed. The findings included: Review of the facility policy Abuse, last revised June, 2014, revealed .1. When an allegation or a suspicion of abuse/neglect/exploitation is made, the employee should immediately notify he (the) Administrator or his/her designee (preferably the DON (Director of Nursing) ) . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nurses event note dated 6/26/17 revealed .Pt (patient) was confused the morning of 6/23/17 and had been up in the hallway yelling for help. I assisted pt back to bed. Pt began yelling for help again and .CNA (Certified Nursing Assistant) and myself went into pt room .Pt looked up and stated I don't think this is my bed and I think I have beaten and raped . Review of the facility investigation dated 6/26/17 revealed .Date of Occurrence: 6/23/17 .This is a new nurse and she did not report the event until today . Interview with Licensed Practical Nurse (LPN) #3 on 12/18/17 at 12:35 PM on the 100 Hall revealed she did not report the incident at the time the allegation was made. Interview with the DON on 12/20/17 at 8:10 AM in the DON office confirmed LPN #3 did not report the allegation of abuse timely.",2020-09-01
900,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2018-03-21,609,D,1,0,ZD9T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review and interviews, the facility failed to report to the state agency allegations of abuse to include an injury of unknown origin for one resident (#4) of five sampled residents reviewed for allegations of abuse. The findings included: Review of the facility policy Abuse, Neglect, Mistreatment and Misappropriation of Resident Property dated 12/4/2017, revealed allegations of abuse are to be reported to the Administrator, State Agency, law enforcement, the physician, and the resident and/or Power of Attorney. Review of the medical record revealed the facility admitted Resident #4 on 5/3/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed Resident #4 had a chest x-ray on 1/2/2018 due to a cough. Review of the medical record revealed KUB (Kidney, Ureters, and Bladder) x-rays were done on 1/29/18, 1/30/18, and 2/1/18. These x-rays reported a metallic screw over the right upper quadrant of the abdomen. Review of the medical record revealed the physician was notified of the KUB x-ray results on 1/29/18, 1/30/18 and 2/1/18. Review of the nurse's note dated 2/1/18 revealed the POA agreed with the doctor for Resident #4 to be admitted to the hospital on [DATE] for evaluation of the screw in the abdomen. Review of the Op Note (surgical note) dated 2/1/18 revealed the screw was removed from the resident's duodenum (upper part of the small intestine) with a scope inserted down the resident's throat. Resident #4 tolerated the procedure well and returned to the facility on [DATE]. Interview with Resident #4 was attempted on 3/19/18 at 1:00 PM, on in the 300-500-unit dining room, and Resident #4 was unable to answer any questions. Interview with the Medical Director, who was also the attending physician, on 3/20/18 at 1:30 PM, at the nurses' station on the 300-500 units, revealed, Later when I looked at the chest x-ray films, I thought I saw a foreign body on the films even though the chest x-ray report did not mention it so I ordered the KUB x-ray. I have no idea where the screw came from. The screw showed up on a chest x-ray so I ordered a KUB (x-ray of the abdomen) three times to verify that this was a screw and not an artifact. The resident had no pain or vomiting or change in bowel habits. Once I verified that it was a screw I admitted her to the hospital under the care of a [MEDICATION NAME]. The screw was removed without any adverse effect to the resident. The Medical Director stated Resident #4 had no prior history of putting non-food items in her mouth. Interview with the Director of Nursing (DON) on 3/20/18 at 11:30 AM, in the DON's office, revealed the incident of Resident #4 having a screw in her abdomen was not reported. The DON stated a screw in the abdomen is an unusual finding and we should have reported it. Since she (Resident #4) didn't have any outcome we just didn't think to report it.",2020-09-01
1446,BRIARCLIFF HEALTH CARE CENTER,445260,100 ELMHURST DR,OAK RIDGE,TN,37830,2018-05-23,609,D,1,0,I0PH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview the facility failed to follow their abuse policy for reporting allegations of abuse for 1 resident (#1), and failed to report allegation of abuse within federally required time frame for 1 resident (#1) of 5 residents reviewed for abuse. The findings included: Review of the facility policy Abuse Policy dated 2/17 revealed .All alleged violations involving mistreatment, neglect, abuse, or exploitation .are reported immediately to the Administrator/Director of Nursing and to other officials in accordance with State law through established procedures (including to the State survey and certification agency) .Immediately means as soon as possible: .Any allegation of abuse within two hours . Medical record review revealed Resident #1, was admitted to the facility on [DATE], and discharged on [DATE], with the [DIAGNOSES REDACTED]. Interview with Licensed Practical Nurse (LPN) #1 on 5/21/18 at 11:20 AM, in the conference room confirmed it was between 8:15 AM, and 8:30 AM, on 4/25/18 when I went in the resident's room, she was clearly upset. She said she didn't want her back in her room, and I said who. She said the Certified Nurse Aide (CNA) that worked last night. I asked her why and she said, she had told her to shut up, and had shaken her bed. She appeared fearful and scared. Continued interview confirmed I filled out the Customer Concern Form and put it under the Social Service Director's (SSD) door. Interview with the SSD on 5/21/18 at 2:15 PM, in the conference room confirmed she had gotten to the facility around 9:00 AM, on 4/25/18. I went to morning meeting before I went to my office, so I probably found the grievance form about 10:30 AM. I read it and I went to the Administrator's office, he wasn't in his office, so I took it to the DON's (Director of Nursing) office and I left it on her desk. Interview with the Administrator on 5/21/18 at 4:46 PM, in the conference room confirmed he was in his office on a conference call with the DON and someone (he couldn't remember who) brought in some papers, and DON showed it to me. I saw the Customer Concern Form for the first time at approximately 3:30 PM. Interview with the DON on 5/21/18 at 6:52 PM, via telephone confirmed she was not sure if someone had brought the Customer Concern Form to her, handed it to her on her way to the Administrator's office, or if she had it already in her hand when she went to the conference call at 3:15 PM. Interview with the DON on 5/21/18 at 7:00 PM, via telephone confirmed, the Customer Concern Form should not have been placed under the SSD's office door, or laid on her desk, but should have been reported to the Administrator immediately. Continued interview confirmed the facility failed to follow their abuse policy for reporting an allegation abuse, and failed to report the allegation of abuse to the State Agency within the federally required time frame.",2020-09-01
3278,"THE WATERS OF SMYRNA, LLC",445502,202 ENON SPRINGS ROAD EAST,SMYRNA,TN,37167,2018-01-16,660,D,1,0,POU411,"**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 have evidence of thorough discharge planning for 2 residents (#6, #19) of 5 residents who were reviewed for transfer/discharge requirements. The findings included: Review of facility policy Transfer and Discharge Policy and Procedure, dated 1/11/17, revealed .The facility will provide provisions for continuity of care and in non-emergency situations, a care plan meeting will be held with the appropriate parties to determine a relocation plan .The facility must provide sufficient orientation and preparation to ensure a safe and orderly transfer . Medical record review revealed Resident #6 was admitted to the facility on [DATE] for long term care with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set (MDS), 10/1/17 revealed the resident had severe cognitive impairment, based on a Brief Interview for Mental Status (BIMS) score of 3/15. Continued review of the MDS revealed the resident had delusions, required supervision with ambulation, and wandered daily. Further review of the MDS revealed the resident's behavior of daily wandering did not place her at significant risk of getting to a potentially dangerous location, and did not significantly intrude on the privacy of others. Continued review of the Admission Minimum Data Set (MDS) dated revealed no discharge planning was in effect. Medical record review of Nursing Progress Note dated 9/21/17, revealed the resident .is alert with confusion. Ambulates independently. Resident confused as to why she is here. Asks random questions and makes random statements. Resident is pleasantly confused and redirected as needed. Resident ambulates independently .Wanderguard placed to body rt (related to) confusion and wandering . Medical record review of her Comprehensive Care Plan revealed that on 10/4/17, staff documented the resident was .admitted for long term care services for [DIAGNOSES REDACTED]. She requires 24-hour nursing care and constant supervision as she is unaware of her own safety needs . The care plan for this problem included interventions introducing the resident to the facility, and encouraging the resident/family to be involved in care planning and meeting. The care plan did not address any plans for discharge of the resident. Medical record review of the Progress Note dated 10/31/17, the facility contacted the family to inform them the resident was not a good fit due to safety concerns after the resident had eloped from the facility and been found without her Wanderguard (personal alarm to notify an exit of a set perimeter) device on. Medical record review revealed no evidence of thorough discharge planning for the resident. Review of her Comprehensive Care Plan revealed it was not revised when the need for a discharge was identified on 10/31/17. Review of the Comprehensive Care Plan revealed the Care Plan for long term care services was never updated prior to her discharge on 11/13/17, when her Care Plan was marked as canceled. The facility failed to make the resident's hard copy health record available for review to determine if additional information regarding discharge planning was documented. Interview with the Social Services Director (SSD), on 1/10/18 at 9:56 AM in the conference room, confirmed that there should have been documentation of discharge planning for the resident. Continued interview revealed she stated that she had worked with the family and had sent out referrals to other facilities once the facility decided to discharge Resident #6. Further interview revealed she confirmed, I did not document on all of it. Medical record review revealed Resident #19 was admitted to the facility on [DATE]. Medical record review of the Admission MDS dated [DATE] revealed there was no active discharge planning and the resident expects to remain in this facility. Medical record review of Progress Notes dated 11/1/17 at 6:29 PM revealed a nurse found the resident in bed, passing a cigarette to a visitor in the room. Continued review of the Progress Notes documented the resident stated I am sorry, I will not do again. Further review revealed the Director of Nursing (DON) and Administrator were called and made the decision to discharge the resident due to him violating the facility's smoking policy. Continued review of this note revealed Resident #19's Power of Attorney/friend was called to inform him the resident would be discharged the following day (11/2/17). Further review of an additional Progress Note dated 11/2/17 at 3:32 PM confirmed the resident was discharged to another facility on 11/2/17, less than 24 hours after the facility first informed the resident he was being discharged for not following facility rules. Continued review revealed the only information related to discharge planning for the resident was an 11/2/17 Progress Notes entry at 1:14 PM which stated the SSD had called another facility and secured a place for the resident, arranged transportation, and notified his contact the resident was being discharged the same day. Interview with the SSD, on 1/10/18 at 11:08 AM in the DON's office, confirmed Resident #19 was discharged because he had not complied with the facility's smoking policy. Continued interview revealed she stated she did not have the authority to decide the discharge, but once she was informed that the facility would no longer allow him to stay, she contacted a nearby facility who agreed to take him. Further interview with the SSD, on 1/15/18 at 1:09 PM in the conference room, revealed she was not aware of the need to develop a written discharge plan once a facility identified the resident was to be discharged from the facility. Continued interview revealed she stated she had never been told that this was required and had not been completing them.",2020-09-01
5330,SERENE MANOR MEDICAL CTR.,4.4e+252,970 WRAY ST,KNOXVILLE,TN,37917,2016-04-08,514,E,1,0,GQVT11,"**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 complete and accurate clinical records related to Behavior/Intervention Flow Record for 2 residents (#1, #7); Medication Administration Record [REDACTED]. The findings included: Review of facility policy, Behavior Assessment and Monitoring (no date) revealed .if a resident is being treated for [REDACTED].the nursing staff will monitor for side effects and complications related to psychoactive medications . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set (MDS) revealed the resident scored 06/15 (severely cognitive impairment) on the Brief Interview for Mental Status (BIMS) and required limited assistance for ambulation in the room, dressing, and bathing. Medical record review revealed Resident #1 was actively seen by psychiatric services related to anxiety, agitation, dementia, and paranoia. The resident is confused, inappropriate to content, disorganized thinking, judgment poor, impulse control fair, and delusional. Medical record review of the Behavior/Intervention Monthly Flow Record for 10/15,11/15, and 1/16 revealed Resident #1 was monitored for hitting and agitation. Continued review revealed the flow record asked questions related to number of behavior episodes, intervention, outcome, and side effect with multiple blank spaces noted all months. Further review revealed multiple blank spaces noted on the flow record for 10/15, 11/15, and 1/16 and no record could be located for 12/15. Interview with the Administrator on 4/7/16 confirmed the Behavior/Intervention Monthly Flow Record for 10/15, 11/15, and 1/16, had multiple blank spaces and the record for 12/15 could not be located. Continued interview confirmed a record for 12/15 should have been completed. Medical record review of a physician's telephone order for Resident #1 dated 1/1/16 revealed .[MEDICATION NAME] ER (extended release - mood stabilizer) 500 mg (milligrams) PO (by mouth) at HS (hour of sleep) . and on 1/4/16 the orders read .[MEDICATION NAME] (for Alzheimer/Dementia) 5 mg po qd (everyday) x 7 days, bid (twice daily) x 7 days, tid (three times daily) x 7 days then 10 mg bid .Increase [MEDICATION NAME] ER to 750 mg po q HS .[MEDICATION NAME] to 20 mg qd .DC (discontinue) [MEDICATION NAME] (antidepressant) . Medical record review of the Medication Observation Record for Resident #1 revealed the order for [MEDICATION NAME] was not documented as given at 8 AM on 1/5/16. Continued review revealed when transcribed to the Medication Observation Record the [MEDICATION NAME] ER 500 mg had not been discontinued nor was the new [MEDICATION NAME] ER dosage of 750 mg transcribed on the record and on 1/4/16 and 1/5/16 the nurse documented both the [MEDICATION NAME] ER 500 mg and the [MEDICATION NAME] ER 750 mg. Review of the 24 hour chart check (an in-house form) revealed .review all new orders, both telephone and written on the physician's orders [REDACTED]. Interview with Licensed Practical Nurse (LPN) #2 on 4/7/16 at 4:15 PM, in the Administrator's office confirmed when she transcribed the orders for 1/4/16 she failed to transcribe the new dosage amount of 750 mg to the [MEDICATION NAME] ER entry and failed to discontinue the [MEDICATION NAME] ER 500 mg. Continued interview revealed LPN #2 was on duty on 1/5/16 at 8:00 AM and had failed to document the administration of the [MEDICATION NAME] 5 mg but was sure she had administered the medication. Interview with LPN #1 on 4/7/16 at 4:15 PM, in the Administrator's office confirmed she had documented giving both the [MEDICATION NAME] ER 500 mg and the [MEDICATION NAME] 750 mg but only gave the 750 mg and had made a mistake charting on both dosages. Further interview with LPN #1 confirmed she gave the [MEDICATION NAME] 5 mg on 1/5/16 at 8 AM but had failed to document administering the medication on the Medication Observation Record. Interview with LPN #3 on 4/8/16 at 7:40 AM, in the front lobby confirmed she had completed the chart check on 1/4/16 - 1/5/16 and should have .caught that .(transcription error and the documentation errors) . related to the [MEDICATION NAME] ER. Interview with the Quality Assurance (QA) nurse and the Director of Nursing (DON) on 4/8/16 at 9:30 AM, in the front waiting area confirmed the Behavior/Intervention Flow Records for each month were to be completed without any blank spaces. Further interview confirmed the nurses had failed to correctly and accurately transcribe the orders for the [MEDICATION NAME] ER; failed to document the administration of the [MEDICATION NAME]; and had documented the administration of [MEDICATION NAME] ER 500 mg and 750 mg on 1/4/16 and 1/5/16. 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 12 (cognitive intact) on the Brief Interview for Mental Status (BIMS). Continued review revealed the resident required extensive assistance of 2 for transfer and the assist of 1 for dressing and hygiene/bathing. Medical record review of Resident #7's Medication Observation List for 3/16 revealed the resident was started on [MEDICATION NAME] (antipsychotic) 25 mg 3 times daily on 11/4/15. Medical record review of the Behavior/Intervention Monthly Flow Record for 12/15, 1/16, 2/16, and 3/16 revealed the resident was monitored for depressed/withdrawal, mood changes, agitated, danger to self, anxiety, and uncooperative. Continued review revealed the flow record asked questions related to number of behavior episodes, intervention, outcome, and side effect with multiple blank spaces noted all months. Interview with the QA nurse and the DON on 4/8/15 at 9:30 AM, in the front waiting area, confirmed Behavior Monitoring Sheets are to be filled out for residents with behaviors and residents receiving antipsychotic medications. Continued interview confirmed Resident #7 was receiving [MEDICATION NAME] and behavior monitoring sheets had been initiated, however multiple blanks were noted on the 12/15, 1/16, 2/16, and 3/16 monitoring records.",2019-04-01
842,"GALLATIN HEALTH CARE CENTER, LLC",445183,438 NORTH WATER AVE,GALLATIN,TN,37066,2019-06-12,689,J,1,0,HPNL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview the facility failed to prevent elopement from the facility to the facility parking lot for 1 resident (Resident #1) of 3 residents reviewed. The findings include: Review of facility policy, Elopements, revealed .when a departing individual returns to the facility the Director of Nursing Services or Charge Nurse shall .complete and file Report of Incident /Accident . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an annual Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 8 indicating moderate cognitive impairment. Medical record review of an elopement risk evaluation dated 4/22/19 revealed a score of 9 (9 or greater indicated a risk of elopement). Continued medical record review of an elopement risk evaluation dated 5/18/19 revealed a score of 21. Further review of the medical record revealed Resident #1 was care planned for wandering and exit seeking. Interview with the Director of Nursing (DON) on 6/11/19 at 8:40 AM in the conference room revealed video footage of Resident #1's elopement on 5/17/19 was reviewed. Continued interview confirmed the DON stated the video showed the resident pushing open the door (key pad coded) and self-propelling from inside the facility to outside the facility. Further interview revealed the video footage was no longer available due to the facility video system auto-erasing every 14 days. The DON confirmed an investigation was not done for Resident #1's elopement on 5/17/19. Interview with Licensed Practical Nurse (LPN) #1 on 6/11/19 at 12:10 PM in the Unit Manager's office revealed Resident #1 self-propelled from the resident's room to the rehabilitation (rehab) unit as he desired. Continued interview with LPN #1 revealed the resident had a pattern of going to the rehab unit most everyday. Further interview with the LPN revealed when the station 3 nursing staff could not locate the resident they would look in the rehab unit. LPN #1 confirmed the resident had exit seeking behaviors. Interview with LPN #3 on 6/11/19 at 4:35 PM in the conference room revealed as she was leaving the facility on 5/17/19 at approximately 7:00 PM she observed an empty wheelchair with a person sitting by a truck, on his butt, on the asphalt and touching the truck. Continued interview revealed she observed the person as was Resident #1. Further interview revealed the resident stated he was working on this truck; I've been meaning to get to it all day. LPN #3 did a quick assessment of Resident #1 for injuries as she used her cellular phone to call the nursing staff for assistance with the resident. Continued interview revealed LPN #3 was told by Resident #1 he was unsure how he got outside. Interview with the Administrator on 6/12/19 at 9:05 AM in the conference room revealed the video footage from 5/17/19 was auto-erased by the video program system. Continued interview revealed the Administrator gave a description of the video to this surveyor. Further interview revealed the Administrator stated Resident #1 was seen rounding the corner of the hall into the area in front of the door #13 (key pad coded). The Administrator confirmed the resident was seen on the video to push open the door and self-propel himself outside. Continued interview confirmed Resident #1 was unable to be seen on the video in the parking lot. Further interview confirmed the video monitor for the facility was not watched 24/7. The Administrator confirmed the time frame Resident #1 was out of the building was unknown. Validation of the IJ removal plan was completed on 6/12/19 through review of the facility documentation, observations and interviews. Surveyor verified the IJ removal plan by: 1. Resident #1 was returned to the facility and the facility policy for elopement appropriately followed as evidenced by nursing progress notes, event notes and staff interviews. The resident was checked every hour by physician's orders [REDACTED]. 2. In-service education was provided 5/20/19 for wandering and elopement as evidenced from sign-in rosters and staff interviews. Daily door audits were initiated 5/20/19 and performed by the department heads. Audits were ongoing every shift for 2 weeks then weekly for 3 months. Key pad coded doors (4) in the rehab unit were scheduled for installation of alarms the week of 6/17/19. 3. Resident assessments were checked for current status to match condition on 6/12/19 and performed by the DON and nursing staff. The maintenance director will continue daily door audits for proper operation for an additional 2 weeks and then resume daily audits. 4. Presentation of all audits by the DON and maintenance director to the Quality Assurance Committee (QAC) monthly for 3 months; with the first presentation at the 6/12/19 meeting.",2020-09-01
4493,CUMBERLAND HEALTH CARE AND REHABILITATION INC,445262,4343 ASHLAND CITY HWY,NASHVILLE,TN,37218,2016-09-21,514,E,1,0,KCHW11,"**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 accurately document controlled medications on the Medication Administration Record [REDACTED]. The findings included: Review of facility policy, Controlled Drug Accountability Procedure, dated 4/22/14 revealed, .Each dose administered is to be signed out by the nurse on the controlled drug record and on the patient's eMAR (electronic medication administration record) . Medical record review of a Controlled Drug Receipt/Record/Disposition Form for Resident #4 revealed [MEDICATION NAME]/APAP (narcotic pain medication) 10-325 mg (milligrams) tablets with documentation 1 tablet signed out on 7/1/16 at 2:40 PM by RN #1. Continued review of the MAR for 7/1/16-7/25/16 revealed no documentation the [MEDICATION NAME] was administered to Resident #4 at 2:40 PM by RN #1. Medical record review of a Controlled Drug Receipt/Record/Disposition Form for Resident #5 revealed [MEDICATION NAME]/APAP (narcotic pain medication) 7.5-325 mg tablets with documentation 1 tablet was signed out on 6/30/16 at 11:50 PM, and 1 tablet was signed out on 7/1/16 at 3:00 PM by RN #1. Continued review of the MAR for 6/30/16 revealed no documentation 1 tablet was administered to the resident at 11:50 PM. Continued review of the MAR for 7/1/16 revealed no documentation 1 tablet was administered to Resident #5 at 3:00 PM by RN #1. Medical record review of a Controlled Drug/Receipt/Record/Disposition Form for Resident #6 revealed [MEDICATION NAME]/APAP 7.5-325 mg tablets with documentation 1 tablet signed out on 6/30/16 at 11:50 PM, and 1 tablet signed out on 7/1/16 at 3:00 PM by RN #1. Continued review of the MAR for 6/30/16 revealed no documentation 1 tablet was administered to the resident at 11:50 PM. Continued review of the MAR for 7/1/16 revealed no documentation 1 tablet was administered to Resident #6 at 3:00 PM by RN #1 Medical record review of a Controlled Drug/Receipt/Record/Disposition Form for Resident #6 revealed [MEDICATION NAME] 15 mg tablets with documentation 1 tablet was signed out on 6/30/16 at 3:00 PM and another tablet signed out at 10:20 PM by RN #1. Continued review revealed 1 tablet was signed out on 7/1/16 at 3:00 PM by RN #1. Review of the MAR for 6/30/16 revealed no documentation the medication was administered to the resident at 3:00 PM or 10:20 PM. Continued review of the MAR for 7/1/16 revealed no documentation 1 tablet was administered to Resident #6 at 3:00 PM by RN #1. Medical record review of a Controlled Dug/Receipt/Record/Disposition Form for Resident #7 revealed [MEDICATION NAME] IR 10 mg tablets with documentation 1 tablet signed out on 6/30/16 at 10:40 PM and 1 tablet signed out on 7/1/16 at 2:50 PM by RN #1. Review of the MAR for 6/30/16 revealed no documentation 1 tablet was administered to the resident at 10:40 PM. Continued review of the MAR for 7/1/16 revealed no documentation 1 tablet was administered to Resident #7 at 2:50 PM by RN #1. Interview with the Administrator in the Conference Room on 8/22/16 at 2:15 PM, confirmed the facility failed to accurately document administration of controlled medications for Resident's #4, #5, #6, and #7 on the Medication Administration Record.",2019-09-01
1403,SUMMIT VIEW OF ROCKY TOP,445259,204 INDUSTRIAL PARK RD,ROCKY TOP,TN,37769,2020-01-17,655,D,1,0,XWNL11,"**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 address the risk for falls on the baseline care plan for 1 resident (Resident #2) of 4 residents reviewed for accidents. The facility's failure placed Resident #2 at risk for falls and injury. The findings include: Review of facility policy, Care Plans-Baseline, dated 12/2016, showed .a baseline care plan to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Admission Evaluation and Interim Care Plan dated 12/6/2019 showed the section Screen for Fall Risk was left blank. Review of the admission Minimum Data Set ((MDS) dated [DATE] showed Resident #2 was moderately cognitively impaired, inattentive, required limited assistance of 1 staff member for activities of daily living (ADLs), except toileting, which required extensive assistance of 1 staff member, and eating, which required supervision and set up. The resident's gait was unsteady, but the resident was able to stabilize without staff assistance during transitions and walking. The resident did not use mobility devices, had a urinary catheter, was frequently incontinent of bowels, and had a previous fall with minor injury. Interview with the Director of Nursing on 1/14/2020 at 3:46 PM, confirmed the facility failed to develop a baseline care plan to address Resident #2's fall risk.",2020-09-01
5105,CHURCH HILL CARE & REHAB CTR,445237,701 WEST MAIN BLVD,CHURCH HILL,TN,37642,2016-05-24,309,D,1,0,ID7311,"**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 directed by the Physician for one Resident (#2) of 4 residents reviewed for medication compliance of 5 residents reviewed. The findings included: Review of facility policy, Medication Administration Guidelines, effective (MONTH) 2012 revealed nurses must follow the 6 Rights of Administration .right patient .right medication .right dose .right time .right route .right documentation .After Hours Procedure .When a medication is needed after the pharmacy's normal business hours .call the on call pharmacist .on call pharmacist will call meds not in .to a local backup pharmacy for a 3 day supply and have delivered to facility .the nurse should never .simply mark .unavailable from pharmacy . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the electronic Medication Administration Record [REDACTED]. Continued review revealed the resident left the faciity on an outing with a family member without taking either medication. Continued medical record review revealed no indications the facility had attempted to obtain supplies of either medication from the back up pharmacy in accordance with facility policy. Interview with Licensed Practical Nurse (LPN #10) (the nurse responsible for medication administration to the resident that day) on 5/12/16 at 2:15 PM, in the wound care office revealed the resident's supplies of both medications had been exhausted the day prior and refills ordered had not yet arrived to the facility at the time the medications were due. Continued interview revealed LPN #10 was aware the resident had a scheduled outing that day and was aware the medications were not available for use in the appropriate dosage forms in the facility emergency supply and confirmed she did not contact the on call pharmacist to obtain supplies of either medication from the back up pharmacy and documented the missed doses as not available. Continued interview revealed LPN #10 did not contact the Physician in an effort to obtain orders for alternative dosing of both medications that were available for use in the facility's emergency supply. Interview with the Director of Nursing (DON) on 5/12/16 at 2:40 PM, in the DON's office confirmed the facility had failed to obtain either of the medications from the back up pharmacy in accordance with facility policy and had failed to administer the medications to the resident in accordance with Physician orders [REDACTED].",2019-05-01
550,QUALITY CENTER FOR REHABILITATION AND HEALING LLC,445154,932 BADDOUR PARKWAY,LEBANON,TN,37087,2018-01-24,656,D,1,0,BRJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview, the facility failed to develop a comprehensive plan of care for 1 resident (#9) of 9 sampled residents. The findings included: Review of facility Policy and Procedure MDS/Care Plans undated, revealed .The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetable to meet a resident's medical, nursing, mental and psychological needs which are identified in the comprehensive assessment and lead to the resident's highest obtainable level of independence .Procedure .When making decisions about the care plan .a. Determine whether the problem needs an intervention. b. Evaluate the resident's goals, wishes, (advance directives), strengths and needs. c. Design interventions that address cause, not symptoms. d. Establish which items need further assessment or review . Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. Medical record review revealed an assessment of Resident #9 signed by the Attending Physician dated 11/7/17 of an .acute left humerus fracture without fall. Possibly when rolled to clean her, fracture with underlying [MEDICAL CONDITION] . Medical record review of the Plan of Care initiated 9/2/16 and revised on 11/17/17 revealed no objectives, goals, or interventions to direct staff in providing care and services to Resident #9 whose condition was compromised after a fracture and who had a [DIAGNOSES REDACTED]. Interview with the Administrator and the Director of Nursing in the Administrator's office on 1/24/18 at 11:30 AM confirmed the care plan for Resident #9 failed to identify objectives, goals, and interventions to direct the staff in the care of the resident with a compromised condition.",2020-09-01
2348,MANCHESTER HEALTH CARE CENTER,445391,395 INTERSTATE DRIVE,MANCHESTER,TN,37355,2017-06-06,284,F,1,0,GYB111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview, the facility failed to develop, implement, and document an effective discharge planning process for 3 resident's (#1, #2, #3) of 3 residents reviewed. The findings included: Review of facility policy, DISCHARGE PR[NAME]ESS, revised 2009 revealed .When the facility anticipates a resident's discharge to a private residence or to another nursing care facility .a Post Discharge Plan will be developed which will assist the resident to adjust to his or her new living environment .The Post Discharge Plan will be developed by the Interdisciplinary Care Plan Team . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 15 indicating the resident was cognitively intact. Further medical record review revealed Resident #1 was discharged on [DATE] at 10:00 AM. Medical record review revealed no documentation or implementation of discharge planning in the medical record for Resident #1. Interview with the Social Services Director (SSD) on 6/5/17 at 4:04 PM in the conference room when asked about the discharge date for Resident #1 revealed .we had never set a date for (Resident #1) to go home .We didn't give him a discharge because we didn't know when he was leaving . The SSD confirmed there had been no documentation or implementation of discharge planning for Resident #1. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MDS 30 day assessment dated [DATE] revealed Resident #2 had a BIMS of 14 indicating the resident was cognitively intact. Medical record review revealed no documentation or implementation of discharge planning in the medical record for Resident #2. Interview with the Social Services Director on 6/5/17 at 4:22 PM in the conference room confirmed there had been no documentation or implementation of discharge planning for Resident #2. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MDS Discharge assessment dated [DATE] revealed Resident #3 had a BIMS of 15 indicating the resident was cognitively intact. Further medical record review revealed Resident #3 was discharged on [DATE]. Medical record review revealed no documentation or implementation of discharge planning in the medical record for Resident #3. Interview with the SSD on 6/5/17 at 4:28 PM in the conference room when asked for documentation of discharge planning for Resident #3, the SSD stated there wasn't any .If I documented everything I did, I'd be sitting in my office all day just typing. Interview with the Director of Nursing (DON) on 6/6/17 at 10:00 AM in the conference room revealed discharge planning should begin on admission and/or at least a month before discharge if possible. The DON reviewed Resident #1, #2, and #3's medical records and was unable to find any documentation or implementation of discharge planning by social services or any other department. The DON confirmed the facility had failed in documentating and implementing an effective discharge planning process. Interview with the Administrator on 6/6/17 at 11:02 AM in the conference room when asked when he became aware of pending discharges for Resident #1 stated the middle of May; for Resident #2 stated on (MONTH) 30; for Resident #3 he was unsure. Continued interview revealed discharge planning should begin at admission. Further interview with the Administrator revealed It's clear it could be improved .I can see we have a documentation issue. Further interview with the Administrator confirmed the facility had failed to develop, implement, and document an effective discharge planning process for Residents #1, #2, and #3.",2020-09-01
3387,NASHVILLE CENTER FOR REHABILITATION AND HEALING LL,445512,832 WEDGEWOOD AVENUE,NASHVILLE,TN,37203,2017-09-27,226,G,1,0,9IDG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview, the facility failed to ensure an allegation of abuse was reported immediately to the Administrator in accordance with facility policy for 1 resident (#24) of 22 sampled residents. Resident #24 was deprived care and threatened with the deprivation of care by a staff member when she was left in her own incontinence for 9.5 hours after being told she would only receive incontinence care once on the night shift and staff did not immediately report this to the Administrator. The deprivation of care resulted in HARM for Resident #24. The findings included: Review of facility policy, Abuse, revealed the definition of abuse included that it was a willful infliction of injury resulting in physical harm, pain or mental anguish. The abuse should be reported immediately to the charge nurse. The charge nurse was to assure the resident was safe and any needed medical interventions for the resident had been obtained, and the charge nurse was to report to the Administrator, the Director of Nursing, the physician and the family. Medical record review revealed Resident #24 was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #24's Care Plan dated 4/19/17 revealed the resident required assistance with activities of daily living; had a suprapubic catheter due to [MEDICAL CONDITION] Bladder, [MEDICAL CONDITION], Overactive Bladder, and Bowel Incontinence; was at risk for developing skin breakdown related to impaired mobility, occasional suprapubic catheter leakage and occasional bowel incontinence. Further review revealed no skin breakdown was included on the Care Plan and no specific interventions to address the resident's needs to prevent skin breakdown. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) was 15 out of 15 indicating the resident was cognitively intact. Continued review of the MDS revealed the resident required extensive assistance to total dependence for activities of daily living except for eating and was always incontinent of bowel and had an indwelling catheter. Interview with Resident #24 on 9/26/17 at 10:15 AM in her room revealed the staffing was low. Continued interview revealed the Certified Nurse Aides (CNAs) had told her they could not get her up due to not enough staff. She stated last night (9/25/17) at 10:00 PM she had been incontinent of stool and her indwelling urinary catheter had a large amount of leakage. Resident #24 stated CNA #8, while cleaning the resident informed her, she would only clean her up once during the night shift. The resident stated she did not get checked or changed until the dayshift when CNA #5 came in this morning at 7:30 AM and changed and repositioned her. Resident #24 stated the CNA told her she was still dirty on her buttocks. Interview with CNA #5 on 9/26/17 at 10:30 AM in the 500 unit hall revealed Resident #24 was drenched with urine and stool when he went to change her at 7:30 AM today. He stated there was a large amount of stool and urine that was almost the consistency of mud. Continued interview revealed the resident told him what CNA #8 had told her last night, about only clean(ing) her up once during the night shift, and no one had checked or changed her since 10:00 PM the previous night. CNA #5 stated he changed and repositioned the resident, then reported the resident's condition to Registered Nurse (RN) #4. Further interview revealed he stated he did not tell the RN what CNA #8 said to Resident #24, about only clean(ing) her up once during the night shift. CNA #5 stated the resident had an indwelling urinary catheter that consistently leaked urine, her buttocks and the back of her thighs were red and there had been an open area on the back of the upper left thigh for a week. Interview with RN #4 on 9/26/17 at 10:35 AM in the 500 unit hall revealed CNA #5 had reported the resident's condition at 8:00 AM that morning, and she had not reported anything to anyone else. She stated she was going to report it, just not immediately. Interview with the Assistant Director of Nursing (ADON) on 9/26/17 at 12:15 PM in the Director of Nursing's office revealed RN #4 reported the incident regarding Resident #24 at about 11:00 AM today. The ADON confirmed the RN should have reported the incident immediately and CNA #5 should have reported what CNA #8 said to the resident. Interview with the Administrator on 9/26/17 at 12:30 PM in the DON's office confirmed he and the ADON were not notified by RN #4 about this abuse until 11:00 AM on this date.",2020-09-01
2257,LIFE CARE CENTER OF HIXSON,445380,5798 HIXSON HOME PLACE,HIXSON,TN,37343,2019-05-30,684,D,1,0,2XHI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview, the facility failed to ensure the correct medications were sent home on discharge with 1 resident (#8646) of 3 residents reviewed. The findings include: Review of facility policy, Transfers and Discharges Effective Date 5/6/19, revealed .Discharge Responsibilities of Nursing: 1) Explain discharge procedure and reason to resident. Give copy of the Notice of transfer or Discharge as required,; include resident representatives. 2) .If medications are to be included, write this order, e.g. discharge to home with daughter; may take all medications. The discharge order form is used to document the discharge order. 4) Medications, if discharged to a home . Medical record review revealed Resident #8646 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. The resident was discharged home at 10:20 AM on 1/9/19. Interview with Licensed Practical Nurse (LPN) #1 on 5/29/19 at 11:05 AM in the conference room revealed the LPN had discharged the resident home on 1/9/19 at 10:20 AM, gave discharge instructions to the resident's husband including a list of the correct medications to be given to the resident at home but sent another resident's (#8629) medications home with the husband in error. The LPN explained the incorrect resident's medications were in a drawer in front of Resident #8646's medications and the Nurse accidently took the wrong medications to send home with the resident's husband. Upon discovery of the error during a subsequent medication pass the husband was notified of the mistake and arrangements were made to exchange the resident's medications for the wrong resident's medications. The LPN made the exchange with the husband giving him the correct medications and receiving the incorrect medications to return to the facility. The incorrect medications were returned to the facility and discarded by the Nurse. Review of a pharmacy document dated 1/14/19 revealed Resident #8629 was reimbursed for the medication signed out to her due to the LPN's mistake. Telephone interview with the resident's husband on 5/29/19 at 11:30 AM revealed the husband had not given the resident any of the other resident's medication to Resident #8646. Continued interview revealed the husband had been informed of the mistake by the facility, and he met with the Nurse at an agreed location and exchanged the medications for the correct medications for Resident #8646. Interview with the Assistant Director of Nursing on 5/28/19 at 3:49 PM in the conference room confirmed the LPN sent the wrong medications home with Resident #8646's husband on 1/9/19.",2020-09-01
468,BRADLEY HEALTH CARE & REHAB,445141,2910 PEERLESS RD,CLEVELAND,TN,37312,2017-08-08,226,D,1,0,IIH211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview, the facility failed to follow facility policy during an investigation of an allegation of abuse for 1 resident (#1) of 3 residents review for abuse. The findings included: Review of the facility's Policy and Procedure for Resident Abuse, last revised 11/6/11, revealed .any employee suspected of resident abuse .will be promptly removed of duty until the supervisor and/or administrator and abuse coordinator completes an investigation .nursing staff will thoroughly examine the resident for any signs of injury or abuse . Medical record review revealed Resident #1 was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. Medical record review of a Nurse's Progress Notes dated 7/18/17 at 4:00 AM revealed .At 0300 (3:00 AM) CNA's (Certified Nurse Assistants) .entered room to change resident after small BM (bowel movement) .CNAs were administering peri-care when resident states 'they are hurting me' . (Licensed Practical Nurse (LPN) #4) and CNA entered the room to check on resident and resident stated 'I want my door closed because my private area has just been abused' .Notified abuse coordinator and investigation process stated (started) . Review of CNA #1 and CNA #2's time card report dated 7/18/17 revealed CNA #1 and CNA #2 left the facility at 6:23 AM (3 hours and 23 minutes after the allegation was made). Interview with the Director of Nursing (DON) on 8/7/17 at 3:20 PM, in the conference room, revealed she was not sure when the CNAs exited the facility. Telephone interview with LPN #4 on 8/7/17 at 3:44 PM confirmed CNA #1 and CNA #2 remained on the unit and continued to provide care to other residents during the investigation. Interview with the Administrator on 8/7/17 at 6:01 PM, in the conference room, revealed .talked to (Registered Nurse (RN) #1) .was told the CNAs were removed .CNAs not to do care .felt it (allegation of abuse) was not valid .if it were a situation where we immediately felt like resident were abused they'd be sent home immediately .I know they were not to perform care . Continued interview confirmed CNA #1 and CNA #2 were not removed from resident care during an investigation of an allegation of abuse and the facility failed to follow facility policy.",2020-09-01
1534,GREEN HILLS CENTER FOR REHABILITATION AND HEALING,445267,3939 HILLSBORO CIRCLE,NASHVILLE,TN,37215,2017-10-31,279,D,1,0,EO0911,"**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 identify an implanted cardiac defibrillator with care and interventions for 1 resident (#17) of 28 residents reviewed; failed to complete a comprehensive care plan timely, and failed to provide interventions to prevent falls for 1 resident (#19) of 7 residents reviewed for falls; and failed to identify a focus of behaviors with interventions for 2 residents (#20, #22) of 4 residents reviewed with behaviors. The findings included: Review of facility policy, Comprehensive Care Plan, revised 8/2017 revealed, .The facility will develop a comprehensive person-centered care plan that identifies each resident's medical, nursing, mental, and psychosocial needs within 14 days of admission .The comprehensive care plan must describe services that are provided to the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .and must include .Interventions .to prevent an avoidable decline in function .and to attempt to manage risk factors . Medical record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a hospital History and Physical dated 9/7/17 at 3:18 PM revealed, .He was found on the floor on the side of his bed this morning with evidence of trauma to the front of his head .more confused from baseline admitted in (MONTH) with heart failure exacerbation .started on .[MEDICATION NAME] for [MEDICAL CONDITION] . Continued review revealed a past surgical history of a permanent pacemaker with transvenous [MEDICATION NAME]; [MEDICAL CONDITION] and an active [DIAGNOSES REDACTED]. Further review of the physical exam revealed, .Large nodule on front of forehead .2 (plus) [MEDICAL CONDITION] to flanks . Continued review revealed, .he is chronically hypotensive related to [MEDICAL CONDITION] . Medical record review of the Comprehensive Care Plan dated 9/22/17 revealed no focus, care, or interventions for an ICD were present. Interview with Minimum Data Set (MDS) Coordinator #2 on 10/30/17 at 3:30 PM in the conference room confirmed when asked if identification and care for an ICD was included on the Comprehensive Care Plan for Resident #17 confirmed, No, but we should have been monitoring it. We missed it. Medical record review revealed Resident #19 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED].#2, History of Falling, Head Injury, Weakness, Hypertension, Anorexia, Lack of Coordination, and Difficulty Walking. Medical record review of an Admission MDS dated [DATE] revealed the resident was cognitively intact, required extensive assistance of 1 person for bed mobility, transfers, and ambulation in her room. Continued review revealed she was not steady on her feet and was only able to stabilize with staff assistance. Medical record review of a Fall Risk assessment dated [DATE] revealed the resident was assessed to be at High Risk for falls. Medical record review of an initial Comprehensive Care Plan dated 9/26/17 revealed a focus of Safety/Fall Risk related to History of Falls and decreased safety awareness with interventions to observe for placement and function of medical equipment per facility protocols and initiate safety checks as indicated. Medical record review of the Care Conference Note date 9/28/17 revealed, .Resident is a high fall risk . Medical record review of a Situation, Background, Assessment, Recommendation Summary (SBAR) dated 10/8/17 at 5:19 AM revealed the Resident had a fall and, .resident was getting up from bed to go walk to restroom when she slipped . Medical record review of a SBAR Summary dated 10/16/17 at 12:13 AM revealed, .fell (complained of) (left) hip pain .resident was transferring self with walker to restroom, staff heard loud noise, enter(ed) room observed resident lying on floor on back in front of toilet, stated she hit her head, staff assisted resident up and to bed. (Complained of) pain to (left) hip while walking, notified md on call orders received to send to hospital for (evaluation) . Medical record review of a Comprehensive Care Plan dated 9/26/17 revealed a focus of at risk for falls related to confusion at times, gait/balance problems, incontinence, and pain with interventions dated 9/26/17 for (1) .10-8-17 send sock home with family, provide non skid socks in room .; (2) Anticipate and meet the resident's needs; (3) Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; (4) Ensure the resident is wearing appropriate non skid footwear when ambulating, transferring or mobilizing in wheelchair; (5) 10/9/17 landing pads (fall mats) to bedside. Interview with MDS Coordinator #2 on 10/30/17 at 3:30 PM in the conference room confirmed the initial Comprehensive Care Plan dated 9/26/17 had no interventions to prevent falls as the resident did not have any medical equipment and there was no protocol for safety checks. Further interview confirmed the facility failed to complete the Comprehensive Care Plan timely. Interview with the Director of Nursing (DON) on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed Resident #19 was still in the hospital due to the fall on 10/16/17 with a left [MEDICAL CONDITION]. Continued interview confirmed the facility failed to provide interventions on the Comprehensive Care Plan to prevent falls resulting in a fracture for Resident #19. Medical record review revealed Resident #20 was admitted to the facility on [DATE], readmitted on [DATE] and 9/14/17, and was discharged to a psychiatric facility on 10/9/17 with [DIAGNOSES REDACTED]. Medical record review of a Discharge Return Anticipated MDS dated [DATE] revealed the resident was severely cognitively impaired and had behaviors of inattention, physical behaviors directed to others, and wandering. Continued review revealed she received antipsychotic, antianxiety and antidepressant medications. Medical record review of the Comphrensive Care Plan dated 4/22/16 revealed the following focus: (1) Receives antipsychotic medications related to dementia with behavior management; (2) Receives anti-anxiety medications as needed related to anxiety and agitation. Continued review revealed interventions were for medication administration and monitoring for side effects and effectiveness of the medications. Further review revealed the Care Plan did not contain any non-pharmacological interventions and did not identify behaviors as a problem with interventions to address the residents documented behaviors. Medical record review of a SBAR Summary dated 6/5/17 revealed, .increased confusion and combative disorder observed .wandering everywhere, (patient) opened break room, linen room .stated that 'I have to get out of here. I will go home. If somebody touch(es) me I will kill them' .kicking with agitation .transfer to hospital . Medical record review of a SBAR Summary dated 6/11/17 revealed, .Resident returned from hospital on [DATE] as (with) same problems .lunch time she opened door and suddenly threw the food toward staff .when staff trying to control her behavior she hit, scratched staff and yelling out. After closed door she threw the food tray on the floor . Medical record review of a Behavior Note dated 7/26/17 revealed, .increasing agitation this pm. combative .(continues) back and forth between room & (and) nurses station . Medical record review of a Behavior Note dated 8/4/17 revealed, .wandering hallway sometimes .entering other resident's room, if nurse gave orientation, (patient) has agitation. At 6 pm .in Resident #10's room and stood up from (wheelchair) (knocking on) window and stated 'I have to get out of here' . Medical record review of a SBAR Summary dated 8/7/17 revealed, .Resident has been having psychiatric behavior recently pt (patient) increased agitation, self harming and other harming behavior, wandering kicking toward staff, verbally aggressive, restlessness noted . Medical record review of a Behavior Note dated 8/18/17 revealed, .Resident returned from hospital still pt has confusion, wandering, agitation observed pt trying to use elevator to get out of here and laid down in front of elevator . Medical record review of an SBAR Summary dated 8/24/17 revealed, .Resident has been having agitation, combative disorder, suicidal idea so multiple times pt transferred to psychiatric hospital. Today pt has significant behavior observed pt trying to jump toward the window for suicide and keeping razor to her abdomen also pt crying all day long . Medical record review of a Nurses Note dated 10/9/17 revealed, .Pt rolling around day room in (wheelchair) rolling up to pt striking at another pt. Pt rolling around reaching and try(ing) to hit at other residents. Interview with MDS Coordinator #2 on 10/30/17 at 3:30 PM in the conference room confirmed the resident's Care Plan did not address a focus of behaviors or interventions to care for the resident. Continued interview revealed the MDS Coordinator stated, Social Services does Behavior Care Plans and it should have been in there. Interview with the DON on 10/30/17 at 6:40 PM in the conference room confirmed the facility failed to implement a Behavior Care Plan for Resident #20 and the facility failed to provide the care needed. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of MDS for Resident #22 dated 9/15/17, 9/22/17,10/6/17, and 10/27/17 revealed .no behaviors exhibited .no signs of physical behavioral symptoms directed toward others, such as hitting, kicking, pushing, grabbing . Continued medical record review of initial Comprehensive Care Plan dated 9/19/17 revealed, .is an elopement risk/wander r/t (related to) adjustment to nursing home .has impaired cognitive function/dementia or impaired thought processes r/t Alzheimers, Dementia . Medical record review of SBAR Summary written by Licensed Practical Nurse (LPN) #6 for Resident #22 dated 9/25/17 at 11:06 AM revealed .no injuries noted son stated that resident would walk and slid(e) down against walls or furniture if he began to become weak and believed that he was going to fall . Medical record review of Behavior Note for Resident #22 dated 10/5/17 at 11:09 PM written by Licensed Practical Nurse (LPN) #5 revealed .7:00 PM (patient) became agitated. Went into Resident #8's room and removed several of the blinds and carried them down the hall. Able to redirect but for short period. Attempted several times to get out of unit door. Patient later took and threw an empty bucket. Medical record review of a SBAR Summary written by Registered Nurse (RN) #4 dated 10/22/2017 at 1:34 PM revealed .Patient agitated. Additional Nursing Notes as applicable: Family health care agent notified at 11:00 AM on 10/22/17. Primary Care Clinician Notified: Nurse Practioner at 11:00 AM on 10/22/17 . Medical record review of the Progress Notes of Resident #22 dated 10/26/17 at 10:56 PM revealed LPN #4 documented . patient agitated . Telephone interview with RN #2 on 10/27/17 at 10:50 AM revealed she was informed of Resident #22 grabbing the arm of Resident #2. RN #2 stated .told me about it . RN #2 stated .One more time he have (had) those behaviors, he tried to hit Resident #21 in the hallway . Further interview revealed Resident #22 picked up the plastic planter and attempted to hit other residents. RN #2 when asked if she reported the assault she stated .no, I did not . Further medical record review revealed a facility investigation dated 10/27/17 at 1:00 AM written by LPN #3 revealed .Patient was yelling, this nurse went to her room and a male patient was in her room. She states that he was trying to kill her, he grabbed her left arm, and she has a bruise on her left arm . Medical record review of the Psychiatric Diagnostic Evaluation performed by Psychiatric (Psych) Nurse Practitioner dated 9/11/17 revealed .On exam patient is impulsive, anxious, and confused .9/18/17 .Psych visit after med (medication) changes last week for agitation, wandering, increased confusion and questionable [MEDICAL CONDITION] .9/29/17 .Increased confusion intermittently with negative urinanalysis (U/A) .10/17/17 .[MEDICAL CONDITION], trying to shoot others playfully but also paranoid and aggressive. Trying to get off of floor, took butter knife and tried to unscrew the elevator keypad. (Resident #22) was attempting to get out of the secured doors. Verbally and physically aggressive towards other residents and staff members .10/24/17 .Patient reportedly tried to hit another resident with a fairly strong object .He continues to be psychotic with aggression and agitation was difficult to redirect. Patient threatening towards staff at times especially when they attempt to redirect . Interview with Nurse Practitioner (NP) #1 on 10/30/17 at 10:40 AM in the conference room revealed she was made aware of the incident of 10/17/17 with Resident #22 on 10/30/17. NP #1 stated .Resident #22 was moved to the third floor due to possible elopement .He tried to shoot at people with a plastic plant water bottle, and tried to hit Resident #21. Continued interview with NP #1 when asked about the quality of care Residents were receiving on the secured unit she stated .consistency, I think it could be better with different staff, I know these residents and when I only come twice a week I rely on the staff to inform me of changes . Medical record review revealed a Minimum Data Set ((MDS) dated [DATE], 9/22/17, 10/6/17, and 10/27/17 revealed Behavioral Symptom-Presence and Frequency for Resident #22 Physical behaviors directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) Behavior not exhibited . Based on medical record review, observation, and interview, the facility failed to protect Resident #2 from abuse by Resident #22. Continued investigation revealed the facility failed to report previous abuse of Resident #2 by Resident #22, of 23 residents reviewed. Further interview with the DON on 10/31/2017 at 1:50 PM in the conference room confirmed the facility failed to investigate report and protect Residents from physical abuse.",2020-09-01
5612,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2016-01-05,224,D,1,0,8BJL11,"**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 implement its written policies and procedures to investigate injuries of undetermined origin for 1 Resident (#6) of 5 residents reviewed. The findings included: Review of facility policy, Accident and Incident Investigation, effective date 11/30/14 revealed .injuries of unknown origin will be investigated to determine root cause and provide for opportunity to decrease future occurrences .using the appropriate investigation form .The Executive Director and Director of Clinical Services are to be notified immediately of injuries of unknown origin .The Executive Director, Director of Clinical Services .or designee must begin a documented investigation of the cause of the injury . Closed medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medcial record review of the Nursing Notes dated 8/10/15 at 9:00 PM revealed Resident #6 reported to Registered Nurse (RN #2) .he fell or was dropped . during a shower sometime between 8/7/15 and 8/9/15 and had sustained 3 abrasions to his toes as a result. Continued review of the Nursing Notes revealed RN #2 notified the Unit Manager of the resident's statements, notified the Physician of the new onset of 3 superficial abrasions to the resident's 1st, 2nd and 3rd toes and obtained orders for treatment. Continued medical record review revealed no evidence the Unit Manager notified the Director of Nursing (DON) or launched an investigation into the cause of the resident's injuries. Interview with RN #2 on 12/8/15 at 7:00 PM by telephone revealed RN #2 reported she questioned the resident about his injuries and the resident reported they had occurred over the prior weekend. RN #2 stated she was not on duty at the time the injuries occurred, had discovered the injuries while she evaluated the resident on Monday Night 8/10/15, had last seen the resident on the overnight shift Friday 8/7/15 and the [MEDICAL CONDITION] were not present at that time. Continued interview revealed RN #2 had cared for Resident #6 for several years at another local facility and in spite of his [DIAGNOSES REDACTED]. Interview revealed RN #2 stated she questioned the resident about the cause of his injuries and the resident informed her he had been dropped in the shower by a Certified Nursing Assistant (CNA). Continued interview revealed RN #2 stated the resident described the physical appearance of the person who allegedly dropped him in the shower and the resident's description matched one of a CNA she knew to be on duty the prior weekend and the resident's description of the CNA included second shift. Further interview revealed RN #2 stated she checked the staff schedule and verified a CNA who matched the physical appearance described by the resident was in fact on duty at the time the resident reported he had been dropped in the shower and had in fact showered the resident on Saturday 8/8/15. RN #2 reported the resident could not name the CNA by name. Continued interview revealed RN #2 questioned the CNA identified by her review of the schedule and medical records and was informed by the CNA she did not know how the resident had been injured and the CNA denied knowledge of any accidents or incidents that involved Resident #6 over the weekend. Further interview revealed RN #2 stated she informed the Unit Manager of her findings on 8/10/15 at which time the Unit Manager informed RN #2 she felt the resident was not a reliable historian and failed to initiate an investigation. Interview revealed RN #2 reported she waited several days after her conversation with the Unit Manger and then upon learning no investigation had been completed by the Unit Manager informed the former DON of the situation and asked the former DON if a report of the alleged incident had been forwarded to her for investigation and stated .she never gave me a straight answer . Continued interview revealed RN #2 submitted her resignation to the facility the following afternoon, completed a 7 day notice and voluntarily terminated employment. RN #2 stated .I am ashamed I worked there and won't even claim it on my resume .(former DON) didn't even investigate it .I knew (Unit Manager) never reported it and I knew they would never report it .I wrote that Nursing Note in the record and prayed someone would find it after I quit .obviously you did . Further interview with CNA #2 on 12/8/15 at 7:45 PM in the conference room revealed the CNA stated she was aware of the alleged incident and stated .he (Resident #6) claimed he fell . Continued interview revealed CNA #2 had been assigned to care for Resident #6 on the weekend in question and confirmed she had showered the resident that weekend. CNA #2 reported she was questioned by a nurse regarding the resident's allegations but could not recall the nurse's name. Continued interview revealed CNA #2 stated she did not drop the resident in the shower and stated she was never approached or interviewed by the Unit Manager, DON, or Administrator, to discuss the incident and to her knowledge the facility did not investigate the occurrence. Interview with the Administrator and Corporate Nurse on 12/8/15 at 8:00 PM, in the conference room confirmed the facility failed to implement its written policies to investigate injuries of undetermined origin to prevent abuse for resident #6.",2019-01-01
5613,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2016-01-05,225,D,1,0,8BJL11,"**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 investigate and report injuries of undetermined origin to the State Survey and Certification Agency in accordance with Federal Requirements for 1 Resident (#6) of 5 residents reviewed. The findings included: Review of facility policy, Accident and Incident Investigation, effective date 11/30/14 revealed .injuries of unknown origin will be investigated to determine root cause and provide for opportunity to decrease future occurrences .using the appropriate investigation form .The Executive Director and Director of Clinical Services are to be notified immediately of injuries of unknown origin .The Executive Director, Director of Clinical Services .or designee must begin a documented investigation of the cause of the injury .all injuries of undetermined origin or allegations .must be reported to the appropriate agencies per state specific protocols . Closed medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Nursing Notes dated 8/10/15 at 9:00 PM revealed documentation that indicated Resident #6 reported to Registered Nurse (RN #2) .he fell or was dropped . during a shower sometime between 8/7/15 and 8/9/15 and had sustained 3 abrasions to his toes as a result. Continued review of the Nursing Notes revealed RN #2 notified the Unit Manager of the resident's statements, notified the Physician of the new onset of 3 superficial abrasions to the resident's 1st, 2nd and 3rd toes and obtained orders for treatment. Continued record review revealed no evidence the Unit Manager notified the Director of Nursing (DON) or launched an investigation into the cause of the resident's injuries. Interview with RN #2 on 12/8/15 at 7:00 PM, by telephone revealed RN #2 reported she questioned the resident about his injuries and the resident reported they had occurred over the prior weekend. RN #2 stated she was not on duty at the time the injuries occurred, had discovered the injuries while she evaluated the resident on Monday Night 8/10/15, had last seen the resident on the overnight shift Friday 8/7/15 and the [MEDICAL CONDITION] were not present at the time. Continued interview revealed RN #2 had cared for Resident #6 for several years at another local facility and in spite of his [DIAGNOSES REDACTED]. Interview revealed RN #2 stated she questioned the resident about the cause of his injuries and the resident informed her he had been dropped in the shower by a Certified Nursing Assistant (CNA). Continued interview revealed RN #2 stated the resident described the physical appearance of the person who allegedly dropped him in the shower and the resident's description matched one of a CNA she knew to be on duty the prior weekend and the resident's description of the CNA included second shift. Further interview revealed RN #2 stated she checked the staff schedule and verified a CNA who matched the physical appearance described by the resident was in fact on duty at the time the resident reported he had been dropped in the shower and had in fact showered the resident on Saturday 8/8/15. RN #2 reported the resident could not name the CNA by name. Interview revealed RN #2 questioned the CNA identified by her review of the schedule and medical records and was informed by the CNA she did not know how the resident had been injured and the CNA denied knowledge of any accidents or incidents that involved Resident #6 over the weekend. Continued interview revealed RN #2 stated she informed the Unit Manager of her findings on 8/10/15 at which time the Unit Manager informed RN #2 she felt the resident was not a reliable historian and failed to initiate an investigation or report the allegations to the Director of Nursing (DON). Further interview revealed RN #2 did not report the Unit Manager's failure to investigate the allegations or forward her findings to the Administrator immediately on 8/10/15. Continued interview revealed RN #2 reported she waited several days after her conversation with the Unit Manger and then upon learning no investigation had been completed by the Unit Manager, informed the former DON of the situation and asked the former DON if a report of the alleged incident had been forwarded to her for investigation and reported to the State Survey and Certification Agency and stated .she never gave me a straight answer . Interview revealed RN #2 submitted her resignation to the facility the following afternoon, completed a 7 day notice and voluntarily terminated employment. RN #2 stated .I am ashamed I worked there and won't even claim it on my resume .(former DON) didn't even investigate it .I knew (Unit Manager) never reported it and I knew they would never report it .I wrote that Nursing Note in the record and prayed someone would find it after I quit .obviously you did . Interview with CNA #2 on 12/8/15 at 7:45 PM, in the conference room revealed the CNA stated she was aware of the alleged incident and stated .he (Resident #6) claimed he fell . Further interview revealed CNA #2 had been assigned to care for Resident #6 on the weekend in question and confirmed she had showered the resident that weekend. CNA #2 reported she was questioned by a nurse regarding the resident's allegations but could not recall the nurse's name. Continued interview revealed CNA #2 stated she did not drop the resident in the shower and stated she was never approached or interviewed by the Unit Manager, DON, or Administrator to discuss the incident and to her knowledge the facility did not investigate the occurrence or report it to the State Agency. Interview with the Administrator and Corporate Nurse on 12/8/15 at 8:00 PM, in the conference room confirmed the facility had no documentation of an investigation of the allegations and the facility had failed to investigate and report Resident #6's injuries of undetermined origin to the State Survey and Certification Agency in accordance with Federal Requirements and the facility's policy.",2019-01-01
3034,CORNERSTONE VILLAGE,445483,2012 SHERWOOD DRIVE,JOHNSON CITY,TN,37601,2017-05-17,325,G,1,1,LW9W11,"**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 acceptable nutritional status, resulting in a 10.9% weight loss in one month (harm) for 1 resident (#51) of 4 residents reviewed for nutrition of 46 residents reviewed. The findings included: Review of the facility policy Weight Loss Prevention (undated) revealed .Weight loss intervention will be implemented for those residents experiencing a weight loss .Weight loss intervention is implemented to prevent further weight loss and to maintain improve the resident's nutritional status . Medical record review of the hospital admission report dated 2/13/17 revealed Resident #51 weighed 177 pounds. Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed Resident #51 discharged to the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Baseline Admission Care Plan dated 2/18/17 revealed .consumes less than 75% of food/or fluids at most meals .broken or missing teeth .weigh and monitor results Observe for s/s (signs/symptoms) of dehydration & (and) report to nurse . Medical record review of the Daily Charting completed by the Certified Nurse Assistants (CNAs) dated 2/18/17 to 3/24/17 revealed Resident #51 consumed 25% or less for 71 of 102 meals, and 18 meals had no documentation if the resident consumed any of the meal. Medical record review of the laboratory results dated [DATE] revealed the resident was anemic (low iron) with a Hemoglobin of 11.5 (normal values are13.5-17.5 g/dl) and a Hematrocrit of 34.2 (normal values are 38.0-50.0). Medical record review of Resident #51's weights dated 2/21/17 (3 days after admission) revealed a weight of 164.4 pounds (lbs). Medical record review of the Physician Standing Orders, signed by the resident's physician on 2/22/17 revealed .Weekly weights X (times) 4 weeks on admission, if stable then monthly . Medical record review of Dietitian Communication/Order Form dated 2/22/17, revealed .recommend multivitamin for (increased) nutrient needs . Medical record review of the admission Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating Resident #51 had severe cognitive impairment, and the resident required extensive assistance for bed mobility, dressing, toileting, and personal hygiene. Continued review revealed Resident #51 was total dependence for transfer, eating, and bathing. Medical record review of Resident #51's care plan dated 2/28/17 revealed .I am at risk for altered nutritional status r/t (related to) assistance with all meals and a dx (diagnosis) of dementia .I will have a PO (by mouth) intake of at least 51-75% of most meals by next review .Weigh me and monitor my weight per facility policy .Monitor my daily food and fluid intake .Coordinate my nutritional care with RD (Registered Dietitian), MD (Medical Doctor), and other disciplines as necessary . Medical record review of a weight dated 3/17/17 (approximately 1 month after admission) revealed Resident #51 weighed 146.2 lbs, a weight loss of 18.2 lbs or 10.9% of the resident's body weight. The only weights documented in the resident's medical record were weights on 2/21/17, of 164.4 lbs, and on 3/17/17. Interview with the Certified Dietary Manager (CDM) and the Executive Chef on 5/12/17 at 2:35 PM, in the conference room, revealed the CDM monitored residents' weights obtained by the weight team. Further interview revealed the CDM used the weights to determine if he recommended the RD see the resident. Continued interview revealed Resident #51 was not weighed for several days after admission. Further interview revealed for several weeks in (MONTH) and (MONTH) there were no weights obtained by the weight team, and the CDM reported this to the Administrator and Director of Nursing (DON) in morning meetings. Interview with the Administrator and the DON on 5/12/17 at 3:15 PM, outside of the Administrator's office, confirmed only 2 weights were obtained during Resident #51's stay at the facility. Interview with Licensed Practical Nurse (LPN) #6 on 5/15/17 at 9:56 AM, at the downstairs nurse's desk, confirmed he was aware of Resident #51's poor intake and did not take any action. Interview with LPN #7 on 5/15/17 at 9:56 AM, at the downstairs nurse's desk, confirmed she was aware of Resident #51's poor intake and did not take any action. Interview with Certified Occupational Therapist Assistant (COTA) #1 on 5/15/17 at 10:01 AM, in the upstairs dayroom, revealed COTA #1 worked with Resident #51 during his stay in the facility. Further interview revealed Resident #51 mostly picked at his food, preferred smooth consistency, and did better with finger foods due to his impaired vision. Continued interview with COTA #1 confirmed she did not report to the RD he wasn't eating .that is nursing's job . Interview with NP (Nurse Practitioner) #1 on 5/16/17 at 11:21 AM, in the small conference room, revealed NP #1 was in the facility Monday through Friday each week. Further interview revealed new admission residents were weighed weekly for 4 weeks and then monthly. Continued interview revealed NP #1 usually received reports from Nursing Supervisors or the CDM if a resident had a poor appetite. Continued interview revealed the NP was not notified of Resident #51's poor appetite or severe weight loss until 3/24/17, the day Resident #51 was discharged to the hospital. Interview via telephone with Resident #51's physician on 5/16/17 at 1:30 PM, revealed the physician was first notified of Resident #51's poor nutritional intake on 3/23/17, the day before Resident #51 was discharged to the hospital. Further interview confirmed had the physician been notified of the poor intake, she could have made recommendations to try and increase the resident's intake and reduce the weight loss. Interview via telephone with the RD on 5/16/17 at 2:00 PM, revealed the RD ordered the multivitamin because the laboratory results dated [DATE] showed the resident was anemic. Further interview revealed the RD was never notified of Resident #51's poor intake or severe weight loss. Continued interview revealed the RD would have made recommendations for interventions, since the 177 pound hospital weight was on the lower aspect of the resident's Ideal Body Weight. Interview with the Administrator on 5/16/17 at 3:00 PM, in the small conference room, confirmed the facility did not follow Physician's Orders or facility policy to obtain weights for Resident #51 and did not implement interventions for the resident with a poor appetite, to prevent severe weight loss, resulting in a 10.9% weight loss in less than a month.",2020-09-01
767,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2017-10-26,323,G,1,0,KCFU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview, the facility failed to maintain an environment free from accidents for 3 residents (#7,#6, #4) of 7 residents reviewed. The facility's failure to recognize fall risk and identify interventions for three residents (#7, #6, #4) resulted in falls with injury (HARM). The findings included: Review of facility policy, Accidents and Supervision to Prevent Accidents, dated 4/28/2011 revealed .The center provides an environment that is free from accidents hazards .Implementation of interventions to reduce hazard(s) and risk(s) .Monitors to verify interventions are in place .Evaluates interventions at designated interval for effectiveness .Modifies and/or replaces ineffective interventions when necessary . Medical record review revealed Resident #7 admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS (Minimum Data Set) dated 10/10/17 revealed Resident #7 had a Brief Interview Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Further review revealed the resident required extensive assistance with transfers and Activities of Daily Living (ADL) and had no impairment of the upper and lower extremities. The resident was occasionally incontinent of the bowel and bladder. Medical record review of a Progress Note dated 9/5/17 revealed Resident #7 had a fall with no injury to occur on 9/5/17 and 9/9/17. Review of the Care Plan initiated on 8/7/17 for Resident #7 revealed it was not updated after the fall occurred on 9/5/17, 9/9/17, 9/17/17, and only revised on 10/24/17. Medical record review of a Post Fall Investigation dated 9/17/17 revealed .heard resident yelling .went to room and the resident was sitting on the floor on the L (left) side of the bed .was sitting on her botttom with her leg bent at the knee under her. When the resident tried to straighten it out she yelled and there was a popping noise . Continued review revealed the resident was transferred to the hospital and admitted for a Nondisplaced Midcervical Fracture of Right Femur. Interview with LPN (Licensed Practical Nurse) #9 on 10/26/17 at 9:20 AM in the conference room revealed the nurse was to update the Care Plan with interventions after each fall. LPN #9 confirmed she failed to update the Care Plan after Resident #7 fell on [DATE] and another fall occurred on 9/17/17. Interview with the Administrator on 10/26/17 at 10:52 AM in the Social Services office revealed the Care Plans were to be updated with interventions after every fall by the nurse. After review of the Care Plan, the Administrator confirmed the facility failed to update the Care Plan with interventions after Resident #7 had a fall with injury (HARM) on 9/17/17. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 30-day MDS dated [DATE] revealed Resident #6 had severe cognitive impairment with short and long term memory problems. The resident required extensive assistance with bed mobility, transfers, dressing, personal hygiene, eating and toileting and required total dependence for bathing. Continued review revealed Resident #6 was always incontinent of bowel and bladder, had bilateral impairment of both upper and lower extremities and utilized a wheelchair for mobility. Medical record review revealed Resident #6 had falls to occur on 8/11/17, 8/12/17, 8/13/17 and 8/14/17. Continued review revealed the following interventions were put in place after the falls occurred: .encourage to participate in activities .Strips to be placed to floor on each side of bed .encourage resident to toilet upon rising, before meals and after meals, and before bed .assist resident to common area .apply dysum pad to w/c (wheelchair) when arising to w/c . Medical record review of a Progress Note dated 8/27/17 revealed Resident #6 had a witnessed fall to occur as he was attempting to get up from the wheelchair. Review of the Care Plan revealed no intervention was put in place after the fall occurred on 8/27/17. Medical record review of a Progress Note dated 9/6/17 revealed Resident #6 had an unwitnessed fall to occur. Resident #6 was found by staff .sitting on his bottom beside of the end of the bed with his legs outstretched and his hands to his side. The residents pants were slightly pulled down as if the resident was trying to go to the restroom and his diaper was wet . Continued review of a Progress Note dated 9/7/17 revealed .MD (Medical Doctor) notified that Pt (patient) is now c/o (complaining of) discomfort in the left ribcage area. Pt grimaces with pain when area is palpated. Received order for x-ray . Medical record review of a Radiology Report dated 9/7/17 revealed .Conclusion: Acute right lateral ninth rib fracture . Review of the Care Plan revealed no intervention was put in place after the fall occurred on 8/27/17. Interview with LPN #9 on 10/26/17 at 9:20 AM in the conference room revealed after each fall the nurse was required to update the Care Plan with interventions. LPN #9 confirmed she failed to update the Care Plan with an appropriate intervention after Resident #6 fell on [DATE]. Interview with the Administrator on 10/26/17 at 10:52 AM in the Social Services office revealed the Care Plan was to be updated with interventions after every fall by the nurse. After review of the Care Plan, the Administrator confirmed the facility failed to maintain an environment free from accidents for Resident #6 who had a fall to occur on 9/6/17 which resulted in a fracture of the rib (HARM). Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quartely MDS dated [DATE] revealed the resident has a BIMS score of 7 (severe impairment). The Resident was extensive assist with 1 person for transfer, extensive assist with 1 person for transfer, dressing and personal hygeine, independent with ambulationwith wheelchair, set up only, limited assist with 1 person for eating and total dependence with 1 person for bathing. The residnet had impairment on one side for upper and lower extremities and frequesntly incontinent of bowel and bladder. Medical record review of a fall investigation dated 9/17/17 revealed Resident was trying to get in to bed without assist (resident knows to ask for help) and sat on the floor beside the bed. Denies injury at this time .Neuro checks and 30 minute checks started .no injuries noted . Review of a Progress Note dated 9/18/17 revealed Called mobile with x-ray order. Review of the Progress Notes dated 9/20/17 revealed .Received resident Tibia/Fibula x-ray report on 9/19/17 at 1800 (6:00 PM). Noted abnormal x-ray .Notified NP (Nurse Practitioner) via phone .of x-ray results. Received the following new MD (Medical Doctor) orders. 1. consult with (orthopedic) . Review of a Progress Note dated 9/21/17 revealed MD applied cast at this time to right lower extremeity. MD wants to follow up with an x-ray on Monday 9/25/17 to check placement with new cast. MD wants to follow up in four weeks to change cast on 11/19/17. Family made aware . Medical record review of the Care Plan for Resident #4 revealed the facility failed to update the Care Plan after the 9/17/17 fall and place new interventions in place to prevent falls. Interview on 10/26/17 with the Administrator at 9:33 AM in her office revealed the facility failed to update the Care Plan after the 9/17/17 fall.",2020-09-01
1402,"SUMMIT VIEW OF FARRAGUT, LLC",445258,12823 KINGSTON PIKE,KNOXVILLE,TN,37923,2019-10-10,580,D,1,0,2OD411,"**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 representative of an injury for 1 resident (#1) of 3 residents reviewed for a notification of a change in condition. The findings included: Review of the facility policy Accident and Incidents-Investigating and Reporting, last revised 7/2017, revealed 1.The nurse .shall promptly initiate and document investigation of the accident or incident . 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: a. the date and time the accident or incident took place; b. the nature of the injury/illness (e.g., bruise, fall, etc.); . h. The date/time the injured person's family was notified and by whom . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 5 Day Minimum Data Set ((MDS) dated [DATE] revealed the resident was moderately impaired for daily decision making and was rarely/never understood. Continued review revealed the resident required total dependence on staff for bed mobility, transfers, and dressing with 2 person assist. Further review revealed the resident had an indwelling urinary catheter, an abdominal feeding tube, oxygen therapy, suctioning, and [MEDICAL CONDITION] care. Medical record review of Resident #1's admission face sheet revealed the resident's daughter was listed as the next of kin. Medical record review of a Physician's Assistant progress note dated 10/2/19, not timed, revealed .(Resident #1) having increased agitation that results in jerking and thrashing of her upper body against rails of the bed. Patient subsequently had small abrasion of L (left) supraorbital (above the eye) ridge. There is small bruise here . Interview with Respiratory Therapist (RT) #1 on 10/10/19 at 3:45 PM, in the Director of Nursing's (DON) office revealed Resident #1's daughter asked the RT why the resident had a bruise to her eye. Interview with Registered Nurse #2 on 10/10/19 at 4:00 PM, in the DON's office, revealed .(on 10/2/19) asked a CNA (certified nursing assistant) to help me pull her (Resident #1) up in bed .noticed she (Resident #1) had some blood above her left eye .cleaned the area, placed an ice pack on her eye .it happened at the end of my shift .did not contact the family .she can be very active in bed at times . Interview with the Assistant Director of Nursing on 10/10/19 at 4:30 PM, in the Administrator's office, confirmed the facility failed to advise Resident' #1's family of the bruising to the resident's eye.",2020-09-01
3027,CORNERSTONE VILLAGE,445483,2012 SHERWOOD DRIVE,JOHNSON CITY,TN,37601,2017-05-17,157,G,1,1,LW9W11,"**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 the Physician or the Nurse Practioner (NP) of poor nutritional intake, resulting in a 10.9% weight loss in a one month period (harm) for 1 resident (#51) of 4 residents reviewed for nutrition, of 46 sampled residents. The findings included: Review of the facility policy Weight Loss Intervention (undated) revealed .Weight loss intervention will be implemented for those residents experiencing a weight loss .Weight loss intervention is implemented to prevent further weight loss and to maintain/improve the resident's nutritional status .Steps .5% weight loss in 30 days .Referral to Registered Dietician, Physician . Medical record review revealed Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed Resident #51 was discharged to the hospital on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Daily Charting completed by the Certified Nurse Assistants (CNAs) dated 2/18/17 to 3/24/17 revealed Resident #51 consumed 25% or less for 71 of 102 meals, and 18 meals had no documentation if the resident consumed any of the meal. Medical record review of the laboratory results dated [DATE] revealed a hemoglobin of 11.5 (normal 13.5 - 17.5) and a hematocrit of 34.2 (normal 38.0 - 50.0), indicating the resident was anemic (low iron). Medical record review of the Physician Standing Orders signed by the resident's physician on 2/22/17 revealed .Weekly weights X (times) 4 weeks on admission, if stable then monthly . Medical record review of the admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating Resident #51 was severely cognitively impaired, and the resident required extensive assistance for bed mobility, dressing, toileting, and personal hygiene. Continued review revealed Resident #51 was total dependence for transfer, eating, and bathing. Further review revealed Resident #51 had no problems with eating. Medical record review of Resident #51's care plan dated 2/28/17 revealed .I am at risk for altered nutritional status r/t (related to) assistance with all meals and a dx (diagnosis) of dementia .I will have a PO (by mouth) intake of at least 51-75% of most meals by next review .Weigh me and monitor my weight per facility policy .Monitor my daily food and fluid intake .Coordinate my nutritional care with RD (Registered Dietitian), MD (Medical Doctor), and other disciplines as necessary . Medical record review of the resident's weights revealed the resident weighed 164.4 pounds (lbs) on 2/21/17 (3 days after admission) and was 146.2 lbs on 3/17/17 (approximately 1 month after admission), a weight loss of 18.2 pounds, or 10.9% of the resident's body weight. Interview with Licensed Practical Nurse (LPN) #6 on 5/15/17 at 9:56 AM, at the 600 nurse's desk, confirmed he was aware of Resident #51's poor intake and did not notify the Nurse Practitioner (NP) or the physician. Interview with LPN #7 on 5/15/17 at 9:56 AM, at the 600 nurse's desk, confirmed she was aware of Resident #51's poor intake and did not notify the NP or the physician. Interview with NP #1 on 5/16/17 at 11:21 AM in the small conference room, revealed NP #1 was in the facility Monday through Friday each week. Further interview revealed new admission residents were weighed weekly for 4 weeks and then monthly. Continued interview revealed NP #1 usually received reports from the Nursing Supervisors or the Certified Dietary Manager if a resident had a poor appetite, but was not notified of Resident #51's poor appetite or weight loss until 3/24/17, when Resident #51 was discharged to the hospital. Interview via telephone with Resident #51's physician (who was also the Medical Director) on 5/16/17 at 1:30 PM, revealed the physician was first notified of Resident #51's poor nutritional intake, the resident not being weighed weekly, and weight loss on 3/23/17, the day before Resident #51 was discharged to the hospital. Further interview confirmed had the physician been notified sooner of the poor intake, she would have made recommendations to try and increase the resident's intake and reduce the amount of weight loss. Refer to F325.",2020-09-01
4342,SUMMIT VIEW OF ROCKY TOP,445259,204 INDUSTRIAL PARK RD,ROCKY TOP,TN,37769,2016-10-03,157,G,1,0,HV9H11,"**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 the physician immediately of the development of wounds for 3 residents (#2, #5, and #6) of 5 residents reviewed, resulting in harm to Resident #2. The findings included: Review of the facility policy, Prevention of Pressure Ulcers dated 3/2005, revealed .The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family and addressed . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12 (moderate cognitive impairment). Continued review revealed the resident required extensive assistance for all levels of activities of daily living (ADLs) and was always incontinent of bowel and bladder. Medical record review of the weekly skin assessment dated [DATE], revealed .New Stage II ulcer on Coccyx .2 cm (centimeters) W (width) 1 cm L (length) . Review of the Medical Doctor/Nurse Practitioner (MD/NP) form, undated, revealed the staff left a note for the Nurse Practitioner (NP) regarding the new pressure wound to Resident #2's coccyx. Continued review revealed the document was initialed by the NP on 5/9/16 (2 days after discovery of the wound). Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated of 7/16/16 revealed Resident #5 had a BIMS score of 6 (severely impaired cognition), was total assist for transfers, required extensive assistance with dressing, eating, personal hygiene, and bathing, and was always incontinent of bowel and bladder. Medical record review of the weekly skin assessment dated [DATE] revealed .shearing prominent to left and right shoulders . Review of the MD/NP form, undated, revealed the staff left a note for the NP regarding the wound to Resident #5's scapulas. Continued review revealed the document was initialed by the NP on 7/20/16 (2 days after discovery of the wound). Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated of 4/3/16 revealed Resident #6 had a BIMS score of 8 (severely impaired cognition), required extensive assistance with transfers, limited assistance with dressing, eating, and personal hygiene, and was always incontinent of bowel and bladder. Medical record review of the weekly skin assessment dated [DATE] revealed .open area barrier cream applied (diagram indicated the location was on the buttocks) . Review of the MD/NP form, undated, revealed the staff left a note for the NP regarding the wound to Resident #6's buttocks. Continued review revealed the document was initialed by the NP on 8/01/16 (4 days after discovery of the wound). Interview with the treatment nurse on 10/3/16 at 12:00 PM, in the conference room, confirmed the staff nurse who discovered the wound was responsible for completion of the MD/NP form. Continued interview revealed the form was placed into a MD/NP communication book for review on the next provider visit. Further interview confirmed the facility did not have a process in place for immediate notification to the MD/NP between the time the wound was discovered and the time the provider was next in the facility. Interview with the Director of Nursing on 10/3/16 at 12:30PM, in the conference room, confirmed the facility failed to notify the Physician immediately of the wounds for Resident #2, #5, and #6. Refer to F-314",2019-10-01
341,"THE WATERS OF GALLATIN, LLC",445124,555 EAST BLEDSOE STREET,GALLATIN,TN,37066,2017-10-11,223,D,1,1,AQJ411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview, the facility failed to prevent abuse/exploitation for 1 residents (#81) of 5 resident reviewed for abuse. The findings included: Review of facility policy, Cell Phone Policy, undated, revealed .It is Facility's policy that representatives of our organization do not use cell and /or smart phones while performing work tasks. Further, video and or pictures should not be taken of residents, PHI (Protected Health Information) and ePHI (electronic Protected Health Information) . Medical record review revealed Resident #81 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #81 discharged from the facility on 7/28/17. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status score of 15, indicating she was cognitively intact. Review of the facility investigation revealed a written statement from Certified Nurse Aide (CNA) #2 dated 6/27/17 .I was shown a picture by (CNA #1). It was an inappropriate picture of the resident in 408B. I also witnessed (CNA #1) showing the picture at the nurse's station one night & laughing about it . Telephone interview with CNA #1 on 10/11/17 at 6:35 PM revealed she admitted taking a picture of Resident #81 while the resident was transferring from the bedside commode to the bed. It was unknown when this picture was taken. Further interview revealed the resident was not clothed from the waist down. Further interview revealed approximately 2 months later the CNA sent the picture to CNA #2 and denied showing the picture to any other staff. Interview with the Administrator on 10/11/17 at 4:30pm in her office revealed confirmed the facility failed to prevent abuse/exploitation for Resident #81.",2020-09-01
1650,GRACE HEALTHCARE OF WHITES CREEK,445281,3425 KNIGHT DRIVE,WHITES CREEK,TN,37189,2018-03-02,602,D,1,1,GWBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview, the facility failed to prevent misappropriation for 1 Resident #74 of 49 residents reviewed. Findings include: Review of facility policy, Abuse Prevention Policy and Procedure, revised 10/01/17 revealed, The facility shall not condone .any acts of misappropriation of resident property by any staff member, other residents .It is the policy of this facility .to protect the residents from misappropriation of property .preventive steps will be taken to reduce the potential for such occurrences . Medical record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status Score (BIMS) of 15, indicating the resident was cognitively intact. Medical record review of the facility investigation dated 9/10/17 at 10:30 AM revealed the resident was missing cigarettes on 9/10/17. Medical record review of a facility investigation and interview with the accused staff member by the Manager on Duty on 9/10/17 revealed the accused staff member denied taking the cigarettes at first but later admitted he did take them. Medical record review of a facility investigation and a statement by the accused staff member dated 9/10/17 revealed he used the resident's cigarettes because he was running late that morning and couldn't stop to get any. Medical record review of a Personnel Consultation Form dated 9/10/17 revealed the staff was questioned regarding the missing cigarettes and he denied the allegation but later admitted to inappropriately using the resident's cigarettes. The staff member was immediately removed from the facility and later terminated due to the investigation findings. Interview with the Activity Aide on 1/30/17 at 9:48 AM in the Activity Room revealed she heard a rumor that someone had seen the staff member take the cigarettes but she didn't see him take anything. Further interview revealed the cigarettes stay locked up in the medication storage room in a lock box until smoke time. Continued interview revealed on this day the smoking aprons were hanging at the door of the medication storage room with the cigarettes in them, because it was the smoking time and the staff was going to take the residents out to smoke. Interview revealed the cigarettes were there when taken out of the lock box and put in the aprons, because the Activity Aide and another staff counted them. Interview with the Director of Nursing on 2/1/18 at 3:37 PM in the hallway outside her office confirmed the facility failed to prevent misappropriation of property for Resident #74.",2020-09-01
3712,"THE WATERS OF ROBERTSON, LLC",445137,104 WATSON ROAD,SPRINGFIELD,TN,37172,2017-03-03,224,D,1,0,UP9L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview, the facility failed to prevent neglect for 1 resident (#5) of 14 residents reviewed. The findings included: Review of facility policy, Abuse Prevention Program, updated 1/19/17 revealed .The facility will not tolerate resident abuse or treatment by anyone including staff members, other residents, consultants, volunteers, staff of other agencies, family members, legal guardians, friends, or other individuals .All personnel must promptly report any incident or suspected incident of resident abuse, mistreatment, or neglect including injuries of unknown origin .Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being .Neglect means the failure to provide or willful withholding of adequate medical care, mental health treatment, psychiatric rehabilitation, personal care or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #5 scored 14 on the Brief Interview for Mental Status, indicating she was alert and oriented, able to make her needs known. Continued review revealed she required extensive assistance with transfers, dressing, and grooming; was dependent for bathing; required supervision with eating; had an indwelling urinary catheter in place; and was always incontinent of bowel. Review of Emergency Department (ED) notes dated 11/20/16 revealed at .7:17 AM the resident's temperature was 94.0 on arrival. The reason for the visit as stated by the resident was ' .I'm just cold .' Patient disheveled and malodorous. Pt. pale and cool to touch. Sent for evaluation of confusion. Continued review of ED notes dated 11/20/16 revealed the resident's eyes were matted; mouth was crusted; perineal area was crusted around the catheter; feces was present on the resident; hair was dirty; and bed linens were dirty. Further review of the ED notes at 7:50 AM revealed .the patient was given mouth care. Foley care given. Pt. cleaned with warm wipes. Eyes and face washed clean with warm wet cloth. Soiled linens from nursing home removed and clean linens given. Pt. soiled and soured . Continued medical record review revealed the resident had a foley in place draining cloudy particulate urine which smelled foul. Further review revealed the resident had 6-8 inches skin breakdown, stage 2, to sacral coccyx area. Telephone interview with the complainant on 2/6/17 at 2:05 PM revealed the complainant had nothing to add to the complaint. Continued interview revealed the resident passed away 2 weeks after admission to the hospital. Further interview revealed the complainant does not want this situation to happen to anyone else's family member. Interview with the Administrator and Director of Nursing (DON) on 2/8/17 at 1:30 PM, in the conference room, revealed the Administrator stated the hospital had called the Business Office Manager to report the condition of Resident #5 on admission. Continued interview revealed the Administrator was angry and upset because this was not the way the facility treated residents. Further interview revealed the DON confirmed if the hospital stated and documented the resident was in that condition then it must be true because they would have no reason to lie.",2020-03-01
5420,ETOWAH HEALTH CARE CENTER,445422,"409 GRADY ROAD, PO BOX 957",ETOWAH,TN,37331,2016-03-22,250,D,1,0,MXJV11,"**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 provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 3 residents (#2, #4, #18) of 18 residents reviewed for behaviors. The findings included: Review of facility policy, Dementia Care Guidelines, effective 4/1/15 revealed .residents who exhibit .behavioral or psychological symptoms of dementia (BPSD) will have an evaluation by the interdisciplinary team .to identify and address treatable psychiatric, functional, social and environmental factors .will conduct periodic .screening .behavioral interventions are individualized .including direct care and activities that are provided as part of a supportive .environment .and are directed towards preventing, relieving or accommodating .individualized approaches and treatment .addresses the causes .of .behaviors .staff training includes Hand in Hand in-services and on-going in-service and training .Monitoring, Follow Up and Oversight .staff identifies effectiveness of interventions relative to target behaviors .collaborates .adjustments to the interventions based on effectiveness .Quality Assessment and Assurance (QA) .The QA minutes should reflect any quality deficiencies related to the care of residents with dementia .lists of residents with dementia .pharmacological and nonpharmacological interventions are collected and analyzed .the facility shall attempt to establish root causes .of behaviors . Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident with a Brief Interview of Mental Status Score of 8/15 (moderately severe cognitive impairment), impaired thought processes, depressed mood, physical behaviors directed towards others and was dependent upon a wheelchair for ambulation and dependent for Activities of Daily Living. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Comprehensive Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 was severely cognitively impaired, had depressed mood, physical and verbal behaviors directed towards others, was wheelchair dependent and was dependent for activities of daily living. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 day MDS dated [DATE] revealed Resident #18 was cognitively impaired, had verbal and physical behaviors directed at others and was dependent for ADLs. Review of the facility incident logs revealed Residents #2, #4, and #18 were involved in 13 of the facility's 18 incidents of resident versus resident altercations reported to the state agency between the dates of 5/20/15 and 2/14/16. Review of the Care Plan for Resident #2, #4, and #18 revealed a generic Care Plan with no individualized behavioral interventions in place to address the residents documented behaviors which included confusion, combative behaviors towards others, wandering, hits and kicks staff, and lying down in other resident's bed. Interview with the Social Services Director (SSD) on 3/2/16 at 12:45 PM, in the SSD office revealed the SSD reported she did not participate in investigations of resident versus resident altercations or allegations of abuse as those were managed by the Director of Nursing and Administrator. Further interview revealed the SSD was also aware of a pattern of increased resident versus resident altercations in the facility over several months and many of which included Resident #2 or Resident #4 versus other peers in the facility but to her knowledge an interdisciplinary team had not examined the resident's behaviors in an effort to determine a root cause of the altercations that involved the residents nor had an interdisciplinary team discussed the behavioral management plan for both residents with their responsible parties in an effort to reduce the behaviors. Continued interview revealed the SSD had not provided additional resident specific in-service training to staff members related to Resident #2 or Resident #4's behaviors and had not been utilized to provide staff training in behavioral management as a component of the facility Dementia Care Program which was to have been implemented fully several months prior but whose implementation had been placed on hold. Interview with the SSD and Admissions Coordinator on 3/3/16 at 2:30 PM, in the SSD office revealed both confirmed the facility had not yet implemented the Dementia Care Program or formed an Interdisciplinary Team comprised of members of the Social Services, Nursing, Rehabilitation, Activities, Restorative Nursing, or Nursing Departments, to address behaviors as outlined in the policy, nor had any staff training in behavioral management occurred in the facility since 6/2015. Both confirmed the QA committee had not collected data related to resident behaviors for analysis at the time of interview. Interview with the SSD on 3/10/16 at 9:00 AM, in the Conference Room revealed the SSD had not participated in the care planning of behavior management interventions to identify and seek ways to support each resident's individual needs and finding options that meet the physical and emotional needs of each resident (#2, #4, #18).",2019-03-01
2347,MANCHESTER HEALTH CARE CENTER,445391,395 INTERSTATE DRIVE,MANCHESTER,TN,37355,2017-06-06,204,E,1,0,GYB111,"**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 provide sufficient discharge preparation for 2 residents (#1, #3) of 3 residents reviewed. The findings included: Review of the facility policy, DISCHARGE PR[NAME]ESS, revised 2009 revealed .When the facility anticipates a resident's discharge to a private residence or to another nursing care facility .a Post Discharge Plan will be developed which will assist the resident to adjust to his or her new living environment .The Post Discharge Plan will be developed by the Interdisciplinary Care Plan Team . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued medical record review of the annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 15 indicating the resident was cognitively intact. Further medical record review revealed Resident #1 was discharged on [DATE] at 10:00 AM. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MDS Discharge assessment dated [DATE] revealed Resident #3 had a BIMS of 15 indicating the resident was cognitively intact. Further medical record review revealed Resident #3 was discharged on [DATE]. Medical record review revealed no Post Discharge Plan for Residents #1 and #3. Further review revealed no Social Service documentation regarding sufficient discharge preparation for Residents #1 and #3. Interview with the Social Services Director (SSD) on 6/5/17 at 10:30 AM in the conference room when asked about the discharge date for Resident #1 revealed We had never set a date for (Resident #1) to go home; We didn't give him a discharge because we didn't know when he was leaving . Interview with the SSD on 6/6/17 at 7:50 AM in the conference room when asked, When do you begin discharge planning? the SSD replied 1 to 2 days before discharge. Continued interview revealed the SSD was asked about the facility policy regarding Post Discharge Plan when the discharge is anticipated; SSD reviewed the policy and stated he had not documented discharge preparations for Residents #1 and #3. The SSD confirmed there was no documentation of discharge preparation for Residents #1 and #3. Interview with the MDS Coordinator on 6/6/17 at 8:16 AM in the conference room when asked for documentation of discharge preparation in the medical record, she reviewed and then confirmed there was no discharge documentation in the medical record for Residents #1 and #3. Interview with the Director of Nursing (DON) on 6/6/17 at 10:00 AM in the conference room revealed discharge planning should begin on admission and/or at least a month before discharge if possible. The DON reviewed Resident #1 and #3's medical records and was unable to find any discharge planning by Social Services or any other departments. The DON confirmed the facility had failed to complete documentation for discharge preparations. Interview with the Administrator on 6/6/17 at 10:00 AM in the conference room when asked, When should discharge planning begin? the Administrator stated I was taught on admission. After further discussion regarding discharge documentation and the lack of documentation for discharge preparations for Residents #1 and #3 the Administrator stated It's clear it could be improved .I can see we have a documentation issue. Further interview with the Administrator confirmed the facility had failed to provide sufficient discharge preparation for Residents #1 and #3.",2020-09-01
3620,TRINITY HEALTH AND REHABILITATION CENTER,445533,700 WILLIAMS FERRY RD,LENOIR CITY,TN,37771,2019-11-26,623,F,1,0,POO311,"**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 provide written notification and 30 days advance notice of impending facility closure and resident transfer or discharge to residents, resident representatives, State Agency, and State Long-Term Care Ombudsman for 9 residents (#1, #2, #3, #5, #6, #7, #8, #9 and #10) reviewed for transfer or discharge, and potentially affecting all 51 residents residing in the facility on [DATE]. The findings included: Review of the facility policy Transfer or Discharge Notice, last revised 12/2016, revealed .A resident, and/or his or her representative (sponsor), will be given a thirty (30)-day advance notice of an impending transfer or discharge from our facility.The resident and/or representative will be notified in writing of the following information: a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged .A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman.If the facility will be closing, the Administrator will provide written notices to the residents and residents' representatives of the impending closure at least sixty ([AGE]) days prior to the date of closure.If the facility will be closing, The Administrator will provide the following information to the Office of the State Long-Term Care Ombudsman prior to the impending closure: a. Notification of the impending facility closure; and b. The plan for the transfer and adequate relocation of the residents. 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 had short and long term memory loss. Medical record review of a Social Services Progress Notes dated 11/14/19 revealed discharge planning for Resident #1 was initiated with Resident #1's family on 11/14/19. Medical record review of a Social Services Progress Notes dated [DATE] revealed Resident #1's son was advised the resident would be transferred to another long term care (LTC) facility on 11/25/19. Medical record review revealed no documentation Resident #1 or the resident's family was given a 30 day notice of the resident's transfer. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE] revealed Resident #2 scored a 10 (moderate cognitive impairment) on the Brief Interview for Mental Status (BI[CONDITION]). Review of the Social Services Progress Notes dated 11/14/19, revealed discharge planning for Resident #2 was initiated with the resident's family on 11/14/19. Further review revealed the resident was transferred on 11/25/19 to another LTC facility. Medical record review revealed no documentation Resident #2 or the resident's family was given a 30 day notice of the resident's transfer. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] revealed Resident #3 scored a 9 (moderate cognitive impairment) on the BI[CONDITION]. Review of the Social Services Progress Notes dated [DATE] revealed discharge planning was initiated for Resident #3 with the resident's family on 11/14/19. Further review revealed the resident was transferred to another LTC facility on [DATE]. Medical record review revealed no documentation Resident #3 or the resident's family was given a 30 day notice of the resident's transfer. 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 Resident #5 scored a 14 (no cognitive impairment) on the BI[CONDITION]. Medical record review revealed Resident #5 was transferred to a sister facility (SF #1) on 11/15/19. Further review revealed no documentation the resident or the resident's family was given a 30 day notice of transfer. Telephone interview with Resident #5's responsible party (RP #5) on 12/3/19 at 7:00 PM, revealed the Chief Operating Officer (COO) informed families on 11/12/19 the facility had been purchased by new owners and would close. RP #5 confirmed they did not receive a 30 day notice of transfer. RP #5 stated families were informed the facility was slated to close 11/30/19. RP #5 reported she observed the facility daily between [DATE] and 11/15/19 and stated .it was a mad dash moving residents out of that facility. They were getting them out of there as fast as they could.the process was abrupt and poorly planned, and disruptive to families so close to the holidays. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the resident was his own decision maker. Medical record review of a Quarterly MDS dated [DATE] revealed Resident #6 scored a 10 (moderate cognitive impairment) on the BI[CONDITION]. Medical record review revealed Resident #6 was transferred to SF #1 on 11/13/19. Further review revealed no documentation the resident or the resident's family was given a 30 day notice of transfer. Interview with Resident #6 on 11/25/19 at 3:57 PM, in his room at SF #1, revealed he was not given advance notice of the transfer and was not aware of the transfer until the day before it occurred. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] revealed Resident #7 had short and long term memory problems. Medical record review revealed Resident #7 was transferred to SF #1 on 11/14/19. Further review revealed no documentation the resident or the resident's family was given a 30 day notice of transfer. Telephone interview with Resident #7's spouse on 11/25/19 at 5:30 PM, revealed the resident's spouse was verbally informed of the transfer on 11/12/19, during a family meeting held at the facility (2 days prior to the transfer). Resident #7's spouse confirmed they did not receive written notice of the facility's planned closure and was not provided a written 30 day notice to relocate Resident #10. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] revealed Resident #8 had short and long term memory loss. Medical record review revealed Resident #8 was transferred to SF#1 on [DATE]. Further review revealed no documentation the resident or the resident's family was given a 30 day notice of transfer. Telephone interview with Resident #8's spouse on 11/25/19 at 6:10 PM, revealed they were notified of the transfer on 11/12/19 during a family meeting called by the new management. Resident #8's spouse was informed of the meeting 2 hours prior to the meeting and .they told us they were closing by the end of the month; out of the blue. Lots of people at that meeting were unhappy with that and let them know it, but they (facility) didn't seem to care too much about that. Resident #8's spouse confirmed they did not receive written notice of the facility's planned closure and was not provided a written 30 day notice to relocate Resident #10. Medical record review revealed Resident #9 was admitted to the facility on [DATE] for rehabilitation with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] revealed Resident #9 scored a 13 (cognitively intact) on the BI[CONDITION]. Medical record review of a Social Services Progress Notes dated 11/14/19 revealed discharge planning was initiated for Resident #9 with the resident's spouse on 11/14/19. The spouse stated she would take the resident home. Further review revealed no documentation the resident or the resident's family was given a 30-day notice of the facility closure and that Resident #9 would have to transfer to another LTC facility. Continued review revealed the resident was discharged home on[DATE] with family. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] revealed Resident #10 scored a 3 (severe cognitive impairment) on the BI[CONDITION]. Medical record review revealed Resident #10 was transferred to SF #1 on 11/19/19. Medical record review revealed no documentation Resident #10 or the resident's family was given a 30 day notice for the resident's transfer. Telephone interview with Resident #10's Power of Attorney (POA) on 11/25/19 at 5:15 PM, revealed the POA learned of the facility's plan to close during a family meeting at the facility on 11/12/19. Prior to 11/12/19, the POA was not aware Resident #10 would be transferred to another LTC facility. The POA said he was given 3 hours' notice that the family meeting would occur on 11/12/19 and .I got mixed signals regarding the close date. The Chief Officer said he was closing it (the facility) by (11/30/19) but a female speaker got up and then said there was no rush and we could wait. We (Resident #10) didn't leave (transfer) until about 6 days later. We were one of the last ones left. The families were given too short a notice. Resident #10's POA confirmed they did not receive written notice of the facility's planned closure and was not provided a written 30 day notice to relocate Resident #10. Interview with the Administrator on 11/25/19 at 10:00 AM, in the conference room, revealed the facility had been sold and the new ownership had taken operational control on [DATE] at midnight. On [DATE] at approximately 1:00 PM, executives from the new ownership called special group meetings and announced the facility would be closed by the end of November (2019). On 11/12/19 at 6:00 PM, executives from the new ownership group called a special meeting for families and informed them of the facility closure. Resident transfers began on 11/13/19 and were ongoing. The Administrator confirmed the residents, resident representatives, State Long-Term Care Ombudsman, and the State Agency were not given a 30 day notice before the transfers. Telephone interview with the former owner's Regional Vice President (RVP) of Operations on 11/25/19 at 11:00 AM, revealed after the new ownership group took control of the facility, they announced the facility would close. On 11/12/19, a meeting was held with residents' family members and they were advised residents would be transferred to other LTC facilities. Interview with the Regional Director of Clinical Services (RDCS), for the new ownership, on 11/25/19 at 12:33 PM, in the conference room, confirmed resident representatives and the Ombudsman volunteer were notified of the facility's closure plan during the family meeting held on 11/12/19. The RDCS confirmed the new corporate leadership had participated in telephone communications with the State Agency to discuss closure of the facility about 5 days after the new ownership assumed control of the facility and resident transfers had already occurred. Telephone interview with the new ownership group's Chief Operating Officer (COO) on 11/25/19 at 8:00 PM, revealed the company purchased the facility effective [DATE] at midnight and advance notice of the pending facility closure was not disclosed to anyone. The COO confirmed the residents and resident representatives were informed of the facility closure during a meeting on 11/12/19 and resident transfers began on 11/12/19, with many residents being relocated 11/12/19 - [DATE]. Interview with the new ownership's Regional Director of Operations (RDO) on 11/26/19 at 11:45 AM, in the conference room, confirmed the State Ombudsman was notified of the facility's planned closure on 11/12/19, a few minutes before the family meeting. Interview with the Social Services Director (SSD) on 11/26/19 at 1:00 PM, in the conference room, confirmed a 30 day notice was not issued to residents or their representatives at any time. Further interview revealed multiple family members had voiced concerns related to the abrupt nature of the closure and not being provided a 30 day notice. Interview with the Business Office Manager (BOM) on 11/26/19 at 2:00 PM, in the conference room, revealed she was instructed by the new leadership team to begin calling family members on the afternoon of [DATE] to inform them there would be a meeting on 11/12/19 at 6:00 PM to discuss . changes at the facility. Further interview confirmed only 4 resident representatives were contacted on [DATE] and the remaining representatives were contacted throughout the day on 11/12/19, with some not receiving notice of the meeting until a few hours before the meeting. The BOM was present for the family meeting and stated the COO announced during the meeting the plan was to close the facility by the end of November (2019). Refer to F-[AGE]5 and F-[AGE]6",2020-07-01
5421,ETOWAH HEALTH CARE CENTER,445422,"409 GRADY ROAD, PO BOX 957",ETOWAH,TN,37331,2016-03-22,280,D,1,0,MXJV11,"**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 review and revise the behavior care plan for 3 residents (#2, #4, #18) of 18 residents reviewed for behaviors. The findings included: Review of facility policy, Dementia Care Guidelines, effective 4/1/15 revealed .residents who exhibit .behavioral or psychological symptoms of dementia (BPSD) will have an evaluation by the interdisciplinary team .to identify and address treatable psychiatric, functional, social and environmental factors .will conduct periodic .screening .behavioral interventions are individualized . including direct care and activities that are provided as part of a supportive .environment .and are directed towards preventing, relieving or accommodating .individualized approaches and treatment .addresses the causes .of .behaviors .staff training includes Hand in Hand in-services and on-going in-service and training .Monitoring, Follow Up and Oversight .staff identifies effectiveness of interventions relative to target behaviors . collaborates .adjustments to the interventions based on effectiveness .Quality Assessment and Assurance (QA) .The QA minutes should reflect any quality deficiencies related to the care of residents with dementia .lists of residents with dementia .pharmacological and nonpharmacological interventions are collected and analyzed .the facility shall attempt to establish root causes .of behaviors. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident with a Brief Interview of Mental Status Score of 8/15 (moderately severe cognitive impairment), impaired thought processes, depressed mood, physical behaviors directed towards others and was dependent upon a wheelchair for ambulation and Activities of Daily Living (ADL's). Review of the facility investigations revealed Resident #2 was involved in 10 separate incidents of resident versus resident altercations between 5/20/15 and 2/14/16, including 4 separate incidents reported to the State Agency which involved altercations with Resident #4. Review of the Care plan for Resident #2 revealed a generic Care Plan with no individualized behavioral interventions in place to address the resident's documented behaviors which including confusion, combative behaviors towards staff, verbal and physical abusive behaviors, and physical altercations with other residents. Continued review of the Care plan revealed no updates related to individualized approaches for prevention of behaviors between 8/3/15 and 2/14/16, even though Resident #2 had been involved in 8 separate resident versus resident altercations during the time period including 2 incidents between 12/6/15 and 12/10/15 and another 3 incidents between 1/15/16 and 1/20/16. Medical record review of Activities Progress Notes, Social Services Progress Notes, Rehabilitation Notes, Nursing Notes, physician progress notes [REDACTED].#2's behavioral disturbances in an effort to reduce the frequency or prevent altercations with other residents. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Comprehensive MDS dated [DATE] revealed Resident #4 was severely cognitively impaired, had depressed mood, physical and verbal behaviors directed towards others, was wheelchair dependent and was dependent for ADL's. Review of the facility investigations revealed Resident #4 was involved in a total of 6 resident versus resident altercations including 4 separate incidents involving altercations with Resident #2 between 5/20/15 and 12/13/15. Medical record review of the Care Plan for Resident #4 revealed a generic care plan with no individualized behavioral interventions to address the resident's documented behaviors which included confusion, wandering, combativeness with showering, and verbally or physically abusive behaviors towards staff and peers. Continued review of the Care Plan for Resident #4 revealed no updates related to individualized approaches for behavioral management in response to the resident to resident altercations between 5/20/15 and 12/13/15, including 3 resident to resident altercations between 5/20/15 and 6/18/15 in which the resident became engaged in altercations with Resident #2. Medical record review of the Nursing Notes, Social Services Notes, Activities Notes, physician progress notes [REDACTED]. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 8/18/15 revealed Resident #18 was care planned for wandering, resists care, cursing and kicking staff, episodes of verbally or physically abusive behavior, and has aggressive outbursts within group programs. Further review revealed the interventions included: psychosocial program if appropriate, stop care when resident is upset and try again later, encourage resident to perform independent ADLs, approach resident calmly, explain all procedures, discuss concerns, and attempt to refocus behavior to be positive. Medical record review of a Nurse's note dated 8/18/15 revealed Resident #18 does not understand simple commands most of the time. Medical record review of a Nurse's notes dated 8/18/15 until discharge on [DATE], to psychiatric inpatient facility revealed the resident had continued behavior issues such as hits and kicks staff, try to feed other residents in the dining room, disruptive during bingo, tried to hit another resident, combative with staff during care, hard to redirect, continues to lay down in other resident's bed, and will only sit in a chair for short periods. Medical record review of the care plan revealed no new interventions initiated after 8/18/15 related to continued behavioral outbursts. Review of the facility incident logs revealed Residents #2, #4, and #18 were involved in 13 of the facility's 18 resident versus resident altercations reported to the state agency between the dates of 5/20/15 and 2/14/16. Interview with the Director of Nursing (DON) on 3/8/16 at 3:40 PM, in the Conference Room confirmed the care plans for Residents #2, #4 and #18 were not resident specific or individualized. The DON further confirmed some of the interventions listed on the care plans for verbal and physical behaviors needed to be more individualized for the residents. Interview with the Social Services Director (SSD) on 3/10/16 at 9:00 AM, in the Conference Room confirmed she was aware Resident #18's care plan had not been updated to reflect the multiple behavioral issues and confirmed both Resident #2 and Resident #4's care plans were not updated to address frequent altercations between those residents and peers. Continued interview with the SSD revealed the care plan meetings were not addressing the effectiveness of behavioral interventions and if new interventions needed to be put into place to reduce behaviors for Residents #2, #4 and #18.",2019-03-01
342,"THE WATERS OF GALLATIN, LLC",445124,555 EAST BLEDSOE STREET,GALLATIN,TN,37066,2017-10-11,225,D,1,1,AQJ411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview, the facility failed to thoroughly investigate 2 allegations for 1 resident (#81) of 5 residents reviewed for abuse. The findings included: Review of facility policy, Abuse Prevention Program, dated 1/19/17 revealed .Once the Administrator or designee determines that there is a reasonable cause for suspecting abuse, the Administrator or designee will investigate the allegation and obtain a copy of any documentation relative to the incident . Medical record review revealed Resident #81 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #81 discharged from the facility on 7/28/17. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #81 had a Brief Interview for Mental Status score of 15, indicating she was cognitively intact. Review of the facility investigation regarding abuse/exploitation of Resident #81 revealed no statement from the identified staff who took the picture or from Resident #81. Review of the facility investigation of an undated hand written document revealed .Res (resident) reported to nurse that $80 was missing fr (from) wallet. It has been 2-3 days since she saw it . Further review of the facility's investigation revealed 5 witness statements were obtained from staff. Interview with the Administrator on 10/11/17 at 4:30 PM in her office revealed the resident was having hallucinations when she reported the money missing. The Administrator stated the hallucinations worsened as the day progressed, resulted in the resident being sent to local hospital for evaluation. The Administrator confirmed no additional witness statements were obtained nor was a statement obtained from Resident #81. The Administrator confirmed she wrote the hand written document in the investigation. The Administrator confirmed the facility failed to thoroughly investigate 2 allegations of abuse/exploitation and misappropriation of funds for Resident #81. Interview with the Assistant Director of Nursing (ADON) on 10/11/17 at 4:45 PM in the conference room revealed the statements in the investigations were obtained by the Director of Nursing, the Administrator and the ADON. The ADON confirmed no additional statements were obtained from any additional staff, from the identified staff who took the picture of Resident #81 or from Resident #81 about either investigation. The ADON confirmed the facility failed to thoroughly complete both investigations. The facility failed to obtain statements from staff who worked prior to the money being reported missing and from Resident #81 thus the facility failed to completed a thorough investigation of the missing money per the facility. The facility failed to obtain statements from the identified staff who took the picutre of Resident #81 and from the resident thus the facility failed to complete a thorough investigation of abuse/exploitation per the facility policy.",2020-09-01
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
766,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2017-10-26,280,G,1,0,KCFU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interview, the facility failed to update the Care Plan with interventions for 3 residents (#7, #6, #4) of 7 residents reviewed. The facility's failure to identify risk and update the care plan with approporiate interventions resulted in falls with injuries (HARM) for resident #7,#6, #4. The findings included: Review of facility policy, Accidents and Supervision to Prevent Accidents (dated: 4/28/2011), revealed .The center provides an environment that is free from accident hazards .Implementation of interventions to reduce hazard(s) and risk(s) .Monitors to verify interventions are in place .Evaluates interventions at designated interval for effectiveness .Modifies and/or replaces ineffective interventions when necessary . Medical record review revealed Resident #7 admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #7 had a Brief Interview Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Further review revealed the resident required extensive assistance with transfers and Activities of Daily Living (ADL) and had no impairment of the upper and lower extremities. The resident was occasionally incontinent of the bowel and bladder. Medical record review of a Progress Note dated 9/5/17 revealed Resident #7 had a fall with no injury to occur on 9/5/17 and 9/9/17. Review of the Care Plan initiated on 8/7/17 for Resident #7 revealed it was not updated after the fall occurred on 9/5/17, 9/9/17, 9/17/17, and only revised on 10/24/17. Medical record review of a Post Fall Investigation dated 9/17/17 revealed the resident was .heard resident yelling .went to room and the resident was sitting on the floor on the L (left) side of the bed .was sitting on her botttom with her leg bent at the knee under her. When the resident tried to straighten it out she yelled and there was a popping noise . Continued review revealed the resident was transferred to the hospital and admitted for a Nondisplaced Midcervical Fracture of Right Femur. Interview with LPN #9 on 10/26/17 at 9:20 AM in the conference room revealed the nurse was to update the Care Plan with interventions after each fall. LPN #9 confirmed she failed to update the Care Plan after Resident #7 fell on [DATE] and another fall occurred on 9/17/17. Interview with the Administrator on 10/26/17 at 10:52 AM in the Social Services office revealed the Care Plans were to be updated with interventions after every fall by the nurse. After review of the Care Plan, the Administrator confirmed the facility failed to update the Care Plan with interventions after Resident #7 had a fall with injury (HARM) on 9/17/17. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 30-day Minimum Data Set ((MDS) dated [DATE] revealed Resident #6 had severe cognitive impairment with short and long term memory problems. The resident required extensive assistance with bed mobility, transfers, dressing, personal hygiene, eating and toileting and required total dependence for bathing. Continued review revealed Resident #6 was always incontinent of bowel and bladder, had bilateral impairment of both upper and lower extremities and utilized a wheelchair for mobility. Upon admission pt (patient) was identified as falls risk as evidenced by admission Care Plan. Medical record review of Progress Notes dated 8/27/17 and 9/6/17 revealed Resident #6 had falls to occur on these dates. Further review revealed Resident #6 received an injury as a result of the 9/6/17 fall when found on floor. Continued review of a Progress Note dated 9/7/17 revealed .family says he's been c/o (complaining of) left side discomfort . Medical record review of a Radiology Report dated 9/7/17 revealed .Conclusion: Acute right lateral ninth rib fracture . Medical record review of the Care Plan for Resident #6 revealed it was not updated or revised with new interventions after the falls occurred on 8/27/17 and 9/6/17. Interview with Licensed Practical Nurse (LPN) #9 on 10/26/17 at 9:20 AM in the conference room revealed after each fall the nurse was required to update the Care Plan with interventions. LPN #9 confirmed she failed to update the Care Plan with an appropriate intervention after Resident #6 fell on [DATE]. Interview with Administrator on 10/26/17 at 10:52 AM in the Social Services office revealed the Care Plan was to be updated with interventions after every fall by the nurse. After review of the Care Plan, the Administrator confirmed the facility failed to update the Care Plan with interventions after Resident #6 had falls to occur on 8/27/17 and 9/6/17. Medical record review of the Care Plan for Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quartely MDS dated [DATE] revealed the resident has a BMS score of 7 (severe impairment). The Resident was extensive assist with 1 person for transfer, extensive assist with 1 person for transfer, dressing and personal hygeine, independent with ambulationwith wheelchair, set up only, limited assist with 1 person for eating and total dependence with 1 person for bathing. The residnet had impairment on one side for upper and lower extremities and frequesntly incontinent of bowel and bladder. Medical record review of a fall investigation dated 9/17/17 revealed Resident was trying to get in to bed without assist (resident knows to ask for help) and sat on the floor beside the bed. Denies injury at this time .Neuro checks and 30 minute checks started .no injuries noted . Review of a Progress Note dated 9/18/17 revealed the Physician ordered a Tibia/Fibula x-ray. Review of the results of the x-ray dated 9/19/17 revealed an abnormal x-ray and orders to consult with an Orthopedic Medical record review of the Care Plan for Resident #4 revealed the facility failed to update the Care Plan after the 9/17/17 fall. Interview on 10/26/17 with the Administrator at 9:33 AM in her office revealed the facility failed to update the Care Plan after the 9/17/17 fall. The Administrator confirmed the facility failed to update the Care Plan with interventions after falls. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 7 (severe impairment). The resident required extensive assistance with 1 person for transfer, dressing and personal hygiene, independent with ambulation with wheelchair, set up only, limited assist with 1 person for eating and total dependence with 1 person for bathing. The resident had unilateral impairment on one side of upper and lower extremities and frequently incontinent of bowel and bladder. Medical record review of a fall investigation dated 9/17/17 revealed Resident was trying to get in to bed without assist (resident knows to ask for help) and sat on the floor beside the bed. Denies injury at this time .Neuro checks and 30 minute checks started .no injuries noted . Review of Progress Notes dated 9/18/17 revealed the resident with a Tibula/Fibula fracture and placement of a cast. Medical record review of the Care Plan for Resident #4 revealed the facility failed to update the Care Plan after the 9/17/17 fall. Interview with the Administrator on 10/26/17 at 9:33 AM in her office confirmed the facility failed to update the Care Plan after the 9/17/17 fall.",2020-09-01
1334,RIVER GROVE HEALTH AND REHABILITATION,445253,1520 GROVE ST BOX 190,LOUDON,TN,37774,2019-04-18,684,D,1,0,3SWQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interviews, the facility failed to administer medications as ordered by the Physician, for 1 resident (#1) of 3 residents reviewed for medication administration. The findings included: Review of the facility policy, Medication Shortages/Unavailable Medications effective date (YEAR), revealed .Upon discovery that facility has an inadequate supply of medication to administer to a resident, facility should take immediate action to obtain the medication from the pharmacy .if medication is not available in the Emergency Medication Supply, facility staff should .arrange for an emergency delivery . Medical record review revealed Resident #1 was admitted to the nursing home on Friday 1/11/19 with [DIAGNOSES REDACTED]. Medical record review of a Physician's admission orders [REDACTED]. Medical record review of a Medication Administration Record [REDACTED] 1/13/19 revealed the medication was documented as unavailable and was not obtained from a secondary pharmacy. Investigative interview with the Assistant Director of Nursing (ADON) on 4/17/19 at 3:15 PM, in the Director of Nursing's office, revealed on Friday night 1/11/19 the facility electronically forwarded Resident #1's admission orders [REDACTED]. Continued interview revealed the ADON reported the facility pulled the medication from its' emergency stock on 1/12/19 and administered it to Resident #1, which exhausted the facility emergency supply. Continued interview revealed the facility forwarded a second request for Resident #1's [MEDICATION NAME] on 1/12/19. Further interview revealed on 1/13/19 the pharmacy had not fulfilled the facility's second request for [MEDICATION NAME] for Resident #1 and the facility did not utilize the 24 hour back up pharmacy to obtain the medication for Resident #1. Continued interview confirmed the facility failed to administer the medication in accordance with the Physician's orders.",2020-09-01
2084,SIGNATURE HEALTHCARE OF SOUTH PITTSBURG REHAB & WE,445343,201 EAST 10TH STREET,SOUTH PITTSBURG,TN,37380,2018-09-10,578,D,1,0,8TIQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interviews, the facility failed to honor advanced directives for one resident (#18) of 6 residents reviewed for advanced directives of 18 residents reviewed. The findings included: Review of the facility policy Resident Rights dated [DATE] revealed .When providing care and services .stakeholders will respect resident's individuality and value their input .through self-determination . Review of the facility policy Advance Directives Procedure dated [DATE] revealed .if the resident .has completed an advance directive, it shall be documented in the medical record . Review of the facility policy Cardiopulmonary Resuscitation (CPR) dated [DATE] revealed .Cardiopulmonary resuscitation will be attempted for any resident who is found to have no .pulse .or respirations .unless there is a written physician order to the contrary and/or written advance directives .upon identifying a resident with .unresponsive condition .check the medical record for advance directive status . Medical record review revealed Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physician Orders for Scope of Treatment (POST) form dated [DATE] revealed .(if) patient has no pulse and is not breathing .Do Not Attempt Resuscitation . Medical record review of Resident #18's admission care plan dated [DATE] revealed the advance directive status was not indicated. Continued review revealed the resident's advance directive status was not documented in the Electronic Medical Records (EMR). Medical record review of a nurse's note dated [DATE] at 2:04 PM revealed Resident #18 was found in [MEDICAL CONDITION] (absence of a pulse) and CPR was initiated at 2:06 PM. Further review revealed at 2:12 PM the facility ceased CPR after the POST form was located and the attending Physician gave the order to cease CPR. Continued review revealed Resident #18 was pronounced deceased at 2:12 PM. Interview with the Director of Nursing (DON) on [DATE] at 9:40 AM, in the dietary office, confirmed the facility failed to honor Resident #18's advance directives for no CPR in the event of [MEDICAL CONDITION].",2020-09-01
901,"CAMBRIDGE HOUSE, THE",445190,250 BELLEBROOK RD,BRISTOL,TN,37620,2018-03-21,610,D,1,0,ZD9T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interviews, the facility failed to investigate an injury of unknown origin for one resident (#4) of five sampled residents reviewed for abuse. The findings included: Review of the Abuse, Neglect, Mistreatment and Misappropriation of Resident Property dated 12/4/2017, revealed allegations of abuse are to be investigated. Review of the medical record revealed the facility admitted Resident #4 on 5/3/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed Resident #4 had a chest x-ray on 1/2/2018 due to a cough. Review of the medical record revealed KUB (Kidney, Ureters, and Bladder) x-rays were done on 1/29/18, 1/30/18, and 2/1/18. These x-rays reported a metallic screw over the right upper quadrant of the abdomen. Review of the medical record revealed the physician was notified of the KUB x-ray results on 1/29/18, 1/30/18 and 2/1/18. Review of the nurse's note dated 2/1/18 revealed the POA agreed with the doctor for Resident #4 to be admitted to the hospital on [DATE] for evaluation of the screw in the abdomen. Review of the Op Note (surgical note) dated 2/1/18 revealed the screw was removed from the resident's duodenum (upper part of the small intestine) with a scope inserted down the resident's throat. Resident #4 tolerated the procedure well and returned to the facility on [DATE]. Interview with Resident #4 was attempted on 3/19/18 at 1:00 PM, on in the 300-500-unit dining room, and Resident #4 was unable to answer any questions. Interview with the Director of Nursing (DON) on 3/20/18 at 11:30 AM, in the DON's office, revealed no formal investigation had been done or documented. The DON stated the family was interviewed about Resident #4 possibly swallowing a screw prior to admission to the facility, staff were interviewed if Resident #4 had displayed any behavior of putting non-food items in her mouth, and the physician was interviewed. The DON stated the resident had no change in condition related to swallowing, pain or bowel movements. It (the screw) was discovered as a fluke on an x-ray. Interview with the Medical Director on 3/20/18 at 1:30 PM, at the nurses' station on the 300-500 units, revealed he had no idea where the screw came from. The screw showed up on a chest x-ray so I ordered a KUB three times to verify that this was a screw and not an artifact. Once verified, I admitted the resident to the hospital under a [MEDICATION NAME] (physician specializing in the throat, stomach, and intestinal tract). The screw was removed without adverse effect to the resident. I had the staff check the resident's room and wheel chair for missing screws. None were found. Interview with the DON on 3/21/18 at 9:45 AM, in the conference room, confirmed, We did not write up an investigation.",2020-09-01
3412,"NHC HEALTHCARE, TULLAHOMA",445515,1321 CEDAR LANE,TULLAHOMA,TN,37388,2019-05-23,580,D,1,0,DWRW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interviews, the facility failed to notify a resident's representative of a change in condition for 1 resident (#1) of 3 residents reviewed for notification of a change in condition. The findings included: Review of facility policy Emergency Care, not dated, revealed .Sudden Critical Change in Condition .Notify the patient's family or legal representative of change in condition . Medical record review revealed Resident #1 was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum (MDS) data set [DATE] revealed the resident scored a 5 (severe cognitive impairment) on the Brief Interview for Mental Status. Review of a Nurses' Progress Note dated 5/7/19 at 12:05 PM, revealed .Resident sitting up in W/C in common area .Has been agitated this morning .Refused lunch stating I'm getting out of here . Review of a physician's orders [REDACTED].[MEDICATION NAME] .5 mg (milligrams) .PO (by mouth) BID (twice daily) PRN (as needed) X (times) 14 days . Interview with Resident #1's daughter on 5/21/19 at 3:30 PM, in the conference room, revealed .My brother came .they (nursing staff) didn't tell us they had gotten an order for [REDACTED]. Interview with Licensed Practical Nurse (LPN) #1 on 5/23/19 at 4:30 PM, in the conference room, revealed .he (Resident #1) had been agitated for a couple of days, the NP (Nurse Practitioner) was here and saw the agitation first hand and placed the order for a one time dose of [MEDICATION NAME] and a .5 dose BID PRN .I can't remember notifying the family . Interview with the Director or Nursing (DON) on 5/23/19 at 4:35 PM, in the conference room, confirmed .we consider any change in medication or treatment a change in condition and the family should be notified . Continued interview confirmed the facility failed to notify the family of the change in medications for Resident #1.",2020-09-01
2296,HORIZON HEALTH AND REHAB CENTER,445383,811 KEYLON STREET,MANCHESTER,TN,37355,2019-02-20,600,D,1,0,SHR011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interviews, the facility failed to prevent abuse for 1 resident (#4) of 5 residents reviewed for abuse. The findings included: Review of the facility policy, Abuse Prevention/Reporting Policy and Procedure dated 2013, revealed .Every resident has the right to be free from abuse .Residents must not be subjected to abuse by anyone, including, but not limited to employees, other residents, physicians, consultants, volunteers, family members, legal guardians, friend or other individuals .Abuse .Willful inflection .Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflect injury or harm . Medical Record Review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of an Annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderate cognitive impairment. Further review revealed no behaviors had occurred during the assessment period. Medical record review revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of an Annual MDS dated [DATE] revealed a BIMS score of 8, indicating the resident had moderate cognitive impairment. Continued review revealed no behaviors had occurred during the assessment period. Interview with Licensed Practical Nurse (LPN) #3 on 2/20/19 at 12:15 PM, at the 600 Hall Nurses' Station, revealed .I heard a noise in the dining room, I saw .(LPN #4) with .(Resident #5) he was seated at the dining room table .(Resident #4) was coming down the hall toward her room .I heard (Resident #4) say (Resident #5) just slapped me in the face. She said .(Resident #5) just slapped me because I called him a thief . Interview with LPN #4 on 2/20/19 at 12:25 PM, at the 600 Hall Nurses' Station, revealed .I was sitting at a dining room table with a CNA (Certified Nursing Assistant) .I didn't actually see what happened but the CNA saw it and told me (Resident #5) just slapped her (Resident #4). I got up and walked over to the table and got between them (Resident #4 and Resident #5) . Observation/interview with Resident #4 on 2/10/19 at 12:30 PM, in her room, revealed the resident lying in her bed awake and alert. Further observation revealed no redness or marks on the resident's face and no anxious or fearful behaviors were noted. Observation and interview with Resident #4 on 2/19/19 at 1:20 PM, in the front lobby, revealed the resident did not appear anxious or fearful. Interview revealed .I'm ok but I'm trying to make a report that .(Resident #5) just smacked me in the face, he stole one of my cokes, and when I told him about it he slapped me . Further interview revealed the resident denied that she was hurt and stated she was not afraid. Observation and interview with Resident #5 on 2/20/19 at 2:05 PM, in the 600 Hall Dining Room, revealed .I was setting here and she (Resident #4) got in my face and called me a (expletive) thief. She kept on and I told her to stop or I was going to slap her she said 'go ahead and I'll call the cops' .She kept on and on and I backhanded her across the face. I didn't do anything else .the nurse came and got her. They are keeping her away from me now. She would follow me around like a little puppy dog .the Administrator told me to yell for a nurse if she got around me. I've never hit a woman before and that was enough I don't ever want to do that again. I didn't hit her hard, I think it just made her madder than she already was. I've not seen her all day thank goodness . Interview with CNA #2 on 2/20/19 at 12:40 PM, in the conference room, revealed .I was in the dining room .they were sitting at the same table. Out of the corner of my eye, I saw them .he (Resident #5) was sitting and she (Resident #4) was standing over him, I saw his arm come around and pop her on the side of the face. It wasn't a hard slap but you could tell it was deliberate, he intended on slapping her. She was reaching for a cold drink that was on his tray . Interview with the Administrator on 2/20/19 at 1:20 PM, in the conference room, revealed confirmed Resident #5 willfully slapped Resident #4 and the facility failed to prevent abuse for Resident #4.",2020-09-01
1604,CUMBERLAND VILLAGE CARE,445276,136 DAVIS LANE,LAFOLLETTE,TN,37766,2018-08-30,580,D,1,0,O28W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interviews, the facility failed to provide the Power of Attorney (POA) notification of 1 [MEDICAL CONDITION] medication change of 6 [MEDICAL CONDITION] medication changes occurring 1/18/18 through 8/17/18 for one resident (#1) of 4 residents reviewed. The findings included: Review of the facility policy, Condition in Change: Notification of dated 11/28/16, revealed .A Center must immediately inform the patient, consult with the patient's physician, and notify, consistent with his/her authority, the patient's Health Care Decision Maker (HCDM), where there is: .A need to alter treatment significantly (that is, an need to discontinue or change an existing form of treatment .or commence a new form of treatment) . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Physician telephone orders dated 1/18/18, 1/31/18, 2/8/18, 7/31/18, 8/10/18, and 8/17/18, revealed Resident #1 received antipsychotic medication changes on above stated dates. Review of Nurse Practitioner (NP) #2's note dated 5/23/18, revealed a change in [MEDICATION NAME] 2.5 mg (milligrams) from every 8 hours to every 12 hours. Continued review revealed no documentation of family/Power of Attorney (POA) notification of a medication change. Interview with the Director of Nursing (DON) on 8/30/18 at 10:25 AM, in the conference room, revealed Nurse Practitioner (NP) #2 was unavailable by telephone. In an email communication with NP #2, he was unable to confirm he had spoken to Resident #1's POA related to the [MEDICAL CONDITION] medication change on 5/23/18. Continued interview confirmed her expectation was a Resident's POA/family should be notified of every medication change and the facility had failed to follow their policy, for notification of a [MEDICAL CONDITION] medication change for Resident #1.",2020-09-01
4343,SUMMIT VIEW OF ROCKY TOP,445259,204 INDUSTRIAL PARK RD,ROCKY TOP,TN,37769,2016-10-03,280,G,1,0,HV9H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, and interviews, the facility failed to revise the care plan with interventions for the development of a pressure ulcer for 1 resident (#2), of 5 residents reviewed for pressure ulcers, resulting in harm to Resident #2. The findings included: Review of the facility policy Pressure Ulcers/Skin Breakdown - Clinical Protocol dated 4/2007, revealed .staff review and modify the care plan as appropriate, especially when .new wounds develop despite existing interventions . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12 (moderate cognitive impairment). Continued review revealed the resident required extensive assistance for all activities of daily living and was always incontinent of bowel and bladder. Medical record review of the admission Braden Scale (assessment to determine the risk of the development of a pressure ulcer) dated 1/22/16 revealed the resident was at mild risk for the development of pressure ulcers. Medical record review of the interim care plan dated 1/23/16 revealed the facility had not care planned any actual or potential risk for alteration in skin integrity. Continued review of the care plan revealed, on 2/1/16, the facility implemented an intervention of moisture barrier to the resident's skin after bath and incontinence care. Further review revealed the resident required extensive assistance with bed mobility and to reposition every 2 hours. Medical record review of the quarterly Braden scale dated 4/23/16 revealed the resident remained at mild risk for the development of pressure ulcers. Medical record review of the weekly skin assessment dated [DATE], revealed .New Stage II ulcer on Coccyx .2 cm (centimeters) W (width) 1 cm L (length) . Medical record review of the Treatment Record revealed .5/19/16 (12 days after the wound was discovered) .Apply [MEDICATION NAME] (antibiotic) ointment to coccyx then apply Alginate Wound Dressing cover with Island Dressing Daily . Medical record review of the care plan revealed it was revised on 5/19/16 for the identification of a new stage II wound to Resident #2's coccyx. Continued review revealed the interventions implemented included a pressure reducing mattress, sheepskin in wheelchair due to constant scooting motion, and wound treatment as ordered. Interview with the Treatment Nurse on 10/3/16 at 12:00 PM, in the conference room, confirmed Resident #2's weekly skin assessment completed on 5/7/16 identified a new stage II pressure ulcer on Resident #2's coccyx. Continued interview confirmed the pressure ulcer increased in size from 2 cm by 1 cm on 5/7/16 to 2 cm by 2 cm on 5/29/16, and the facility had failed to implement treatment, initiate interventions, and update the care plan until 12 days after the wound was discovered. Interview with the Director of Nursing (DON) on 10/3/16 at 12:30 PM, in the conference room, confirmed the facility failed to initiate timely treatment, update the care plan for Resident #2's stage II pressure ulcer, and failed to follow facility policy, resulting in an increase in size from 2 cm by 1 cm on 5/7/16 to 2 cm by 2 cm on 5/29/16, which resulted in harm to Resident #2. Refer to F-314",2019-10-01
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
4340,LIFE CARE CENTER OF CLEVELAND,445244,3530 KEITH ST NW,CLEVELAND,TN,37311,2016-10-20,323,D,1,0,H8BH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, facility falls investigation, and interview the facility failed to implement an intervention after a fall for 1 resident (#6) and failed to ensure a safety device was in place for 1 resident (#11) of 5 residents reviewed for falls. The findings included: Review of the facility policy Falls Management, undated, revealed .a plan will be identified and implemented as necessary to protect the resident .from recurrence . Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #6 fell from her wheelchair on 1/9/16. Continued medical record review of a facility fall investigation for Resident #6 dated 1/9/16 revealed .recommendations/actions taken .Therapy referral for gait training/balance . Further medical record review revealed the resident was already .on therapy caseload for balance and gait training . Interview with the Director of Nursing on 9/28/16 at 1:35 PM, in the Staff Development Office, confirmed the facility failed to implement a new intervention after Resident #6's fall on 1/9/16 and the facility failed to follow facility policy. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued medical record review revealed the resident had a fall on 5/31/16 and the intervention put in place to prevent falls was .dycem to wheelchair . Medical record review of the care plan dated 5/31/15 revealed .dycem to wheelchair . Observation on 10/18/16 at 2:40 PM, in the South Wing hallway, revealed Resident #11 was seated in her wheelchair with no dycem in the seat. Interview with Certified Nursing Assistant #16 on 10/18/16 at 2:45 PM, at the South Wing hallway, confirmed Resident #11 should have had the dycem in her wheelchair. Interview with the Director of Nursing on 10/20/16 at 11:45 AM, in the staff development office, confirmed the facility had failed to ensure the dycem was in the wheelchair seat as a safety intervention for Resident #11 and the facility failed to follow facility policy.",2019-10-01
713,LIFE CARE CENTER OF CROSSVILLE,445167,80 JUSTICE ST,CROSSVILLE,TN,38555,2017-06-21,282,G,1,1,VPY311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, facility investigation review, and interview the facility failed to provide supervision and assistance based on the resident's individualized care plan for toileting and personal care needs for 1 resident (#66) of 33 residents reviewed. Failure of the facility to provide care directed by the care plan resulted in HARM for Resident #66. The findings included: Review of the facility policy, Fall Management, dated 6/2016, 11/2016, revealed .promote patient safety and reduce patient falls by proactively identifying, care planning .avoidable accident: means that an accident occurred because the facility failed to .implement interventions, including supervision, consistent with a patient's needs, goals, plan of care .in order to reduce the risk of an accident . Medical record review revealed Resident #66 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record of the Care Plan dated 1/12/13 and confirmed with the Director of Nursing (DON) on 6/21/17 at 10:35 AM, in the DON office to be correct for both the MDS assessment and the care plan, revealed Activities of Daily Living (ADLs) requires extensive staff assistance with all ADLs due to impaired mobility and cognitive impairment. Further review of the Falls Care Plan revealed, assist x (times) 2 with bed mobility. Medical record review of the Care Directive Certified Nurse Aide (CNA) guide for care plans dated 1/18/17, revealed, Bed Mobility assist x 2 and Toileting total. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #66 scored 6 out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Further review revealed Bed Mobility and Toilet use had been assessed as Extensive Assistance requiring 2 plus persons for physical assistance. Medical record review of the facility's investigation dated 3/6/17 revealed .CNA was providing pericare (incontinence care) to resident in bed and had resident turned on her left side when CNA turned around to reach for a washcloth and resident slid off the edge of bed . Continued review of the Witness Statement Form revealed CNA #1 .I .was changing (Resident #66) when she had a large BM (bowel movement) .on her left side when I turned away to get another washcloth she had slide off the bed onto the floor . Medical record review of the Progress Notes dated 3/6/17 revealed .staff was providing resident with pericare .slid off the bed and into the floor .observed to be sitting on her bottom .abrasion noted to middle right finger .left leg also noted to be bent behind resident with hard protrusion noted below left knee with laceration .admitted .with [DIAGNOSES REDACTED].'' Medical record review of the Skin Integrity Data Collection dated 3/6/17 revealed .right forearm and hand .skin tear to middle finger right hand .skin tear to left knee below left knee . Medical record review of the hospital's Left Leg X-Ray Two Views findings, dated 3/6/17 revealed .comminuted impacted fractures of proximal left tibia and fibula . Review of facility's inservice training, Providing Care to a Resident While in Bed, dated 3/10/16 revealed .resident should never be rolled away .never turn from resident while providing care .turn attention away .if providing care and needs to reach for an item or look away, the resident should be returned to a safe position .ensure you have appropriate amount of assistance . Interview with Licensed Practical Nurse (LPN) #3 on 6/19/17 at 9:00 AM, at the 100 nursing station confirmed she had been assigned to the care of Resident #66 on 3/6/17 .slipped off the side of the bed . she (CNA #1) rolled her over .legs must have been too close to the edge .(CNA #1) called me into the room .one leg was behind her .(Resident #66) said she had fallen . Continued interview revealed Resident #66 was totally dependent on care. Interview with the Assistant Director of Nursing (ADON) on 6/20/17 at 10:00 AM, in the 100 nursing station confirmed she assisted with Resident #66 after the fall on 3/6/17. Continued interview confirmed .(CNA #1) was on (Resident #66) right side .there was no other staff in the room .the resident was on the floor, her left leg curled behind her, her knee was discolored, a skin tear on her hand and knee .(Resident #66) said she was hurting . Further interview confirmed they called an ambulance and the resident was transported to the hospital. Telephone interview with the Medical Director on 6/21/17 at 10:00 AM, revealed .somebody changed her by herself .she was dependent on care .not sure if she could have held onto a side rail .it sounds reasonable to have 2 persons to assist her . Interview with the Director of Nursing (DON) on 6/21/17 at 10:35 AM in the DON office confirmed Resident #66 was care planned correctly as a 2 person assist for bed mobility and toileting needs. Continued interview confirmed the facility's failure to ensure the care plan for Resident #66 was followed utilizing the amount of assistance required for safe administration of care when working with Resident #66 resulted in a fall with a fracture and HARM to the resident.",2020-09-01
3786,STARR REGIONAL HEALTH & REHABILITATION,445277,886 HWY 411 NORTH,ETOWAH,TN,37331,2017-02-22,225,D,1,0,IXF411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, facility investigation review, and interview, the facility failed to follow the facility's policy to immediately report suspected abuse for 1 resident (#1), of 7 residents reviewed for abuse, of 10 sampled residents. The findings included: Review of the facility's policy titled Resident/Patient Abuse/Neglect/Fiduciary Exploitation dated 06/2015, revealed .Anyone who witnesses and/or suspects an incident of resident/patient abuse is to report it to the Nursing Supervisor immediately . 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 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. Review of a facility investigation witness statement dated 11/7/16, completed by the Occupational Therapist (OT), revealed the resident reported to the OT .I grounded from eating. The red headed nurse said I couldn't have any coffee, (LPN #2). I went off on them last night .I pushed my call light and waited and waited so I was gonna get up myself .(Resident #1 reported to the therapist) The nurse said 'I have 9 other patients to take care of also.' (Resident #1) reported after dinner he was in dining room and the security guard told him he will be getting a shot because of his behaviors .(Resident #1) reported the nurse stated 'you're going to take that shot no matter what' . Further review revealed the OT reported the allegation of abuse to facility administrative staff. Review of a facility investigation revealed an interview was conducted by the Director of Nursing (DON) with Resident #1 on 11/7/16. Review of the documented interview revealed .(Resident #1) stated the red headed nurse (LPN #2) came in and he told her he wanted up to smoke and get coffee .she (LPN #2) told him no and he said would get himself up .(Resident #1) stated the other girls (Certified Nurse Aides (CNAs)) got him some coffee and he went to the dining room .(Resident #1) stated nurse (LPN #2) came in and told him he was going to get a shot . Resident #1 stated the CNAs got him some coffee and he went to the dining room where he watched TV and the security guard came and sat with him. Later the nurse came in and told him he was going to get a shot and the security guard, two CNAs and LPN #2 gave him the shot. After the shot the security guard sat with him and he continued to watch TV. He stated CNA #4 then took him out to smoke. Review of the facility's investigation dated 11/9/16, revealed Certified Nursing Assistant (CNA) #4, #8, and #9 were suspended, pending investigation, for failure to report suspected abuse and violation of resident's rights. Continued review revealed .(CNA #4) stated .I wished I had called DON and reported nurse .I questioned the shot in the dining room . Continued review revealed LPN #2 was terminated by the facility. Interview with CNA #4 on 2/16/17 at 11:30 AM, in the Board Room, confirmed she did not report the incident to the facility. Refer to F222",2020-02-01
1493,LAUGHLIN HEALTH CARE CENTER,445264,801 E MCKEE ST,GREENEVILLE,TN,37743,2018-04-25,609,D,1,0,5BRM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, facility investigation review, review of facility documents, and interviews, the facility failed to ensure allegations of abuse were reported timely to the State Survey Agency for 1 resident (#2) of 4 residents reviewed for abuse of 10 sampled residents. The findings included: Review of the facility policy Abuse, Neglect & Misappropriation of Property last revised (MONTH) (YEAR), revealed .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, if the events that cause the allegation involve abuse or result in serious bodily injury .to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services) . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 14 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance for transfer, dressing, and hygiene/bathing. Medical record review of a nursing progress note dated 4/13/18 at 9:11 AM revealed .(Resident #2) and his wife asked to see me (Director of Nursing) about an employee being rude to him .(employee) said she hated him and he was like his daddy (was a previous resident of the facility) . Review of a facility investigation dated 4/13/18, not timed, revealed Resident #2 and his wife spoke to the DON about an issue regarding CNA #1. Further review revealed the resident stated CNA #1 was rude, called him a jerk, and said she hated him. Continued review revealed the DON asked both the resident and wife if they wanted CNA #1 removed from his care and they both said no and if CNA #1 apologized they would be fine with her caring for him. Medical record review of a Social Services Director's (SSD) progress notes dated 4/19/18 at 10:15 AM revealed .on 4/17/18 (Resident #2) said he had been verbally abused .said that a CNA (Certified Nursing Assistant) her had called him a jerk .(and) said that 'she (CNA #1) hates me' .he also said .(CNA #1) said for him to report her so she would not have to provide care for him .said this happened last week . Review of a facility document revealed the incident was reported to the state agency on 4/19/18 (6 days later). Interview with the DON on 4/25/18 at 9:45 AM, in the conference room, confirmed the facility failed to report the alleged incident timely to the appropriate agencies.",2020-09-01
324,ALEXIAN VILLAGE OF TENNESSEE,445123,671 ALEXIAN WAY,SIGNAL MOUNTAIN,TN,37377,2017-07-19,223,D,1,0,POC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, facility investigation review, time detail review, and interviews, the facility failed to ensure 1 resident (#1) was free from verbal abuse of 4 residents reviewed for abuse of 4 sampled residents. The findings included: Review of the facility's policy titled Reporting Abuse to Community Management last revised 12/2016, revealed .It is the responsibility of our employees, community consultants, Attending Physicians, family members, visitors .to promptly report any incident or suspected incident of neglect or resident abuse including injuries of unknown origin and theft or misappropriation of resident property to community management .Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability .Mental abuse is defined as, but is not limited to humiliation, harassment . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored 10/15 (moderately cognitive impaired) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance for transfer, dressing, eating, and hygiene/bathing, and limited assistance for ambulation. Review of a facility investigation revealed a statement from the Director of Nursing (DON) dated 6/20/17 at approximately 2:00 PM. Further review revealed while the DON was reviewing emails received the previous week (while on vacation), one of the email messages stated VERY URGENT from Certified Nursing Assistant (CNA) #4. Continued review revealed the email was dated 6/17/17 at 12:01 AM. Further review revealed CNA #4 was told by CNA #2 she (CNA #2) overheard Licensed Practical Nurse (LPN) #2 tell Resident #1 to Shut the f*** up. Continued review revealed CNA #2 was in the resident's room talking with the sitter for the resident LPN #2 the room and said .'with the two of yawl in here he's still yelling' then (LPN#2) approached the resident to yell at him saying SHUT THE F*** UP . Further review of a telephone interview conducted with CNA #2 by the Director of Quality (DQ) on 6/20/17 revealed on the evening of 6/16/17 CNA #2 was visiting residents and staff at the facility. Continued review revealed CNA #2 was friends with the sitter and was in the resident's room talking with the sitter when LPN #2 entered the room and stated .there are two of you in this damn room and you can't keep him (Resident #1) quiet .(LPN #2) .went over to (Resident #1) and got in his face and told him to 'shut the f*** up' . Further review of a signed statement from the sitter for Resident #1 revealed the sitter was in the room at the time of the alleged incident and .On (MONTH) 16, (YEAR) a nurse by the name of (LPN #2) came into (Resident #1) room yelling at (CNA #2) and myself about shutting (Resident #1) up. Then she (LPN #2) walked up to (Resident #1) and told him to 'shut the f*** up' before storming out of the room . Continued review revealed the facility investigation began on 6/20/17 (4 days later) and LPN #2 was notified by voicemail of an alleged allegation and was told she was not allowed on the premises until further notice. Interview with LPN #1 on 7/18/17 at 2:00 PM, in the conference room, revealed at times the resident would continually yell and you could hear him outside yelling Help, Help, Help. Further interview revealed LPN #1 would .assess the resident for pain, offer food, and offer a quiet environment .some days nothing seemed to help . Telephone interview with CNA #2 on 7/18/17 at 4:00 PM revealed she was on medical leave and was in the facility to visit because she was bored and the facility was her second home. Continued interview revealed the CNA knew Resident #1's sitter so she went in to chat with her and while she was talking to the sitter LPN #2 came in to give Resident #1 his medications. Further review revealed a .few minutes later the resident was still yelling .the door flew open and (LPN #2) walked in and stated 'there are 2 of you in here I don't understand why you can't keep him quiet' .and then (LPN #2) walked over to the (resident) and was in his face and said 'I need you to shut the f*** up and be quiet' .You are irritating me and getting on my damn nerves . Continued interview revealed CNA #2 and the sitter discussed who they should report this to and CNA #2 decided to report the incident to CNA #4, who stated he would email the DON. Further interview confirmed Resident #1 was verbally abused by LPN #2 and CNA #2 was aware she needed to report the incident immediately to a supervisor or charge nurse but failed to do so. Continued interview revealed LPN #2 remained in the facility for the rest of her shift. Interview with the DON on 7/18/17 at 5:00 PM, in the DON's office, confirmed the resident was verbally abused by LPN #2 and the facility failed to investigate the allegation timely.",2020-09-01
3280,"THE WATERS OF SMYRNA, LLC",445502,202 ENON SPRINGS ROAD EAST,SMYRNA,TN,37167,2018-01-16,689,J,1,0,POU411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, facility investigation review, video review, review of maintenance records, review of alarm company records, observation, and interview the facility failed to ensure each resident received the necessary supervision to prevent elopements from the facility for 2 residents (#6, #23) of 2 discharged residents who eloped from the facility and 7 residents (#16, #26, #27, #28, #29, #30, #31) of 7 residents assessed to be an elopement risk. The facility's failure resulted 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 1/16/18 at 2:10 PM in the conference room. The immediate Jeopardy was effective 8/15/17 and is ongoing. F-689 resulted in Substandard Quality of Care. The findings included: Review of facility policy Elopement, issued 7/1/11, revealed . Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e. an order for [REDACTED].The interdisciplinary notes contain all attempts to elope and efforts and results in locating the resident and who was notified .Ensure all entries are time specific to reflect the responsiveness and timeliness of actions taken by the staff to locate and assess the resident. Document that resident's bracelet alarm/device is in place .When door alarms are in place, they are tested daily by maintenance. The results of the tests are them recorded on designated log. Only the CEO (Chief Executive Officer) may authorize disabling the alarm system and is responsible for the method of monitoring for residents' safety and resetting the alarm . Review of facility policy Missing Resident revised 3/10, revealed .When a door alarm sounds, facility staff will go to the door that is emitting the alarm, and they will go outside the building and search the property for any missing residents. At the same time, other facility staff will immediately do a head count of all residents to check for any missing residents . Medical record review revealed Resident #6 was admitted to the facility on [DATE] for long term care with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had severe cognitive impairment, based on a Brief Interview for Mental Status (BIMS) score of 3/15. Continued review of the MDS revealed the resident had delusions, required supervision with ambulation, and wandered daily. Further review of the MDS revealed the resident's behavior of daily wandering did not place her at significant risk of getting to a potentially dangerous location, and did not significantly intrude on the privacy of others. Medical record review of Nursing Progress Note dated 9/21/17, revealed the resident .is alert with confusion. Ambulates independently. Resident confused as to why she is here. Asks random questions and makes random statements. Resident is pleasantly confused and redirected as needed. Resident ambulates independently .Wanderguard placed to body rt (related to) confusion and wandering . Medical record review of an Elopement Risk Review completed on 9/21/17 found the resident was at risk for elopement and should be care planned. Risk factors included her [DIAGNOSES REDACTED].hangs around facility exits . a physical ability to leave the building, and confusion and/or disorientation or displaying consistently poor judgement. Medical record review of a Care Plan, initiated on 9/22/17, revealed approaches including a wanderguard as ordered by the physician on 9/21/17. Medical record review of Progress Notes for Resident #6 revealed the following: 9/22/17 - She has a wanderguard and does attempt to go home often so far. 9/23/17 - (Late entry) Informed that resident was on another wing and entered another resident's room was standing next to the bed holding scissors. 10/12/17 - Resident's wanderguard was found on bed inside socks. New wanderguard placed to left ankle. Continued review of a Progress Note dated 10/14/17 revealed , .received a call from (another long term care facility)across the street reporting Police Department had a confused pt (patient) there who was found walking down the street. Pt reported her name was (name). I asked to speak with the police officer and told him she was one of our residents. Officer (name) returned resident in ambulatory condition. While testing the wanderguard resident's daughter came in so she was notified of occurrence. Management made aware of occurrence as well . Further review of the Progress Notes revealed, the resident was placed on 15 minute checks and the wanderguard continued to be in place. Review of a copy of the police report revealed that a call was received on 10/14/17 at 10:14:07 AM from a local car dealer located on the same road as the nursing facility. Continued review of the report revealed the .Caller advised of an elderly female who has come inside the business pushing a pink Disney stroller with 2 dolls in it. The female keeps calling the dolls her babies and was asking for the location of an address. The caller advised she seems very disoriented and confused. The caller believes she may have come from one of the nursing homes in the area . The police were dispatched to the car lot where they took possession of the resident. Review of the Police Radio Log and Event Notes Addendum revealed that the police tried 2 other nursing homes to see if the woman resided there, before finally identifying she was a resident of this facility when they brought her back to the building at 10:40 AM. An observation was made on 1/10/18 at 9:00 AM of the distance the resident covered from the back door of the facility to the entrance of the car lot office. Her elopement covered .2 miles in which she crossed a 3-lane road with a speed limit of 35 miles/hour. Further observation revealed additional hazards in the area included a 6-lane road and train track crossing within .3 miles of the facility. Based on the untitled paper provided by the DON as well as the police report, Resident #6 was gone from the facility for 1 hour, between 9:39 AM until 10:40 AM when the police ultimately returned her to the building. Interview with the Director of Nursing (DON) on 1/10/18 at 7:30 AM in the conference room revealed the DON provided documentation which she stated was the facility's complete elopement investigation. Continued interview revealed review of the facility investigation file confirmed on 10/14/17, the facility Received a call from (another nursing home) across the street reporting that Police Department had a confused pt there that was found walking down the street. Pt reported her name was (Resident #6's name). I asked to speak to with the police officer and told him that she was one of our residents and they returned her to the facility .Resident pleasantly confused and unable to elaborate on what happened. Further review of the incident report, no injuries were observed, and upon return to the facility, the resident's wanderguard in place and working order. Continued review of the facility investigation revealed it included multiple factors which the resident displayed, including confusion, being impulsive and resistant to care, impaired memory, decreased safety awareness and agitation/anxiety. Further review of the Elopement Investigation Report provided by the DON confirmed a thorough investigation was not conducted at the time of the elopement. Continued review revealed the facility investigation provided by the DON contained only 3 items that were documented as having been made at the time of the 10/14/17 elopement - the incident report, documentation of 15 minute rounds for 4 days after the elopement, and documentation of checks of other resident's wanderguards. Further review revealed all other information in the investigation file was printed on 1/8/18 between 10:30 PM - 10:50 PM; approximately 10 hours after the complaint survey was initiated and requests for investigation of the elopement were first made. Continued review revealed the additional information printed on 1/8/18 and added to the facility investigation included a copy of the resident's Progress Notes since admission, her physician orders, and Medication Administration Record. Further review revealed there was no evidence the facility had investigated and determined how the resident eloped from the facility and there was no evidence of witness statement from staff, residents, or visitors who were present at the time of the elopement and who might have knowledge of the incident. Continued review revealed there was no evidence the facility reviewed its staffing or investigated why staff were unaware of the resident's elopement until they were notified of the incident by local police. Further review revealed there was no evidence that the facility's investigation included a review of why the wanderguard system had not been effective in preventing the elopement. Continued review revealed although observation during initial tour of the facility on 1/8/18 at 11:00 AM revealed the facility employed a camera system, there was no evidence the video for the day of the elopement had been reviewed and there was no evidence that the facility concluded as to how the elopement occurred, or that corrective actions were implemented to prevent further elopements. Interview with the Maintenance Supervisor at the C Wing Nurses Station on 1/10/18 at 9:31 AM revealed he was aware of the circumstances of Resident #6's elopement. He stated, She went out the door by C Wing. It happened on a weekend. The Maintenance Supervisor stated the resident followed a staff who was pulling a laundry cart out the back door. He added that the staff didn't see her going out behind them. He named the employee, who he said had quit 2-3 days prior to this interview. He stated he thought the resident's wanderguard sounded when she went out the door; however, the laundry employee who was pulling the cart didn't notice it because she was going into the laundry room outside this door and could not hear the alarm in the laundry. He reiterated the laundry employee, just didn't see her get out. The Maintenance Supervisor stated that it appears someone came to the door, but since they didn't see anyone they just turned the alarm off. At 9:40 AM on 1/10/18, the Maintenance Supervisor demonstrated how he tested the wanderguard system, using the C-Wing door through which the resident eloped as an example. He showed when the maglock door was closed and a wanderguard device came within distance, the door would not open, and a chime went off. The Maintenance Supervisor then demonstrated if there was no wanderguard close to the door, a code could be entered into the keypad on the wall next to the door and the maglock door could be opened. Observation during this demonstration revealed if a person with a wanderguard came within the radius of the alarm system while the door was already open, the chiming noise would sound, and could only be turned off via a different alarm pad, which was located on the wall across from the nurse's station. During this interview, the Maintenance Supervisor repeatedly stated the method he demonstrated (testing the door when it was both closed and open) was how he tested the wanderguard system on a daily basis, both before and after this elopement. During this interview on 1/10/18, the Maintenance Supervisor provided documentation of wanderguard/door checks. Review of these records revealed he had documented the wanderguard system at the door through which Resident #6 eloped was functioning correctly on 10/14/17, the day of the elopement. Interview with the Director of Nursing (DON) on 1/10/18 at 12:15 PM in the conference room revealed the facility could not initially figure out how Resident #6 got out of the building on 10/14/17 because she was wearing a wanderguard. Continued interview revealed the DON stated they finally determined the resident had followed a laundry worker out of a door while the employee was pulling a large tub through the door to take it outside to the laundry. Further interview with the DON revealed the employee should have turned around and checked to make sure no one was behind, but she didn't. The DON confirmed the resident had eloped off the property and staff were unaware she was missing until they were contacted by the police. The DON added that she did not think the back-door alarm chimed when the resident went through it, stating, I'm pretty sure something was wrong with the door. Continued interview revealed she stated the wanderguard alarm should have chimed when the resident went through the door which had previously been opened by the laundry employee. Further interview revealed the DON stated they had contacted the alarm company to fix the problem and when they came out on 10/18/17, they found, It didn't ding. Continued interview revealed the DON stated she was not sure, but she thought staff had previously disengaged the alarm so it would not constantly chime as ambulance staff routinely used this door. Further interview revealed the DON stated prior to the elopement, the facility had not identified the wanderguard alarm was not chiming if the door had already been opened via use of the key pad. Continued interview revealed she stated, That's not a standard we would check during routine checks. and added, I'm sure the (Maintenance Director) changed how he was checking to make sure it was dinging since Resident #6's elopement. Further interview with the DON on 1/10/18 confirmed no witness statements had been completed as a part of this investigation. Continued interview revealed she stated the previous administrator looked at the camera system, because we could not figure out how she got out with the wanderguard on. Further interview revealed the DON related the previous Administrator had been the person responsible for the investigation regarding possible malfunctions of the equipment; however, she had no evidence as to anything he had done as part of his investigation. When asked for any additional investigative information, she stated, This is all I have. The DON added the previous administrator might have had more information, but we can't find anything else. Based on the DON's statement, an additional interview was conducted with the Maintenance Supervisor on 1/10/18 at 12:50 PM in the 300 Hall. He reiterated he had always checked the chiming of the wanderguard while the door was open/disengaged via use of the key pad. He reviewed the 10/17 daily documentation of door checks and confirmed that on 10/14/17 (the day of Resident #6's elopement) he had checked the wanderguard system and it was functioning properly. He confirmed the DON's statement that the alarm company had been at the facility on 10/18/17; however, he continued, it was not because of any problems with the wanderguard system on the back door from which Resident #6 eloped. Instead, he stated, the alarm company was there on 10/18/17 because the front door wanderguard system was not working. He stated it was absolutely a nurse who had turned off the wanderguard chime, because they did not see anyone in the area after Resident #6 exited through the open door where the laundry employee was bringing out her cart. An interview was conducted with the Interim Administrator on 1/10/18 at 4:02 PM in his office. He stated that the facility did not have a copy of the video recording from 10/14/17, and one could no longer be located due to retention time of the tapes. He stated the elopement should have been thoroughly investigated, as well as reported to the State Survey Agency (SSA). The Administrator related that a complete investigation should have included witness statements, a review and documentation of the security video tape, and a copy of the police report. In addition, he related there should have been analysis of all the facts learned in the investigation, with a determination as to the root cause of the elopement to prevent further incidents. Further interview with the Interim Administrator revealed because he was not working at the facility at the time of the incident, he did not know why this had not occurred. An additional interview was conducted on 1/10/18 at 4:45 PM with the Maintenance Supervisor in his office. He stated, I was wrong, and retracted his initial statement that there had been nothing wrong with the back door. He stated the alarm company had worked on both the front and back doors on 10/18/17, and there had been a problem with the alarm on the back-door sounding. He was asked to explain his previous statement (that the 10/18/17 visit was for the front door, only) and he stated he had called the alarm company since his previous statement, and they told him they had also worked on the back door on that visit. Further interview with the Maintenance Supervisor revealed, I just don't know whether or not the wanderguard alarm had sounded at the time that Resident #6 eloped on 10/14/17. During an additional interview on 1/10/18 at 5:08 PM at the Nurse's Station by the C-Wing Nurse's Station, in the presence of the DON, the Maintenance Supervisor provided more information which conflicted with his previous statements. The Maintenance Supervisor related he had spoken to the DON and now I believe the alarm wasn't working right. During this interview, he now stated the wanderguard alarm did not chime when the resident went through the door. The Maintenance Director could provide no explanation as to why he initially stated the wanderguard system had chimed when the resident exited the building and a nurse turned if off without looking to see if a resident was missing. An additional interview was conducted with the Maintenance Supervisor in the conference room on 1/10/18 at 5:10 PM. During this interview, the Maintenance Supervisor also contradicted information he had previously provided about the daily testing of the wanderguard system. The Maintenance Supervisor now acknowledged he did not check to see if the wanderguard alarm chimed when the door was already opened. He stated the only step in his daily check of the system consisted of using a wanderguard device which was kept in his clipboard to see if the wanderguard system locked and sounded at each closed exit door in the facility. He stated, As soon as I walk up and it chimes, locks, I move on. He confirmed even after Resident #6's elopement, he did not change the system check to assure that the wanderguard system chimed when the door had already been opened by someone using the code pad. The Maintenance Supervisor related, I didn't see the need to do a check of the chime when the door was open because, It was fixed. Further interview revealed he had not added these checks to his daily monitoring of the equipment, because, It would take 2 people to actually check to see if the chime goes off after the door is opened. Interview with Laundry Employee (LE) #1 by telephone on 1/10/18 at 8:22 PM revealed she stated she was aware Resident #6 was an elopement risk, and had got out a couple of times, including on 10/14/17, when the resident eloped, crossed the road in front of the facility and was found at a local car lot. Continued interview revealed she stated, They said I let her out, but I didn't let her out. She did not follow me out. Further interview revealed LE #1 stated as she was taking her laundry cart out of the door, I heard her say, Hold on, I'm coming and she stated because she knew Resident #6 was an elopement risk, she made sure the resident did not follow her out the open door. Continued interview revealed LE #1 stated, I looked - there was no one behind me when I closed the door. I made sure the door was shut completely and locked before I put the big long cart in the laundry room. Further interview revealed she noted When I heard her saying there was a man behind her. I think he was the one who let her out. Further interview revealed LE #1 stated she did not know the man, who was a family member/visitor. Continued interview revealed she added she never heard an alarm sound when the resident exited the building as she had immediately entered the laundry room and closed the door. Further interview revealed LE #1 stated the previous Administrator told her the facility came to the conclusion she let her out. Continued interview revealed she was certain this is not what happened and LE #1 stated she was aware the facility had a camera system and repeatedly asked to see the tape made at the time of elopement, but they would not let me. Further interview revealed she stated she was never asked to write a witness statement at the time of the elopement and added, I would have been glad to. I would have told them the same thing I'm telling you. Observation with the Interim Administrator and DON on 1/11/18 at 7:38 AM in the Administrator's office revealed that the facility's camera system was not positioned to show the inside of the door from which Resident #6 eloped. Observation of the camera screens and interview with the both the Administrator and DON revealed the doorway from which the resident eloped was around a corner and out of visual range of the camera. In addition, the key pad used to open this door also could not be visualized on the camera. The DON pointed out another camera was placed outside the facility and covered the area after the resident came out the door; however, she confirmed, the outside video did not cover the inside area of the facility to show the activity prior to the elopement. Further interview with the DON on 1/11/18 at 7:38 AM in the Administrator's office revealed she couldn't swear she saw the video of the 10/14/17 elopement but thought she probably did because she would have been the staff to operate the video playback for the previous administrator. Continued interview revealed she stated, If there had been someone else, we would have noted it. Further interview revealed during this interview, the DON stated the Maintenance Supervisor was confused - He should have stated he wasn't sure, rather than stating that a nurse turned off the alarm. Continued interview revealed she stated, It took us a couple of days to figure out what happened - he and I went to all the doors and finally figured out the wanderguard alarm didn't chime when the code had been entered and the door was already open. That's why we called (alarm repair company name). Further interview revealed she stated the facility had invoices to show the alarm company came to repair the alarm at the back door through which Resident #6 eloped, and during this visit, the repair company had also worked on the front door to widen the sensor field for the wanderguard. Review of an alarm company invoice dated 10/18/17 (4 days after the elopement) revealed that Upon arrival, troubleshot issues with Wonderguard (Wanderguard) system. Repaired and tested for proper operation. Interview with the alarm repair technician by telephone on 1/11/18 at 8:10 AM revealed the 10/18/17 repair call was not related to the back door through which the resident eloped. Continued interview revealed he stated he was called in on 10/18/17 because the front door of the facility wasn't locking like it was supposed to. Further interview revealed he stated after repairing the front door, he reconfigured all doors in the facility so when someone with a wanderguard approached the door, it overrode the code buttons for the maglocks on the door. Continued interview revealed he was not told there were any problems with the back-door alarm not chiming, and stated, The only reason I worked on any doors beside the front one was to standardize all of them to the same code. Interview with the DON on 1/11/18 at 1:50 PM in the conference room, revealed in response to the survey team's investigation, the facility had continued to search for evidence regarding Resident #6's elopement on 10/14/17. She stated they had found a piece of paper in the Administrator's office about the elopement. She said this unsigned piece of paper indicated the previous administrator had reviewed the tape showing the resident's elopement. Review of this piece of paper revealed it stated: 10/14. 9:39:39 (Name of Laundry Employee #1) 9:40:01 (Name of Resident #6.) 9:40:38 AM Man. Interview with the DON revealed when informed that this information corresponded to Laundry Employee #1's statement she had seen a man behind Resident #6, and thought he could have let her out, the DON then asked, Have you considered (Laundry Employee Name) might not be telling the truth? However, the DON then confirmed, she had no contemporaneous witness statements from the employee, as well as anyone else, to validate that the facility had determined the actual facts surrounding the resident's elopement. She confirmed the camera system did not record sound, and the unsigned piece of paper which she had provided did not address whether the wanderguard system's alarm had sounded at the time of the resident's elopement. Review of Resident #6's Comprehensive Care Plan for elopement risk, initiated 9/22/17, revealed in addition to the 10/14/17 elopement, the resident also exited building 10/18/17 - returned to building safely by staff no injuries. However, review of the portions of the clinical record which the facility could locate revealed no evidence of this incident. The following Progress Notes were documented for 10/18/17: 3:12 AM - Resident up without assistance. Encouraged to rest in bed. Wanderguard in place. 2:28 PM, - Medication administration notes. 8:56 PM - Resident sitting up feeding self dinner .wander guard in place and working. 9:47 PM - Medication administration notes. None of the Progress Notes for 10/18/17 indicated that the resident exited the building and required staff intervention to return her to the facility. Interview with the DON on 1/9/18 at 4:15 PM in the conference room confirmed the resident had been able to get out of the facility at least one other time. Continued interview revealed she stated in the incident, two little girls who were the children of staff, had let her out of a door and the DON stated this was not considered an elopement as the resident was always in staff view and was returned inside the facility without issue. Further interview revealed the DON could not recall the names of the children who had allowed the resident to leave the facility, or verify the staff who had allegedly had the resident in view and the DON could also not verify the date of this incident and it could not be determined if it was the same incident referenced on the care plan (10/18/17), or was, in fact, a separate incident. Continued interview revealed the DON stated she would provide any documentation on the incident that she could find. However, as of 2:45 PM on 1/11/18, no further information about this undocumented incident had been provided, and the facility failed to provide evidence it had been investigated. Interview on 1/10/18 at 4:20 PM with the Business Manager revealed and she related that she was the only staff who sat in the front office who would have been able to see if the resident was out in the front of the facility; however, she was unaware of any such incidents and stated, No, I never saw her. Further review of Resident #6's Comprehensive Care Plan revealed from 9/22/17, staff were to check the placement of the wanderguard. Review of a 9/22/17 physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of the Treatment Administration Record (TAR) for (MONTH) (YEAR) revealed no evidence of monitoring of the wanderguard placement and function on 5/18 required observations. There was no evidence of monitoring of the wanderguard placement and function on 21 of 62 required observations in (MONTH) (YEAR). There was no evidence of monitoring of the wanderguard placement and function on 8 of 25 required observations in November, prior to her discharge on 11/13/17. Interview with the Assistant Director of Nursing (ADON) on 1/11/18 at 1:50 PM in the conference room revealed she believed staff had checked for the wanderguard's placement and function but had just not documented their findings. However, she could provide no other evidence to verify the wanderguard had been checked in accordance with the physician's orders [REDACTED].>Review of maintenance records revealed the wanderguard system/alarm/doors were not consistently tested on a daily basis. There was no evidence the wanderguard system/doors were checked on 7 of 30 days in (MONTH) (YEAR), 6 of 31 days in (MONTH) (YEAR), 8 of 30 days in (MONTH) (YEAR), or 9 of 31 days in (MONTH) (YEAR). The facility provided the record for (MONTH) (YEAR) on 1/15/18 which showed there was no evidence the system had been checked on 3 of 15 days that month. Interview with the Maintenance Supervisor on 1/15/18 at 10:33 AM at the 100 Hall Door confirmed the system was to be checked on a daily basis. He stated he was the only maintenance person and was not sure who checked the doors and alarm system on days which he did not work. An interview was conducted with the Interim Administrator on 1/15/18 at 12:15 PM at the 100 Hall Nurses Station. During this interview, the Administrator was asked who was designated to check the wanderguard alarm system/doors on the days when the Maintenance Supervisor was not present. The Administrator responded he had not assigned anyone to check the doors on these day, and stated, That's a fallacy - they don't need to be checked every day. The Interim Administrator indicated he was unaware of the facility policy that called for daily checks of the system. Additional interview with the Interim Administrator on 1/15/18 at 12:20 PM in the central hall revealed he had just reviewed the policy and confirmed it stated the checks would be completed daily by maintenance. Interviews revealed even after being made aware by the survey team of concerns about how the wanderguard/alarm system/doors were checked, the facility failed to assure that all components of the system were operating correctly when they performed maintenance checks. Interview with the Administrator on 1/15/18 at 12:35 PM in the front hall revealed when the Maintenance Supervisor was not working on the weekend, the Weekend Manager was responsible for checking the wanderguard system. Interview on 1/15/18 at 12:38 PM with the Dietary Supervisor in the front hall confirmed she had been the Weekend Manager who did the checks the previous weekend. She explained her system and how she performed the checks each day when she was responsible. Continued interview revealed she was not checking the alarm system to see if the wanderguard chimed when the door was already open and a wanderguard came within the vicinity. Further interview revealed she stated she only checked to see if the wanderguard locked the closed door and chimed, and was unaware of the second step to verify that the chime also worked if the door was already open. Continued interview revealed she confirmed she was not doing this step in her system checks, stating, I have never done that. Additional interview with the Interim Administrator on 1/15/18 at 12:40 PM in his office, revealed although one of the theories offered related to Resident #6's elopement was the wanderguard alarm had not chimed when the resident went out the open back door which the laundry staff ha",2020-09-01
2717,CELINA HEALTH AND REHABILITATION CENTER,445445,120 PITCOCK LANE,CELINA,TN,38551,2017-09-20,223,D,1,1,KMM011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, facility investigation, and interview, the facility failed to ensure freedom from abuse/exploitation for 1 resident (#37) of 25 residents reviewed. The findings included: Review of facility policy, Electronic Devices, revealed .Electronic Devices not specifically used in the scope of your job are strictly prohibited inside the Facility .The use of personal electronic devices (including cellphones with cameras) while at work is strictly prohibited as they cause distractions, productivity problems, privacy issues and safety concerns and follows: Dignity/Privacy concerns if an employee is .taking unauthorized pictures without appropriate written consent and only for Facility use violates dignity and privacy rights .Videotaping, recording and picture taking of Residents, Family members or associates must have written consent to do so and must be for Facility use only . Resident #37 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #37 had a Brief Interview for Mental Status of 13, indicating she was cognitively intact. Review of the medical record revealed no signed consent for photography for Resident #37. Review of the facility investigation and a statement dated 8/12/17 from Certified Nursing Assistant (CNA #1) revealed she witnessed CNA #9 taking a picture with Resident #37. Further review of a statement dated 8/12/17 from Resident #37 revealed .Employee laid on her bed and took a picture of them. She didn't give permission but didn't think anything about the incident . Further review revealed Resident #37 was unable to recall the day or the name of the employee. Continued review of a statement dated 8/13/17 from Resident #37 revealed .'the little girl that wears the boots all the time' climbed into her bed and took a picture of them together. The resident claimed that they gave audible warning to the CNA not to take her picture . Continued review of the facility investigation of a statement dated 8/12/17 from the roommate of Resident #37, revealed .she laid on the bed with (name Resident #37) and took the picture . The roommate named CNA #9 as a person involved. Further review of a statement dated 8/13/17 from the roommate of Resident #37 revealed .a CNA climbed in the bed, laid down next to resident (room number), and held a phone out in front of them, appearing to take a picture . Interview with Resident #37 on 9/18/17 at 3:20 PM in her room revealed an aide did take a picture of her (Resident #37) and the aide. This occurred last month but she was unsure of the exact date or the aide's name. The resident stated the aide laid in the bed with her and took the picture with a cell phone. Resident #37 stated she did not give verbal permission for the picture but did not think the aide would share picture or post for public viewing. Resident #37 stated this incident occurred after dinner because she was in bed with her gown on. Interview with Resident #37's roommate on 9/18/17 at 3:45 PM in her room revealed the roommate witnessed an aide take a picture with Resident #37. The roommate was unsure of the date this occurred but stated it was last month. The roommate was also unsure of the name of the aide who took the picture. Continued interview revealed the picture was taken with a cell phone and the aide laid in the bed with Resident #37 to take the picture. Further interview revealed the resident did not give permission for the aide to take the picture. Interview with CNA #1 on 9/19/17 at 9:00 AM in the Administrator's office revealed last month she observed CNA #9 laid in the bed with Resident #37 and took a picture of Resident #37 and CNA #9 with a cell phone. CNA #1 stated CNA #9 told Resident #37 .we're going to take a picture . Further interview revealed CNA #1 did not feel Resident #37 understood what CNA #9 was doing. CNA #1 stated CNA #2 said she was going to put the picture on Snapchat (social media application). CNA #1 stated Resident #37's roommate was in the room when the picture was taken and Resident #37 was in bed with her gown on and was under the covers when the picture was taken. Interview with CNA #4 on 9/20/17 at 9:50 AM at the nurses station confirmed he had completed an interview with Resident #37 on 8/13/17. Further interview revealed CNA #4 was able to identify the CNA the resident was referring to as CNA #9 because she did wear cowboy boots daily. The facility failed to ensure Resident #37 was free from abuse/exploitation of being photographed without written permission for facility use only.",2020-09-01
793,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2018-03-21,622,J,1,0,9RON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, facility record review and interview, the facility failed to ensure resident wasn't discharged during the appeal process, for an involuntary discharge of 1 resident (#123), of 3 residents reviewed for discharge. The facility's failure to ensure a safe and orderly discharge resulted in Resident #123 being discharged to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The findings included: Review of facility policy Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman .10. At the time of notification, the facility will provide each resident .with the following information: a. The plan for the transfer and adequate relocation of the resident .c. Assurances the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, services and location . Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the facility admission followed an acute care hospital stay due to a Traumatic Subdural Hemorrhage requiring surgery. Further review revealed 2 additional [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, out of a possible 15, indicating the resident was cognitively intact. Review of an Interdisciplinary Progress Note dated 12/21/17 at 9:20 AM revealed .Staff brought to administrator team concern that resident may have been smoking in one of the common areas of the facility this morning. Administrator and this writer met with resident in his room to discuss .Resident denies smoking in common area. Initially he refused to allow administrator to search his room but then consented (and) also submitted a blue lighter that he had on his person .Smoking policy/agreement reviewed with resident (and) he was informed that smoking privileges are now suspended. Resident acknowledged this. Also informed resident that he would be issuing him a 30 day discharge . Continued medical record review revealed no evidence the resident had received education and training on the smoking policy and the consequences of noncompliance, prior to this incident. Review of the facility's, Notice of Involuntary Discharge, revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the Notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Review of a Nurse's Note dated 1/20/18 revealed, .Voices needs without diff (difficulty). Forgetful @ (at) times . independent c (with) transfers and ADLs (activities of daily living). Propels self about facility in w/c (wheel chair). Continent of B&B (bowel and bladder), toilets self. Feeds self .sets up own tray . Review of a Nurse's Note dated 1/21/18 revealed, .Q (every) 15 minute checks/Smoking in bathroom! Continued review revealed the record of the every 15 minute checks began at 7:30 AM on 1/21/18 and continued until 6:15 PM on 1/30/18. Review of the Nurse Practitioner's (NP) #1 Progress Note dated 2/9/18 revealed, .I am seeing pt (patient/Resident #123) today to discharge. Pt was caught again smoking in a restricted area. Pt is hostile at assessment. Refuses to give name of PCP (primary care physician) or pharmacy. Has letter of court date continuation and believes he can stay here by law. He allows me to assess him, but tells me 'you cannot discharge me!!' Has general body pain, but denies C/P (chest pain), N&V (nausea and vomiting), chills or fever. SS (social services) to arrange for hotel .meds (medications) will be faxed to a local pharmacy .transfer care to Dr. (formal name) . Interview with the Interim Administrator and the Social Services Director (SSD) on 3/7/18 at 10:50 AM, in the Social Services office, confirmed Resident #123 filed an appeal on 1/3/18 related to the Involuntary Discharge notice dated 12/21/17. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Commissioner's Designee for the Tennessee Department of Finance and Administration, and the presiding Administrative Law Judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Interview continued and the Interim Administrator stated Resident #123, .broke his contract with me (on 2/9/18) .he smoked unsupervised in the designated outside smoking area .he refused to give me his igniter (clarified lighter or matches) . Interview continued and the Interim Administrator stated the facility had a right to emergently discharge the resident, .he would not give me his igniter .he endangered the safety of the other residents . Continued interview revealed the Interim Administrator clarified the contract with Resident #123 was a verbal agreement between the Interim Administrator and the resident, not a written agreement. Resident #123 was discharged on [DATE] to a hotel via the facility's van. Continued interview with the SSD on 3/7/18 at 10:50 AM, in the Social Services office, revealed the SSD notified the resident's sister by phone on 2/9/18, at 4:00 PM after the resident's discharge and gave her his hotel room number. Further interview revealed the sister was not the resident's responsible party and the Interim Administrator stated .he was responsible for himself .we paid for 3 nights .our van took him to the hotel .the hotel provided a phone and complimentary breakfast meal. Further interview confirmed the SSD did not know if Resident #123 had any money, and no other arrangements had been made for Resident #123 to receive meals. Continued interview with the SSD on 3/7/18 at 10:50 AM, in the Social Services office, confirmed the resident's prescribed medications were called to a local pharmacy for delivery to the resident at the hotel. Continued interview confirmed the medications had not been delivered to the resident. Further interview confirmed the SSD and Licensed Practical Nurse (LPN) #4 had taken some of the prescribed medications that remained at the nursing home to the resident's hotel room on 2/13/18. Continued interview confirmed the resident had been visited at the Long Term Care Facility and assessed by the TennCare Choices (part of the state Medicaid program) Transition Coordinator and a representative from a local group living home. Further interview confirmed the Choices Transition Coordinator had not been informed of the resident's impending discharge on 2/9/18. Interview with the Interim Administrator on 3/19/18 at 3:30 PM, in room [ROOM NUMBER], revealed the Interim Administrator began working at the facility on 1/29/18. Interview continued and in response to why the documented every 15 minute checks on Resident #123 began on 1/21/18, had ended on 1/30/18, the Interim Administrator responded, First I have heard of every 15 minute checks . Interview with the Interim Administrator on 3/20/18 at 11:40 AM, in room [ROOM NUMBER], revealed .He was discharged because he had continued to violate the smoking policy. I don't know if I would have discharged him but he refused to give me the matches or lighter and he refused to give them to either of us (reference to the SSD) .were not aware of a plan for him to visit (group homes) the following Thursday (2/15/18). Continued interview revealed the facility's interdisciplinary team, the supervising Administrator for the Interim Administrator, the resident's Medicaid insurance case manager, and the Medical Director had not been consulted prior to the decision to discharge Resident #123 to a hotel room on 2/9/18. Interview continued and the Interim Administrator responded to the question of why the Commissioner's Designee was not informed of the impending discharge, I am not required to contact them . Refer to F623, F624",2020-09-01
796,BROOKHAVEN HEALTH AND REHABILITATION,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2018-03-21,745,J,1,0,9RON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, facility record review, and interview, the facility failed to ensure the Social Services Director fulfilled their duties and responsibilities when a resident was discharged , during the appeal process for an involuntary discharge of 1 resident (#123), of 3 residents reviewed for discharge. The facility's failure to ensure a safe and orderly discharge resulted in the discharge of Resident #123 to an unsafe environment and placed Resident #123 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/9/18 and is ongoing. The facility was cited F 745 at a scope and severity of J, which constitutes Substandard Quality of Care (SQC). The findings included: Review of facility policy Transfer or Discharge Notice, not dated, revealed, .1. A resident .will be given a thirty (30) day written notice of an impending transfer or discharge .3. The resident will be notified in writing .c. The location to which the resident is being transferred or discharged .10. At the time of notification, the facility will provide each resident .with the following information: a. The plan for the transfer and adequate relocation of the resident .c. Assurances the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, services and location . Medical record review revealed Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the facility admission followed an acute care hospital stay due to a Traumatic Subdural Hemorrhage requiring surgery. Further review revealed 2 additional [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, out of a possible 15, indicating the resident was cognitively intact. Review of an Interdisciplinary Progress Note dated 12/21/17 at 9:20 AM revealed .Staff brought to administrator team concern that resident may have been smoking in one of the common areas of the facility this morning. Administrator and this writer met with resident in his room to discuss .Resident denies smoking in common area. Initially he refused to allow administrator to search his room but then consented (and) also submitted a blue lighter that he had on his person .Smoking policy/agreement reviewed with resident (and) he was informed that smoking privileges are now suspended. Resident acknowledged this. Also informed resident that he would be issuing him a 30 day discharge . Continued medical record review revealed no evidence the resident had received education and training on the smoking policy and the consequences of noncompliance, prior to this incident. Review of the facility's Notice of Involuntary Discharge revealed the notice was hand delivered to Resident #123 on 12/21/17. Review of the Notice revealed, .you have recently had multiple violations of the Resident Smoking Rules . Review of a Social Progress Note by the SSD dated 12/29/17 revealed, Received phone call from Choices (State Medicaid program) case manager asking why (Resident #123) had been issued 30 day notice. I told her it was rule violation (smoking). She stated she was getting ready to call (Resident #123's) sister .Spoke with her again later and was advised (sister) is going to start hunting place . Review of a Social Progress Note by the SSD dated 2/2/18 revealed, This writer contacted (Choices Transition Coordinator) for update. He said he would set up transportation for resident to look at house and meet roommates next week. Interview with the Interim Administrator and the SSD (Social Services Director) on 3/7/18 at 10:50 AM, in the Social Services office, revealed Resident #123 filed an appeal on 1/3/18 for the Involuntary Discharge issued 12/21/17. Continued interview revealed on 2/2/18, a conference call was conducted with Resident #123, his sister, the Interim Administrator, the SSD, the Commissioner's Designee for the Tennessee Department of Finance and Administration, and the presiding Administrative Law Judge (ALJ). Further interview confirmed the ALJ issued a continuation of the appeal and set the next court date for 2/21/18 to allow time for Resident #123 to obtain an attorney. Continued interview revealed the SSD notified the resident's sister by phone on 2/9/18, at 4:00 PM of the resident's discharge and gave her his hotel room number. Further interview revealed the sister was not the resident's responsible party. Continued interview revealed the facility paid for 3 nights in a hotel (Friday, Saturday, and Sunday from 2/9/18-2/11/18). Further interview revealed .the hotel provided a phone and complimentary breakfast meal. Continued interview confirmed the SSD did not know if Resident #123 had any money, and no other arrangements had been made for Resident #123 to receive meals. Further interview confirmed the resident's prescribed medications were called to a local pharmacy for delivery to the resident at the hotel. Continued interview confirmed the medications had not been delivered to the resident and the SSD had not known this prior to the Ombudsman's visit on 2/12/18. Further interview confirmed the Choices Transition Coordinator (State Medicaid Care Coordinator) had not been contacted on 2/9/18 with information of the resident's impending discharge. Continued interview revealed the facility had not made a plan to check on the resident's wellbeing and did not visit the resident until 2/13/18, when the SSD and LPN #4 delivered some medications to the resident. Interview with the SSD on 3/19/18 at 3:30 PM, in room [ROOM NUMBER], revealed she had been in her position at the facility for [AGE] years. Continued interview confirmed she had not made contacts with other facilities in an effort to seek placement for Resident #123 after the 30 day notice was issued and revealed, .it was up to Choices . Interview continued and the question of why Choices was not contacted on 2/9/18, was asked and revealed, .something that didn't even come to mind. Refer to F622, F624",2020-09-01
3388,NASHVILLE CENTER FOR REHABILITATION AND HEALING LL,445512,832 WEDGEWOOD AVENUE,NASHVILLE,TN,37203,2017-09-27,279,G,1,0,9IDG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, interview, and observation, the facility failed to ensure Care Plans were initiated and interventions implemented to address alterations in skin integrity and/or incontinence care for 4 residents ( #11, #13, #23, #24) of 22 sampled residents. The facility's failure contributed to the development of Resident #24's Stage III pressure ulcer and Resident #24 was deprived care and threatened with the deprivation of care by a staff member, when she was left in her own incontinence for 9.5 hours after being told she would only receive incontinence care once on the night shift resulting in HARM for Resident #24. The findings included: Review of facility policy, Bowel and Bladder Management, undated revealed .The facility would evaluate bowel and bladder status upon admission, readmission, significant change and quarterly .If the resident was incontinent, a baseline elimination status would be completed to assess the bowel and bladder patterns .The interdisciplinary team (IDT) would review bowel and bladder data to determine if retraining would be an option or a pattern had been identified .If retraining was indicated, the care plan would be updated to reflect the interventions .If a pattern was identified, the IDT would implement a voiding plan and the care plan updated. Medical record review revealed Resident #24 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 4/19/17 revealed Resident #24 required assistance with activities of daily living (ADL), had a suprapubic catheter due to [MEDICAL CONDITION] bladder, [MEDICAL CONDITION], overactive bladder, and bowel incontinence. Continued review revealed the resident was at risk for developing skin breakdown related to impaired mobility, occasional suprapubic catheter leakage, and occasional bowel incontinence. The Care Plan did not include actual skin breakdown, there were no specific interventions to address the resident's needs to prevent skin breakdown, and there were no interventions that addressed the leaking catheter. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the Brief Interview of Mental Status (BIMS) score was 15 out of 15 indicating the resident was cognitively intact. Continued reveiw revealed the resident required extensive assistance to total dependence for ADLs except for eating. Continued review revealed the resident was always incontinent of bowel and had an indwelling catheter for the bladder. Further review revealed the resident had no skin integrity concerns. Medical record review revealed there was no Bladder Continence Assessment that resulted in an understanding of the resident's individual urinary continence needs and there was no Care Plan that addressed those needs. Interview with Resident #24 on 9/26/17 at 10:15 AM in her room revealed the Certified Nurse Aides (CNAs) told her they could not get her up due to not enough staff. She stated last night (9/25/17) at 10:00 PM she had been incontinent of stool and her indwelling urinary catheter had a large amount of leakage. Continued interview revealed the resident stated she did not get checked or changed until the dayshift CNA (#5) came in this morning at 7:30 AM when the CNA changed and repositioned her. Resident #24 stated CNA #5 told her she was still dirty on her buttocks. Interview with CNA #5 on 9/26/17 at 10:30 AM in the 500 unit hall revealed Resident #24 was drenched with urine and stool when he went to change her at 7:30 AM today. He stated there was a large amount of stool and urine that was almost the consistency of mud. Continued interview revealed the resident told him that no one had checked or changed her since 10:00 PM last night. CNA #5 stated he changed and repositioned the resident then reported the resident's condition to Registered Nurse (RN) #4. Further interview with CNA #5 confirmed the resident had an indwelling urinary catheter that consistently leaked urine, her buttocks and the back of her thighs were red, and there had been an open area on the back of her upper left thigh for a week. The deprivation of care resulted in HARM for Resident #24. Medical record review revealed Resident #11 was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 4/25/17 revealed the resident was at risk for developing skin breakdown related to frequent incontinence, needed assistance for ADLs, and was frequently incontinent of bladder. There were no specific interventions addressing the incontinence. Medical record review of the Quarterly MDS dated [DATE] revealed the BIMS score was 3 out of 15, indicating the resident was severely cognitively impaired. Further review revealed the resident required limited assistance to extensive assistance with ADLs and required extensive assistance with toilet use and was frequently incontinent of bladder and bowel. Medical record review revealed there was no Bladder Continence Assessment that resulted in an understanding of the resident's individual urinary continence needs and there was no Care Plan that addressed those needs. Medical record review revealed Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 10/31/16 Care Plan revealed the resident had impaired cognitive skills related to forgetfulness and required staff assistance with ADLs. Medical record review revealed there was no Care Plan addressing the resident's needs regarding bladder incontinence. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 out of 15, indicating the resident was cognitively intact, required extensive assistance to total dependence for activities of daily living and was always incontinent of bowel and bladder. Medical record review revealed there was no Bladder Continence Assessment that resulted in an understanding of the resident's individual urinary continence needs and there no Care Plan that addressed those needs. Medical record review revealed Resident #23 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 6/27/17 Care Plan revealed Resident #23 required staff assistance for ADLs had impaired cognitive/communicative skills and was at risk for the development of skin breakdown related to impaired mobility and bladder incontinence. Medical record review of the Quarterly MDS 9/18/17/revealed the BIMS score was 4 out of 15, indicating severe cognitive impairment, the resident required limited assistance with toileting and was occasionally incontinent of bladder. Medical record review revealed there was no Bladder Continence Assessment that resulted in an understanding of the resident's individual urinary continence needs and there was no Care Plan that addressed those needs. Observation on 9/25/17 at 2:50 PM revealed a very strong urine odor was noted in the hall outside Resident #23's door. Certified Nurse Aide (CNA) #1 confirmed the odor at that time, but did not enter the resident's room. Resident #23 allowed the surveyor to enter her room. Interview with Resident #23 revealed she did not have to go to the bathroom. The resident eventually realized she was very wet with urine on her clothes and bedding and verbalized she was upset that it had happened. Interview with Licensed Practical Nurse (LPN) #1 on 9/25/17 at 2:55 PM in the 500 hall revealed the LPN thought Resident #23 went to the bathroom independently and stated she was unaware the resident was incontinent. Interview with the Corporate Care Consultant RN on 9/26/17 at 12:30 PM in the Director of Nursing (DON)'s office confirmed there were no assessments completed that resulted in an understanding of the resident's individual urinary continence needs and there was no Care Plan that addressed those needs. The DON confirmed there were no Care Plans that addressed the specific needs of the residents and there were no actions to be taken regarding incontinence care for Residents #11, #13. #23, or #24. The DON confirmed there was not a Care Plan that addressed the alterations in skin integrity for Resident #24.",2020-09-01
4034,BROOKHAVEN MANOR,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2016-12-07,225,K,1,0,E8N511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, interview, review of the facility's investigations and observation, the facility failed to immediately report allegations of abuse and complete thorough investigations for allegations of abuse for 7 residents (#75, #103, #65, #106, #27, #68, and #12) of 15 residents reviewed for abuse. The facility's failure placed residents ((#75, #103, #65, #106, #27, #68, and #12) in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death). The Immediate Jeopardy was effective 2/6/16 and is ongoing. The facility was cited F 225 at a scope and severity of K, which constitutes Substandard Quality of Care (SQC). The findings included: Review of the facility policy Accidents and Incidents, dated (MONTH) 2001, revealed .An incident is any occurrence, which is not consistent with the routine operation of the institution or the routine care of a particular patient. It may involve an injury .charge nurse shall: Examine all .victims .Notify the .physician and inform of the accident /incident .Regardless of how minor .it must be reported to the department supervisor, and a report form is to be completed on the shift .must be reported to the Director of Nursing and the Director of Risk Management .All details are to be recorded in the nurses' notes, including disposition and follow up care for a period of 72 hours .The Risk Manager will review .investigation as needed . Review of the facility policy Abuse, undated, revealed .The facility will report and investigate all alleged incidents of resident abuse, mistreatment, neglect .and misappropriation of property. The facility will complete a thorough investigation of an alleged incident by the appropriate staff .Procedures .The charge nurse notifies the shift supervisor of the allegation. The supervisor initiates notification to the Social Services Department (SSD) and begins an investigation immediately .Immediately notify the Director of Nursing (DNS) and the Administrator by phone, if necessary. Investigate the alleged incident during the shift on which the allegation of abuse occurred .Interview the resident or other witnesses. The interview is to be dated, documented and signed by the supervisor. Interview the staff implicated. Have the employee document, in writing if able, their knowledge/version of the incident. Ensure the employee's written narrative is signed and dated. Interview any staff witnesses or other available witnesses. Have the witnesses document their knowledge/version of the incident. If the witnesses are unable to write their knowledge/version, have an administrative staff member write it for them. Ensure the witnesses sign and date their written narrative. Interview all staff on the unit to make sure all the information is gathered promptly. When a staff member is implicated in potential resident abuse situation, the employee is to be removed from all patient care areas and sent home after the narrative is obtained from the employee. The employee is instructed to contact the DNS (Director of Nursing Services) or Administrator the next day .Reporting and Documentation Requirements Facility investigation continues as needed over the next 24-48 hours .Place documentation in the resident's Medical record to reflect any direct observable facts .Social Services should document resident's psychosocial status and assessment of feelings, re: (regarding) safety, any counseling efforts. Documentation should continue over the next few days . Medical record review revealed Resident #75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility investigation for Resident #75 revealed on 2/6/16 at approximately 5:00 AM Resident #75 reported to Registered Nurse (RN) #2 Certified Nursing Assistant (CNA) #14 told her she was wet and nasty and he was going to change her, he then grabbed her legs and made her move over. The resident reported the CNA told her I wouldn't have to do this if your filthy lazy ass would get up and go to the bathroom instead of pissing on yourself. The resident began screaming and crying. RN #2 stated she had never heard the resident do that before, she immediately went to the resident's room and as she entered the room CNA #14 was exiting. RN #2 assessed the resident for injury and administered [MEDICATION NAME] to help calm the resident. The CNA was told not to go back in the residents' room and was allowed to finish his shift unsupervised. Further review revealed on 2/8/16 the facility conducted interviews with all the residents that had a BIMS score greater than or equal to 9 (moderately impaired to cognitively intact score 0-15). Resident #65 and #103 reported CNA #14 had made inappropriate comments to them on 2/6/16. The facility substantiated the allegation for verbal abuse and terminated CNA #14. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #75 had a Brief Interview Mental Status (BIMS) score of 15 out of a possible 15 which indicated she was cognitively intact. Review of the Timecard Report for CNA #14 clocked out on 2/6/16 at 6:39 AM. Review of the personnel file revealed CNA #14 was suspended on 2/6/16 through 2/10/16 pending investigation. Investigation substantiates verbal abuse, terminated. Telephone interview with RN #2 on 11/3/16 at 4:45 PM revealed she did not know if CNA #14 had entered Resident #65 and #103's room before or after Resident #75's room. Telephone interview with RN #2 on 11/3/16 at 4:45PM, revealed she did not know if CNA#14 had entered Resident #65 and #103's room before or after Resident #75's room. Telephone interview with CNA #14 on 11/14/16 at 11:45 AM, confirmed he had finished his dry round and wrote a statement before he exited the building. Interview with the Director of Nursing (DON) on 11/7/16 confirmed CNA #14 was terminated for verbal abuse. Continued interview revealed the DON stated .called abuse registry and reported CNA #14 .do not have documentation of report . Interview with Resident #75 on 11/19/16 at 12:30 PM, in the resident's room, revealed .I feel like it was abuse because of what he said and because he said no one would believe me . Review of the facility Reportable Event Form revealed the incident occurred on 2/6/16 at 5:30 AM and was reported to the state agency on 2/10/16 at 6:26 PM (This is 3 days past the deadline of 24 hours). Review a facility investigation dated 2/6/16 revealed Resident #103 had reported to CNA #2 on 2/6/16 she did not want CNA #14 back in her room. The CNA had entered the room to provide incontinence care, grabbed the resident by her left arm and pulled her over. Resident #103 told him not to do that because it hurt. CNA #2 stated . could hurt her if he wanted to because it was his job to change her . Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 Day MDS dated [DATE] revealed Resident #103 scored a 15 out of a possible 15 on the BIMS which indicated she was cognitively intact. Interview with the DON on 11/14/16 at 11:35 AM in her office confirmed an investigation was not completed for Resident # 103 .because she (Resident #103) did not know if what he did was intentional or not . In summary, the facility investigation consisted of interviews with residents that had a BIMS score greater than or equal to 9, statements from CNA #5, RN #2, and Resident #75. The facility failed to: suspend CNA #5 immediately (continued to work at least 1 1/2 hours) , interview all staff working during the shift, complete skin assessments for all residents with a BIMS score of less than 9, and failed to investigate Resident's #65 and #103 allegation of abuse. The facility failed to report an allegation of abuse to the state agency. Review of a facility investigation revealed Resident #65 had reported on 2/7/16 she had told CNA #14 she was soaking wet and requested to be changed. CNA #14 told the resident he was 2 hours behind and he could not get to her and did not return. RN #2 reported this to the DON on 2/8/16. The DON interviewed Resident #65 and the resident repeated the same incident. Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Annual MDS dated [DATE] revealed Resident #65 scored a 14 out of a possible 15 on the BIMS which indicated the resident was cognitively intact. Interview with the DON on 11/14/16 at 11:35 AM in her office revealed the allegation of abuse for Resident #65 was .not investigated because the resident did not know if CNA #14 was joking or not . Interview with Resident #65 on 11/9/16 revealed .can't remember exactly what he said .didn't have time or something like that .it made me feel like I wasn't important . Interview with the Administrator on 11/28/16 at 3:55 PM, in the conference room revealed .this allegation was not investigated separately because it was a part of . (Resident #75's) .investigation. It was the same perpetrator and he was suspended and then terminated . Continued interview with the Administrator confirmed he would expect the facility to have followed the procedures outlined in the facility Abuse policy. Review of a facility investigation revealed on 7/8/16 the facility initiated an investigation for 2 reported allegations of abuse for Resident #106. The first occurred on 6/24/16 when Certified Nursing Assistant (CNA) #8 allegedly grabbed Resident #106 by the arm to roll her over. The second occurred on 7/1/16 when CNA #8 entered the residents' room and began slinging linens and things around and cursed the resident. Both allegations were witnessed by CNA #16 and reported to Licensed Practical Nurse (LPN) #3 on the date of the occurrence. Further review revealed CNA #8 was employed by the facility through a staffing agency and the facility contacted the agency on 7/8/16 by phone and reported the allegations and requested an interview with CNA #8. The facility again contacted the agency on 7/12/16 with no reported response. Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 Day Minimum (MDS) data set [DATE] revealed Resident #106 had a Brief Interview Mental Status score of 3 out of a possible 15 which indicated a severe cognitive impairment. Review of the daily staffing sheets revealed CNA #8 continued working his shift on 6/24/16 and was assigned to Resident #106 on 6/27, 7/1, 7/2, and 7/3 during 4 of 7 shifts. Telephone interview with LPN #3 on 11/7/16 at 5:45 PM confirmed she did not report the allegations to Administration and did not recall anyone asking her about either of the allegations. Continued interview revealed .she (CNA #16) came and talked to me and she said something happened .I think something happened a few days before that too . I told him not to go back in that room .she (Resident #106) had a habit of saying ouch, ouch, when she was moved .so I didn't think anything had happened . Telephone interview with LPN # 3 on 11/7/16 at 6:20PM revealed .CNA #16 said she had talked to the DON about the 1st incident so I just thought they knew about it .it was almost time for the Risk Manager (RM) to come to work when she told me so I told her we would talk to her when she came in . Interview with the RM on 11/9/16 at 12:00 PM in her office revealed she was notified by CNA #15 on 7/8/16 of the allegations of abuse and reported to Administration immediately. Interview with the DON on 11/9/16 at 12:30 PM, in her office, .chose who (residents) to interview because of the physical layout of the facility . Interview with LPN #3 on 11/29/16 at 7:00 AM in the conference room confirmed she did not send CNA #8 home .placed him on a different hallway . Continued interview revealed she had asked Resident #106 what had happened and the resident said nothing . Interview with the Social Services Director on 11/29/16 at 4:00 PM, in the conference room, confirmed she felt it was a complete investigation. Interview with the DON on 11/30/16 at 1:00 PM, in the conference room, revealed .I believe I talked to them, but I don't remember, I think I did and they didn't remember anything . Continued interview revealed no other residents were interviewed to determine if any other residents were harmed. In summary, the facility investigation for Resident #106 consisted of 2 statements that were written by CNA #16, notification of the residents' family and the staffing agency, 2 resident interviews, and the resident was assessed by the physician. The facility failed to: suspend the CNA #8 immediately, notify the Administrator or DON timely (13 days after the 1st allegation), interview all residents with a BIMS score of 9 or greater, conduct skin assessments for those residents with a BIMS score less than 9. Review of a facility investigation dated 8/12/16 at approximately 1:30 PM Resident #27 reported to Certified Nursing Assistant (CNA) #7 she was being threatened by the Business Office Manager (BOM). The BOM asked the resident to sign a promissory note for $50.00 a month toward her past due balance. The BOM raised her hand during the conversation and told the resident .Do not talk while I am talking . The BOM was quoted as having said to the resident she was to sign the promissory note or she would be out of here. CNA #7 and the ABOM immediately reported the incident to the Director of Nursing (DON) and the Social Services Director (SSD). The DON then notified the Administrator by phone and made him aware of the allegation. The BOM was notified by the Administrator per a phone call on evening of 8/12/16 (Friday). The BOM was terminated on 8/18/16 (Thursday) for unprofessional conduct. Interview with the ABOM on 11/2/16 at 2:30PM in the small conference room confirmed she had witnessed the incident with the BOM and Resident #27, the BOM had raised her hand during the conversation while telling the resident to stop talking and had told the resident she was to sign the promissory note or she would be out of here. Continued interview revealed .I would never talk to someone like that .I felt it was hostile .I think the resident was just trying to plead her case . Telephone interview with CNA # 7 on 11/3/16 at 11:15 AM confirmed she had overheard the conversation between the BOM and Resident #27. Continued interview revealed .I really don't remember exactly what was said but I know (BOM name) sounded aggressive .if she didn't pay she had to leave .the other girl (ABOM) kept trying to get (BOM name) out of the room and she finally did .I don't know what would have happened if she didn't . Resident #27 .was really upset when I came out of the bathroom .told her I was going to go tell someone . CNA #7 immediately reported to the DON. Telephone interview with the BOM on 11/3/16 at 12:10 PM revealed .that was the biggest joke of an investigation .did not ask me for my statement .I did hold up my hand trying to get her to stop talking . Telephone interview with Resident #27 on 11/21/16 at 9:30 AM confirmed she had felt threatened by BOM during their conversation on 8/12/16. Continued interview with the resident confirmed no one from the facility had followed up with her after the incident to see how she was feeling. Further interview revealed she was scared of her (BOM) . Interview with the Administrator on 11/28/16 at 4:00 PM, in the conference room confirmed he had written the memorandum dated 8/18/16. Continued interview and review of the memorandum revealed the BOM was separated from employment for .unprofessional conduct stemming from an incident that took place Friday, (MONTH) 12, (YEAR). The incident involved a verbal resident altercation in which the resident indicated she felt threatened with having to leave the facility if she did not immediately sign a promissory note to cover an outstanding debt . Interview with the SSD on 11/28/16 at 4:00 PM, in the conference room, confirmed Resident #27 had reported to her on 8/15/16 she was scared of the BOM. Continued interview confirmed the SSD had not interviewed any other residents in the facility. Further interview revealed .it would be in the file if I did . Review of the State Reportable Incident form revealed date of occurrence as 8/12/16 at 3:00 PM with a report date of 8/18/16 (5 days past the required 24 hours). Interview with the Administrator on 11/28/16 at 4:00 PM, in the conference room, confirmed he wrote the memorandum dated 8/18/16. Review of the memorandum revealed the BOM was separated from employment for .unprofessional conduct stemming from an incident that took place Friday, (MONTH) 12, (YEAR). The incident involved a verbal resident altercation in which the resident indicated she felt threatened with having to leave the facility if she did not immediately sign a promissory note to cover an outstanding debt . In summary, the facility investigation consisted of interview and statements from the BOM, ABOM, CNA #7, and Resident #27. The facility failed to: immediately interview and remove the BOM, interview other residents and family members the BOM may have spoken with, and assess, document and provide psychosocial support for Resident #27 following the incident. Review of a facility investigation revealed dated 9/3/16 Resident #27 reported Certified Nursing Assistant (CNA) #4 told Resident #27 she .did not have to get her up that was a privilege . CNA #4 grabbed the draw sheet and slung the resident around causing the resident to fall backwards onto the bed. The CNA then grabbed the resident by the arms and manhandled her into the wheelchair. The Dietary Manager reported to Licensed Practical Nurse (LPN) #7 on 9/3/16 the resident was upset and crying and had told her the nurse and CNA were being hateful and jerking her around. CNA #4 was allowed to finish her shift and continued to provide care for the resident. Continued review revealed on 9/6/16 the Risk Manager (RM) interviewed Resident #27 and reported the incident to the Director of Nursing (DON) and the Administrator. Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #27 had a BIMS score of 15. Interview with Social Services Director (SSD) on 11/7/16 at 9:30 AM, in the small conference room, confirmed she interviewed those residents with a BIMS score of 9 or greater (indication of moderate impairment to cognitively intact). Continued interview confirmed .they all voiced CNA#4 was a good CNA and has never talked harsh or handled them roughly . Interview with the DON on 11/7/16 at 9:30 AM, in the small conference room, revealed .that was the only hall she was working at that time .didn't have a reason to do skin assessments on residents since the residents that were interviewed were saying positive things about her . Telephone interview with Resident #27 on 11/21/16 at 9:35 AM revealed CNA #4 entered room and stated .I don't have to get you up; it's a privilege to get up .she grabbed the draw sheet jerked it and I fell backwards, then grabbed me by my wrists pulled me up, manhandled me and put me in my wheelchair. I got out of the room as fast as I could . When the resident returned to the hallway .she (CNA) said if want to go back to bed you get down here right now .other people heard it .she slammed the door .she said what was you doing outside talking about me? I told her (name of another resident) heard you (CNA) screaming outside of the door .she grabbed me up and put me back in bed .no one else transferred me like that .would use a lift or two people . Interview with the Certified Dietary Manager (CDM) on 11/28/16 at 11:00 AM, at the 100-200 nurses station confirmed she had reported Resident #27 had stated CNA #4 and the nurse had been hateful an jerked her around. Continued interview revealed .I took her (Resident #27) back to her room then went and reported to her nurse that she might want to go check on her because she (resident) was upset and crying . This allegation was not reported to the state agency and was not reported to Administration until 2 days after the incident. Review of the facility investigation revealed on 10/17/16 the SSD and DON were made aware Resident #68 reported she had her call light on for a while and when no one answered she began yelling. Certified Nursing Assistant (CNA) #15 had entered her room and screamed at her saying .For no reason should you shout .You don't talk to me that way. You can tell everyone here I screamed and no one will tell . There was no documentation to whom or when the resident reported the incident to and the SSD and DON could not recall. CNA #15 was allowed to complete her scheduled shift on 10/16/16. Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] revealed Resident #68 had a Brief Interview Mental Status score of 14 out of a possible 15 indicating she was cognitively intact. Interview with the Social Services Director on 11/28/16 at 4:00 PM in the conference room revealed . there were no investigations initiated and no additional information was available . Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating the resident had severe cognitive impairment. Continued review revealed the resident was totally dependent for bed mobility and transfers with 2 or more person physical assist. Review of a Physician's Progress Note dated 7/13/16, authored by Nurse Practitioner (NP) #2, revealed .nursing report pt (patient) w/ (with) LLE (left lower extremity) bruising, [MEDICAL CONDITION] .LLE w/ large bruised/reddened area, warm to touch .painful (grimacing w/palp (palpation)) . Continued review revealed assessment/plan .venous Doppler R/O (rule out) blood clot . Review of Nurse's Notes revealed no documentation of the bruising by the nurses on 7/13/16. Review of a Physician's Progress Note dated 7/19/16, authored by the Physician, revealed .new bruising and swelling of the left leg .no injuries that have been reported by staff .xray to rule out underlying fracture .Ultrasound negative for [MEDICAL CONDITION] ([MEDICAL CONDITION] . Review of an imaging report dated 7/19/16 revealed .proximal (nearer to center) tibial and fibular (bones of lower leg) mildly displaced fractures . Review of a Resident Incident Report dated 7/20/16 revealed .Resident C/O (complained of) pain when turned, order received for xray .Green bruising noted to shin and calf area . Continued review revealed 4 witness statements by staff stated they had no knowledge of the cause of the fractured leg. Further review of a typed summary of the investigation, unsigned, revealed .noted protrusion in wall and bruise consistent with rolling toward wall and coming in contact with the protrusion .resident unable to recall direct force incident .According to research a side ways bend at ankle or knee could have caused practure (fracture) . Review of the Physician's Progress Note dated 7/20/16 revealed .Tib/fib (tibia/fibula bones of lower leg) fx (fracture) . Interview with the Director of Nursing (DON) on12/1/16 at 8:51 AM, in the conference room, confirmed bruises were to be documented by the assigned nurse upon discovery. Further interview confirmed no investigation had been started until the fracture was discovered on 7/20/16. Interview with the DON on12/2/16 at 9:57AM, in the resident's room, confirmed the resident's left leg was probably bent when the resident was turned on her left side. The resident's left leg probably went between the bed and the mattress and hit the protrusion on the wall. Interview and observation with the Maintenance Director on 12/1/16 at 4:10 PM, in resident's room, confirmed there was a buffer (wood panel to prevent bed from scraping wall) on the bed side of the wall 18 from the floor, below the top of the mattress, and extended the entire length of the left wall. Continued observation and interview revealed the protrusion had a curved, smooth surface on the top edge and protruded outward 9/16 of an inch from wall. Interview with Licensed Practical Nurse (LPN) #12 on 12/2/16 at 12:45 PM, at the 300/400 nurses station, confirmed a CNA (couldn't remember which one) reported bruising and swelling to Resident #12's leg on 7/13/16. Continued interview revealed LPN #12 notified the NP on the same day (7/13/16), but did not document in the nurse's notes or fill out an incident report. Further interview confirmed LPN #12 should have documented the bruising and swelling and initiated an incident report. Continued interview confirmed Resident #12 was unable to roll over in the bed independently. Interview with the resident's Physician on 12/2/16 at 3:55 PM, in the conference room, confirmed Resident #12 was seen by Nurse Practitioner (NP) #2 on 7/13/16 for [MEDICAL CONDITION] and discoloration of the left lower leg. Continued interview revealed the Physician was .surprised when the xray report revealed a fracture because the resident was so cooperative with care . Further interview with the Physician revealed the fracture most likely occurred around 7/13/16 (when the bruising and [MEDICAL CONDITION] was first noticed). In summary, review of the facility investigative documentation for Resident #12 revealed the facility did not initiate an investigation into the injury of unknown origin on the date the injury was discovered, 7/13/16. Further review of the facility's investigative documentation revealed the facility failed to obtain interviews from staff who had worked prior to and on 7/13/16. Further review revealed no skin assessments were completed for resident's unable to be interviewed to identify additional potential injuries.",2019-11-01
367,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2020-02-21,552,D,1,0,D6D711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, interviews, the facility failed to obtain consent for administration of a medication for 1 resident (Resident #1) of 3 residents reviewed for medication administration, resulting in Resident #1 receiving an appetite stimulant without approval from the resident or the resident's representative. The findings included: Review of the facility's policy titled, Change in a Resident's Condition or Status, dated 11/17/2017 showed .Our facility shall promptly notify the resident .and representative of changes in the resident's medical/mental condition and/or status . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum (MDS) data set [DATE] showed the resident scored a 6 (severe cognitive impairment) on the Brief Interview Mental Status. The resident required extensive assist for bed mobility and transfers with 2 person assist and required extensive assist for Activities of Daily Living with 1 person assist. The resident was always incontinent of urine and frequently incontinent of bowel. Review of a Practitioner's Order dated 1/27/2020, not timed, showed .Orders .[MEDICATION NAME] (appetite stimulant) 7.5 mg (milligrams) PO (by mouth) q (every) hs (hour of sleep) x (times) 7 days then (increase) to 15 mg q hs . Review of the medical record showed no documentation consent for the appetite stimulant was received from the resident or the resident's representative. During an interview on 2/21/2020 at 10:00 AM Resident #1 stated the resident's daughter .takes care of everything . During an interview on 2/21/2020 at 11:55 AM, Registered Nurse (RN) #1 stated an order for [REDACTED].#1 for her to get permission from Resident #1's daughter prior to administration of the medication. During an interview on 2/21/2020 at 12:15 PM, the Nursing Supervisor stated the facility should have obtained family consent prior to administration of the appetite stimulant. During a telephone interview on 2/21/2020 at 2:15 PM, LPN #1 stated she had not been notified a signature was needed prior to administration of Resident #1's appetite stimulant. During a telephone interview on 2/21/2020 at 2:30 PM, the Assistant Director of Nursing confirmed there was no documentation to indicate consent was obtained prior to administration of the appetite stimulant to Resident #1.",2020-09-01
623,BETHANY CENTER FOR REHABILITATION AND HEALING LLC,445159,421 OCALA DRIVE,NASHVILLE,TN,37211,2018-07-11,880,D,1,1,C2ER11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, observation and interview, the facility failed to change a soiled dressing Percutaneous Inserted Central Catheter (PICC) (a line that goes into your arm and runs all the way to a large vein near the heart for long term intravenous therapy) as ordered for 1 (#1) of 7 residents reviewed. Findings include: Review of facility policy IV Tubing and Dressing Changes dated 10/1/07 revealed .PICC line dressings will be changed weekly . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician order [REDACTED].change PICC line dressing 24-48 hours after insertion of line if dressing is soiled and then every 7 days . Observation on 7/10/18 at 9:50 AM in Resident #1's room revealed an old soiled transparent dressing, covering the PICC line of the upper left arm with a date of 6/20/18. Observation and interview with the Unit Manager on 7/10/18 at 9:52 AM in Resident #1's room confirmed the transparent dressing was dated 6/20/18 to Resident #1's PICC line. Further interview revealed the Unit Manger stated I see it and nodded her head in agreement that the facility failed to change the soiled dressing weekly as ordered.",2020-09-01
1058,RAINTREE MANOR,445216,415 PACE STREET,MC MINNVILLE,TN,37110,2019-06-04,610,D,1,0,IKUY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, observation and interviews the facility failed to follow their abuse policy for investigation of 2 allegations of abuse for 1 resident (#1), and failed to investigate 2 allegation of abuse for 1 resident (#1) of 4 residents reviewed for abuse. The findings included: Review of the facility abuse policy Abuse Prevention Policy & Procedure, revised 10/1/17, revealed .All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the Administrator and Director of Nursing .The investigation protocol must be implemented .All alleged violations involving mistreatment, abuse or neglect will be thoroughly investigated by the facility under the direction of the Administrator and in accordance with state and federal law . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. Observation of Resident #1 on 6/4/19 at 7:50 AM, in her room, revealed the resident was lying in bed, she was awake and alert. Continued observation revealed no anxious or fearful behaviors were identified. Interview with Resident #1's daughter, on 6/4/19 at 9:25 AM, via telephone, revealed we went to her doctor in Murfreesboro on 4/29/19, during that visit she reported to them she had been raped. She said there were 300 women being raped. She said they were making purple stuff and she thought it was like ecstasy but you could buy it at .(popular chain store.) I didn't think she was reporting anything new. Continued interview revealed she had not reported it to the facility. Interview with the Social Service Director (SSD) on 6/4/19 at 9:45 AM, in the conference room, revealed she went to the doctor on 4/29/19, and during that visit she reported to the doctor she had been raped. The Physician's Social Worker called me, said she had to follow up on the concerns .(Resident #1) had reported to the doctor, while the resident was still at the doctor's office. She had said she had been raped at the facility. I told her she had a care plan of making sexual allegations that had been unsubstantiated regarding male staff. I told her in the past if a male walked by her room she would yell out that they had raped her, I know what you did, you raped me. Continued interview revealed she has been making these allegations for some time and is care planned for sexual inappropriate behavior. I reported this allegation to Director of Nursing (DON), immediately after I got off the phone. I told her she was making sexual allegations at the doctor's office. On 4/5/19 she was calling from her room at the Maintenance Assistant stating he was the one who raped her. As far as I know that was the first time she had mentioned anything about rape in the facility. Interview with the DON on 6/4/19 at 10:40 AM, in the conference room, revealed I remember the SSD telling me the resident was at the doctor's office and had made sexual allegations. In my mind she was reporting the resident was stating the same things she says here, and the SSD didn't say anything about .(Resident #1) reporting she had been raped at the facility. There was no investigation of that allegation, because I didn't take it as she was saying anything new, and she had reported she had been raped in the past. I didn't know at that point she was making the allegation she had been raped in the facility. Today is my first knowledge of the resident stating she had been raped in the facility. Continued interview revealed I don't recall being informed she had yelled at the Maintenance Assistant from her room that he was the one who raped her, so no an investigation was not done. Interview with the Maintenance Assistant on 6/4/19 at 12:43 PM, in the conference room revealed, I was walking down the hall and she yelled at me from her room. I didn't know what she said so I went back to her doorway and asked what she had said. She said it is a good thing you admitted it, and I said what? And she said, admitted to raping me. I didn't say anything; I just walked away, and told . (SSD) and .(Admissions Coordinator) was in the office when I reported it. Continued interview revealed I wasn't' placed on suspension, as far as I know there was not investigation. I didn't report it to the Administrator because I reported it to .(SSD) Continued interview revealed, I don't recall ever being in her room before she made that allegation. I've been in there one time since then to fix the plug on her bed but she was not in there. Interview with the Administrator on 6/4/19, at 3:01 PM, in the conference room, confirmed she was unaware Resident #1 had reported on two occasions an allegation of sexual abuse occurring in the facility. Continued interview confirmed the facility failed to follow their policy for investigating 2 allegations of abuse for 1 Resident (#1) occurring on 4/5/19 and on 4/29/19.",2020-09-01
1602,CUMBERLAND VILLAGE CARE,445276,136 DAVIS LANE,LAFOLLETTE,TN,37766,2019-05-30,609,D,1,0,ZCT011,"**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 follow their abuse policy for reporting an allegation of abuse within federally required time frame for 1 resident (#1) of 3 residents reviewed for abuse. The findings included: Review of the facility policy Abuse Prohibition revised 5/1/19, revealed .Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum (MDS) data set [DATE], revealed a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment. Review of a facility investigation dated 5/14/19, revealed on 5/14/19 Certified Nurses Assistant (CNA) #1 reported an incident that occurred on 5/13/19 at 9:30 PM, involving Resident #1. Continiued review revealed Resident #1 was being changed and became combative and spitting. The resident was asked to stop but didn't. CNA #2 allegedly retrieved a sheet and washcloth and tied up the resident's hands and put a washcloth in her mouth. According to the CNA reporting the incident both CNAs proceeded to change her. Continued review revealed CNA #1 and CNA #2 were placed on administrative leave. Observation/interview with Resident #1 on 5/29/19 at 6:15 PM, in her room, revealed the resident lying in bed she was awake, alert, and interacting with a staff member; no anxious or fearful behaviors were identified. Continued observation revealed no bruising, redness, scratches or marks were observed on the residents' face, lips, arms or wrists. Interview with the Director of Nursing (DON) on 5/29/19 at 5:05 PM, in the conference room, revealed All the staff reported during the investigation that[NAME]bsolutely could not stand Tracie, that she makes comments about she wished would get fired, the staff felt like[NAME]just wanted to get Tracie in trouble. It was a he said she said, but the resident did not respond any different to Tracie, there were no marks on the resident to indicate she was restrained in anyway. Interview with CNA #1 on 5/19/19 at 5:20 PM, in the conference room, revealed the incident occurred on 5/13/19, about 9:30 PM, I know I was supposed to report it, but I didn't because I was so torn up, and scared, I didn't know what .(CNA #2) would do when I reported it. Interview with CNA #6 on 5/29/19 at 6:45 PM, in the North Front Hall Charting Room, revealed I was here the night the incident supposedly happened and .(CNA #1) didn't say a word to me. The next day she told me what happened and I told her to go to the office and report it immediately. Interview with the Administrator on 5/30/19 at 11:40 PM, in the conference room, revealed we received the report on 5/14/19 of an alleged abuse occurring on 5/13/19 at 9:30 PM, and .(CNA #2) was placed on administrative leave .very soon into our investigation within 15 minutes we realized .(CNA #1) had continued to provide care in the situation she reported without changing her course of action and she was placed on administrative leave as well. In our interview with .(CNA #1) we questioned why she had not reported the incident, and she acknowledged she knew she was to report the incident immediately. She stated she was afraid of .(CNA #2) and that was the reason she hadn't reported the incident. She had been right there while the alleged incident occurred and that was not okay. Continued interview confirmed the facility failed to follow their abuse policy and had failed to report an allegation of abuse within the federally required time frame.",2020-09-01
950,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,221,D,1,0,SMVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, observation, and interview, the facility failed to ensure 1 resident (#4) of 11 residents reviewed was free of a physical restraint unless it was needed to treat an assessed medical symptom. Resident #4 was restrained in bed through the use of 4 side rails. The restraint was used without assessment for its need, without less restrictive measures attempted prior to its use, without a medical symptom justifying the use of the restraint, and without a physician's orders [REDACTED]. The findings included: Review of facility policy, Restraint Management, revealed Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff conveniences or for the prevention of falls. Physical restraints include, but are not limited to .side rails. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: Using side rails that keep a resident from voluntarily getting out of bed. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention AND a restraint is required to: a. Treat the medical symptom; b. Protect the resident's safety; and c. Help the resident attain the highest level of his/her physical or psychological well being. Prior to applying a restraint, one must have an order for [REDACTED]. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review of the MDS revealed Resident #4 required extensive assistance from staff with bed mobility, transfers, and locomotion, and had no restraints. Review of the medical record revealed no evidence of Physician Orders, Assessment, or Consent for the use of a restraint. Continued review revealed no evidence of an assessment for the use of side rails. Review of the current care plan, with a goal date of 10/17/17, revealed conflicting information about the use of side rails. Review of the Care Plan revealed Self Care Deficit, with approaches including, 7/4/17 .1/4 (one quarter) length side rails up times 2 when in bed to enable participation with bed mobility. However, review of the Care Plan for Fall Risk revealed an approach dated 7/26/17 Staff to ensure placement and raising of lower bedrail to amputation side of the bed in order to assist with safety during sleep. Note: (Resident #4) will still be able to get OOB (out of bed) to her strong side. Observation on 9/18/17 at 8:35 AM and 1:49 PM revealed Resident #4 was asleep in bed. She had 2 one half side rails raised on each side of the bed. The use of these 4 partial rails resulted in the effect of 2 full side rails which blocked normal egress from the bed. Interview on 9/18/17 at 1:52 PM with Certified Nurse Aide (CNA) #3, in the hallway outside the resident's room, confirmed the resident had 4 side rails up while she was asleep in bed. CNA #3 stated she always used all 4 side rails when Resident #4 was in bed. She stated the resident had a leg amputation earlier this year, and After she came back from the hospital, we was (were) told to use all 4 side rails with her because she's a fall risk. Further interview with CNA #3 revealed the use of the 4 side rails restricted the resident's normal movement of exit/entry from the bed, as she stated, Just last week, I found her sliding out the end of the bed when all 4 side rails were raised. Interview on 9/18/17 at 1:55 PM with Licensed Practical Nurse (LPN) #1, in the hallway outside the resident's room, revealed staff were only supposed to use 2 side rails, because if they used all 4 side rails, It would be a restraint. CNA #3, who was present during this interview, confirmed all 4 side rails would constitute a restraint, saying, That's right. However, CNA #3 added, I was told to use all 4 because she's a fall risk. Interview with the Director of Nursing (DON) on 9/18/17 at 2:10 PM, in the first floor administrative wing confirmed, We have not historically done any assessment for side rails. She stated the facility was in the process of adding this to the admission packet, but confirmed no side rail or restraint assessments had been completed for Resident #4. The DON stated 4 side rails constituted a restraint for Resident #4, based on her physical condition. Further interview with the DON revealed she was unaware staff were using all 4 side rails when the resident was in bed, and the resident had no medical symptom to justify the use of a restraint.",2020-09-01
2502,OVERTON COUNTY HEALTH AND REHAB CENTER,445419,318 BILBREY STREET,LIVINGSTON,TN,38570,2019-06-26,880,D,1,0,DVBU11,"**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 bedpans were store in a sanitary manner for 2 residents (#1, #4) of 9 residents reviewed for sanitary storage of bedpans. The findings include: Review of facility policy Bedpan/Urinal, Offering/Removal revised 2/2018, revealed .Clean the bedpan or urinal. Wipe dry with a clean paper towel. Discard paper towel into designated container. Store the bedpan or urinal per facility policy . Review of facility policy Bedpan/Urinal Storage Revised 2/2018, revealed .Store bedpan in plastic bag under resident's sink . Medical record review revealed Resident #1 was admitted to the facility on 7/3/18 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 6/26/19 at 11:10 AM, in Resident #1's bathroom, revealed the resident's bedpan had dried brown debris on the outside and inside of the bedpan and was stored uncovered on top of the trash can. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 6/26/19 at 11:20 AM, in Resident #4's bathroom, revealed the resident's bed pan had dried dark brown debris on the inside of the bed pan and was stored uncovered on the resident's commode. Interview with Licensed Practical Nurse (LPN) #2 on 6/26/19 at 11:20 AM, on the 300 hall, confirmed Resident #1 and Resident #4's bed pans had not been properly cleaned and were stored improperly. Interview with the Director of Nursing on 6/26/19 at 11:45 AM, on the 200 hall, confirmed the facility failed to proper clean and store the resident's bed pans and the facility failed to follow facility policy.",2020-09-01
3391,NASHVILLE CENTER FOR REHABILITATION AND HEALING LL,445512,832 WEDGEWOOD AVENUE,NASHVILLE,TN,37203,2017-09-27,315,E,1,0,9IDG11,"**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 each resident who was incontinent of urine was identified, assessed and provided appropriate treatment and services to achieve or maintain as much normal urinary function as possible for 4 residents ( #11, #13, #23, #24) of 22 sampled residents. The findings included: Review of The Bowel and Bladder Management policy, undated, revealed guidelines that included: The facility would evaluate bowel and bladder status upon admission, readmission, significant change and quarterly .If the resident was incontinent, a baseline elimination status would be completed to assess the bowel and bladder patterns .The interdisciplinary team (IDT) would review bowel and bladder data to determine if retraining would be an option or a pattern had been identified .If retraining was indicated, the care plan would be updated to reflect the interventions .If a pattern was identified, the IDT would implement a voiding plan and the care plan updated . Medical record review revealed Resident #11 was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 4/25/17 revealed the resident was at risk for developing skin breakdown related to frequent incontinence, needed assistance for activities of daily living, and was frequently incontinent of bladder. There was no specific intervention that addressed the incontinence. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the Brief Interview of Mental Status (BIMS) was 3 out of 15, indicating the resident was severely cognitively impaired, required limited assistance to extensive assistance with activities of daily living (ADLs), required extensive assistance with toilet use, and was frequently incontinent of bladder and bowel. Medical record review revealed there was no Bladder Continence Assessment that resulted in an understanding of the resident's individual urinary continence needs, and there was no Care Plan that addressed those needs. Medical record review revealed Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 10/31/16 revealed the resident had impaired cognitive skills related to forgetfulness and required staff assistance with ADLs. Continued review revealed there was no Care plan that addressed the resident's needs regarding bladder incontinence. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 out of 15, indicating the resident was cognitively intact, required extensive assistance to total dependence for activities of daily living. and was always incontinent of bowel and bladder. Medical record review revealed there was no Bladder Continence Assessment that resulted in an understanding of the resident's individual urinary continence needs, and there was no Care Plan that addressed those needs. Medical record review revealed Resident #23 was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 6/27/17 revealed the resident required staff assistance for ADLs, had impaired cognitive/communicative skills and was at risk for the development of skin breakdown related to impaired mobility and bladder incontinence. Medical record review of the Quarterly MDS dated [DATE] revealed the BIMS score was 4 indicating severe cognitive impairment, required limited assistance with toileting, and was occasionally incontinent of bladder. Medical record review revealed there was no Bladder Continence Assessment that resulted in an understanding of the resident's individual urinary continence needs, and there was no Care Plan that addressed those needs. Observation on 9/25/17 at 2:50 PM revealed a very strong urine odor in the hall outside Resident #23's door. Certified Nurse Aide (CNA) #1 was interviewed and confirmed the odor at that time, but did not enter the resident's room. Resident #23 allowed the surveyor to enter her room. Interview with the Resident (#23) revealed she did not have to go to the bathroom. The resident eventually realized she was very wet with urine on her clothes and bedding and verbalized she was upset that happened. Interview with Licensed Practical Nurse (LPN) #1 on 9/25/17 at 2:55 PM in the 500 hall, revealed Resident #23 went to the bathroom independently. LPN #1 stated she was unaware the resident was incontinent. Medical record review revealed Resident #24 was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 4/19/17 revealed the resident required assistance with ADLs, had a suprapubic catheter due to [MEDICAL CONDITION] Bladder, [MEDICAL CONDITION], overactive bladder and bowel incontinence, and was at risk for developing skin breakdown related to impaired mobility, occasional suprapubic catheter leakage and occasional bowel incontinence. There was no skin breakdown included on the Care Plan and no specific interventions to address the resident's needs to prevent skin breakdown, and there were no interventions that addressed the leaking catheter. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 out of 15 indicating the resident was cognitively intact, required extensive assistance to total dependence for ADLs, except for eating, and was always incontinent of bowel and had a catheter for the bladder. The assessment indicated the resident had no skin integrity concerns. Medical record review revealed there was no Bladder Continence Assessment that resulted in an understanding of the resident's individual urinary continence needs, and there was no Care Plan that addressed those needs. Interview with CNA #3, the Restorative Technician, on 9/25/17 at 9:45 AM revealed there were no residents on a Bowel and Bladder Restorative Program. He confirmed there was no scheduled toileting or bladder training done at the facility and stated he was in charge of the Restorative Program. Interview with Resident #24 on 9/26/17 at 10:15 AM in her room revealed the staffing was low. She stated the Certified Nurse Aides (CNAs) had told her they could not get her up due to not enough staff. She stated last night (9/25/17) at 10:00 PM she had been incontinent of stool and her indwelling urinary catheter had a large amount of leakage. The resident stated she did not get checked or changed until the dayshift CNA #5 came in this morning at 7:30 AM and changed and repositioned her. Resident #24 stated CNA #5 told her she was still dirty on her buttocks. Interview with CNA #5 on 9/26/17 at 10:30 AM in the 500 unit hall revealed Resident #24 was drenched with urine and stool when he went to change her at 7:30 AM today. He stated there was a large amount of stool and urine that was almost the consistency of mud. The resident told him that no one had checked or changed her since 10:00 PM last night. CNA #5 stated he changed and repositioned the resident, then reported the resident's condition to the Registered Nurse (RN) #4. CNA #5 stated the resident had an indwelling urinary catheter that consistently leaked urine, her buttocks and the back of her thighs were red, and there had been an open area on the back of the upper left thigh for a week. The CNA stated the resident did not get up due to the lack of staff. Interview with the Corporate Care Consultant RN on 9/26/17 at 12:30 PM in the Director of Nursing's office confirmed there were no assessments completed that resulted in an understanding of the residents' individual urinary continence needs and there was no Care Plan that addressed those needs. Interview with the Administrator on 9/26/17 at 12:45 PM in the Director of Nursing's office confirmed the facility had no restorative bladder programs.",2020-09-01
3277,"THE WATERS OF SMYRNA, LLC",445502,202 ENON SPRINGS ROAD EAST,SMYRNA,TN,37167,2018-01-16,658,E,1,0,POU411,"**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 medications were administered according to professional standards as well as the facility policy for 2 residents (#22, #24) of 24 residents reviewed. The findings included: Review of the Lippincott Manual of Nursing Practice, 10th Edition 2014, Administering Nebulizer Therapy, revealed .Auscultate breath sounds, monitor the heart rate before and after treatment .Instruct the patient to exhale .Tell the patient to take in a deep breath from the mouthpiece; hold breath briefly; then exhale .Observe expansion of chest to ascertain patient is taking deep breaths .Instruct patient to breathe deeply and slowly until all the medication is nebulized .On completion of the treatment encourage the patient to cough after taking several deep breaths . Review of facility policy, Nebulizer (Hand-Held) Treatments, revealed the purpose was to .produce a desired effect, such as more effective removal of trapped mucous, alleviate or reduce laryngeal [MEDICAL CONDITION], and to relieve [MEDICATION NAME] .Continue the nebulized treatment until all the medication is used .During the treatment observe the resident for (a) amount and color of sputum(b) sudden occurrence of [MEDICATION NAME](c) nausea and vomiting(d) [MEDICAL CONDITION].Record date, time, medication, dosage, any adverse reaction to the treatment, and an assessment of the treatment . Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED].[MEDICATION NAME] 0.5-2.5 (3) milligrams (mg) per 3 milliliters (ml) inhale orally three times daily for 7 days for [MEDICAL CONDITION] exacerbation . Medical record review of physician's orders [REDACTED]. Observation of medication administration on 1/10/18 at 11:00 AM on the 100 hall, revealed Resident #22 was seated in bed with a nebulizer mask in place. Interview with Licensed Practical Nurse (LPN) #1 on 1/10/18 at 11:15 AM on the 100 hall revealed he did not know if Resident #22 had been approved for self administration of medications. Continued interview revealed LPN #1 was unaware he was to remain with a resident as the nebulizer treatment was administered. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation revealed Resident #24 was in the A bed in an adjoining room to Resident #22 who was in the B bed. Medical record review of physician's orders [REDACTED].[MEDICATION NAME] 0.5-2.5 (3) mg/ml three times daily for [MEDICAL CONDITION] exacerbation for 7 days . 'Medical record review of physician's orders [REDACTED]. Observation of medication administration revealed Resident #24 seated in bed with a nebulizer mask in place. Continued observation revealed the nurse was at the medication cart, preparing medications for another resident. Interview with Licensed Practical Nurse (LPN) #1 on 1/10/18 at 11:15 AM on the 100 hall revealed he did not know if Resident #24 had been approved for self administration of medications. Continued interview revealed LPN #1 was unaware he was supposed to remain with a resident as the nebulizer treatment was administered. Further observation on 1/10/18 at 11:30 AM revealed LPN #1 continued to administer medications to other residents, leaving Residents #22 and #24 with their masks in place.",2020-09-01
3286,"THE WATERS OF SMYRNA, LLC",445502,202 ENON SPRINGS ROAD EAST,SMYRNA,TN,37167,2018-01-16,880,D,1,0,POU411,"**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 follow acceptable and appropriate infection control practices for dressing change for 1 resident (#5) and nebulizer care for 2 residents (#10, #25) of 30 residents reviewed. The findings included: Review of facility policy, Policy and Procedure Non-Sterile Dressings revealed .Place plastic trash bag within easy reach of worksite .Wash hands and don gloves .expose area to be dressed .Remove soiled gloves and place in plastic trash bag .Wash hands .don new gloves .Clean or irrigate area/wound with solution specified in treatment order .Pat periwound dry using dry gauze .Remove gloves and discard in plastic bag . Review of facility policy,Nebulizer (Hand-Held) Treatments, revealed .Dismantle the nebulizer and rinse it under a stream of running water. Allow the nebulizer to air dry, then reassemble it and place it in a plastic storage bag. NOTE: Failure to properly clean and dry the nebulizer can contribute to the incidence of nosocomial infections . Medical record review revealed Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. Observations of wound care in Resident #5's room on 1/9/18 at 12:45 PM, revealed Licensed Practical Nurse (LPN) #1 brought Resident #5 to his room by wheelchair. LPN #1 then donned gloves without washing his hands first. LPN #1 removed Resident #5's sock. LPN #1 then removed his gloves, went to the medication/treatment cart and obtained saline and gauze without washing his hands. LPN #1 donned another pair of gloves, washed area with the saline and cleaned the area with the gauze. LPN #1 replaced the resident's sock. LPN #1 then removed the gloves, and placed the used saline container, used gauze, and the used gloves in his pocket. LPN #1 pushed Resident #5 back to the hallway in his wheelchair. LPN #1 then put the unused gauze that he had taken into the resident's room and put it back into the medication/treatment cart. LPN #1 then removed the used gloves, used saline container, and used gauze from his pocket and threw them away in the medication/treatment cart. Interview with the Director of Nursing (DON) on 1/9/18 at 4:20 PM, in the conference room, the DON was asked when it is appropriate to wash your hands during a wound treatment. The DON stated, Before you start, gather supplies, wash hands, glove, remove dressing, clean wound. The DON was asked if it would it be appropriate to put used gauze and used gloves in a nurse's pocket until they could be thrown away. The DON stated, No. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED].[MEDICATION NAME] nebulization solution 2.5 milligrams (mg) per 3 milliliters (ml) 0.083% inhale orally four times daily related to influenza, [MEDICAL CONDITION] with exacerbation . Observation of Resident #10's room on 1/14/18 at 6:15 PM revealed the nebulizer was connected to the mask and tubing, hanging over the right side rail of the bed. Continued observation revealed the nebulizer was not in a plastic bag. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED].[MEDICATION NAME] solution 0.5 - 2.5 (3) mg/3 ml, 1 vial inhale orally four times daily for wheezing/shortness of breath . Observation of Resident #25's room on 1/14/18 at 6:25 PM revealed the nebulizer connected to the mask and tubing, lying in a wheelchair with clothing and personal items. Interview with Licensed Practical Nurse (LPN) #8 on 1/14/18 at 6:40 PM on the 100 hall confirmed the nebulizers were uncovered and the policy stated they were to be in plastic bags. Interview with LPN #7 on 1/14/18 at 6:55 PM at the 100 hall nurses' station confirmed uncovered nebulizers were an infection control hazard.",2020-09-01
2509,ETOWAH HEALTH CARE CENTER,445422,"409 GRADY ROAD, PO BOX 957",ETOWAH,TN,37331,2020-02-04,880,D,1,0,46XL11,"**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 isolation precautions for 1 resident (Resident #2) of 4 residents reviewed for infection control. The findings included: Review of the facility's undated policy, Isolation Precautions showed .staff will apply Transmission Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected .to effectively prevent transmission . Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Observation on 2/4/2020 at 11:45 AM showed signage on the door to Resident #2's room, which read .CONTACT PRECAUTIONS .Personal Protective Equipment (PPE) .Don gown upon entry into the room .remove gown and observe hand hygiene before leaving .perform hand hygiene .after contact with inanimate objects .in the immediate vicinity of the patient .after removing gloves . Further observation revealed PPE was stored in a cabinet outside the resident's room and a dispenser containing alcohol based hand sanitizer was affixed to the wall adjacent to the door to the resident's room. Observation outside Resident #2's room on 2/4/2020 at 11:46 AM showed a Psychotherapist entered Resident #2's room without washing the hands or donning PPE. The Psychotherapist sat on a chair across from the resident, interacted with the resident briefly as he held the resident's medical record, and then exited the resident's room without washing his hands. The Psychotherapist proceeded down the hall, entered the Social Services office, sat down at a table, documented in the resident's medical record, and then returned the resident's medical record to the D Wing nursing station, without cleansing the hands. During an interview on 2/4/2020 at 11:59 AM, Licensed Practical Nurse #1 stated Resident #2 was on transmission based isolation precautions and persons who entered the resident's room were expected to perform hand hygiene before entering the resident's room, don PPE prior to entering the room, and after removing the PPE, staff were to perform hand hygiene again. LPN #1 confirmed the Psychotherapist failed to maintain transmission based precautions. During an interview on 2/4/2020 at 2:00 PM, the Administrator and Director of Nursing confirmed the Psychotherapist failed to follow the facility's Isolation Precautions Policy.",2020-09-01
3767,CHURCH HILL CARE & REHAB CTR,445237,701 WEST MAIN BLVD,CHURCH HILL,TN,37642,2017-02-07,241,D,1,0,3T3911,"**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 personal privacy and dignity during a meal for one resident (Resident #6), of 5 residents reviewed for nutritional status, of 9 sampled residents. The findings included: Review of the facility policy Notice of Privacy Practices (undated) revealed .(a) Dignity .The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #6 required maximum assistance of two persons for bed mobility and transfers, maximum assistance of one person for dressing, and required set up assistance of one person for eating. Observation of Resident #6 on 2/2/17 from 12:45 PM to 12:53 PM, from the hallway outside the resident's room, during the lunch time meal, revealed the resident seated on the edge of the bed, with the bed side table and the meal tray pulled parallel to the edge of the bed. The resident's food was partially consumed. Continued observation revealed the resident was lying across the bed in a nearly supine position, with the back of her head braced against the base of the far upper side rail, as her legs hung over the near side of the bed, and the resident's feet were swinging freely above the floor. Continued observation revealed Resident #6's gown was partially open and pulled up around her waist, and the resident's upper leg and inner thighs were exposed, with the resident's adult brief clearly visible from the hallway. Further observation revealed a confidential informant, who was present in the room during the observations, reported the resident had been eating and dressed as observed for the prior 20 minutes. Interview with the Assistant Director of Nursing (ADON) on 2/2/17 at 12:56 PM, in the conference room, confirmed the facility failed to maintain visual privacy and dignity during the meal for Resident #6.",2020-02-01
4212,WEST HILLS HEALTH AND REHAB,445501,6801 MIDDLEBROOK PIKE,KNOXVILLE,TN,37919,2016-12-15,314,D,1,0,91T211,"**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 prevent the development of a pressure ulcer for 1 resident (#3) of 4 residents reviewed for pressure for ulcers. The findings included: Review of the facility policy Wound Care Management, dated 3/13/15 revealed .Each resident receives the care and services necessary to retain or regain optimal skin integrity to the extent possible . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 scored 7 out of a possible 15 on the Brief Interview for Mental Status (BIMS), which indicated a severe cognitive impairment. Continued review revealed the resident required extensive assistance with transfers, dressing, personal hygiene, and bathing with 1-2 person assist. Continued review revealed the resident had an indwelling urinary catheter and was always incontinent of bowel. Further review revealed the resident was at risk for development of pressure ulcers. Medical record review of Resident #3's care plan dated 10/31/16 revealed .at risk for pressure ulcers due to immobility incontinence .avoid use of restrictive clothing .reposition frequently if unable to reposition self .requires use of indwelling urinary catheter related to retention of urine with potential for complications .resident will exhibit no sign of injury due to catheter use through next review . Observation with Certified Nurse Assistant (CNA) on 12/14/16 at 3:05PM, in the resident's room, revealed a discolored area to Resident #3's left upper thigh. Continued observation revealed the urinary catheter was not anchored to prevent tension on the catheter. Interview with CNA #1 on 12/14/15 at 3:10 PM, in the resident's room revealed .maybe the brief or urinary catheter caused it .will tell the nurse .was not like that yesterday . Interview with the Treatment Nurse on 12/15/16 at 1:30 PM, in the rehabilitation conference room, confirmed Resident #3 had developed a stage 2 pressure ulcer to the left inner thigh. Interview with the Director of Nursing on 12/15/16 at 3:05 PM, in the rehabilitation conference room, confirmed the facility had failed to prevent the development of a pressure ulcer for Resident #3.",2019-11-01
1536,GREEN HILLS CENTER FOR REHABILITATION AND HEALING,445267,3939 HILLSBORO CIRCLE,NASHVILLE,TN,37215,2017-10-31,309,K,1,0,EO0911,"**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 care and services for the resident's highest practicable well being by failure to assess the need for pain medication after a fall resulting in a [MEDICAL CONDITION] to1 resident (#1) and prior to removal of embedded sutures to 1 resident (#28) of 6 residents reviewed for pain; failure to monitor blood pressure and heart rate prior to administration of cardiac medications for 1 resident (#17) of 28 residents reviewed; and failure to assess and monitor behaviors for 2 residents (#20, #22) of 4 residents reviewed with behaviors. The resulting failure constituted an 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 District Director of Operations was notified of the Immediate Jeopardy on 10/30/17 at 3:00 PM in the Administrator's Office. F-309 is Substandard Quality of Care (SQC). The findings included: Review of facility policy, Resident Rights, revised 2/2017 revealed, .Facility staff will .care for each resident in a manner and in an environment that promotes the maintenance or enhancement of his or her quality of life, recognizing each resident's individuality . Review of facility policy, Comprehensive Care Plan, revised 8/2017 revealed, .The .facility .must describe services that are provided to the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .and to attempt to manage risk factors . Medical record review revealed Resident #1 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located in the secured unit on the 3rd floor of the facility. Medical record review of a Discharge Return Anticipated Minimum Data Set ((MDS) dated [DATE] revealed the resident was moderately cognitively impaired, ambulatory, occasionally incontinent of urine, and always continent of bowel. She had 1 fall without injury since the prior assessment. Review of an Incident/Accident Report form dated 8/2/17 at 2:00 PM revealed Resident #1 was found on the floor in the dining room, .Resident was sitting in dining room after lunch. Got out of wheelchair and tried to walk . Medical record review of a Nurses Note dated 8/2/17 revealed no documentation regarding the circumstances of the fall, witness names, assessment of the left lower extremity, transferring, positioning, or activity level of the resident after the fall. Medical record review of a Radiology Report for Resident #1 dated 8/2/17 at 5:57 PM eastern time (4:47 PM central time) revealed, .Acute fracture, left femoral neck . Continued review revealed the report was faxed to the facility on [DATE] at 6:01 PM eastern time (5:01 PM central time). Medical record review of a Medical Progress Note dated 8/3/17 revealed, .General Appearance .Disheveled .(positive) pain with slight abduction (moving the leg away from the middle of the body) .(positive) pain during transfer to stretcher . Medical record review of the Comprehensive Care Plan dated 1/18/17 and revised 4/18/17 revealed a focus of at risk for pain related to decreased mobility with interventions to administer pain medications prior to treatments and therapy if indicated; anticipate the resident's need for pain relief and respond immediately; evaluate the effectiveness of pain interventions; provide non-pharmacological interventions: repositioning; support; activities. Medical record review of an 8/2017 Medicaton Administration Record (MAR) revealed orders for [MEDICATION NAME] tablet 325 mg (milligrams). Give 2 tablets by mouth every 4 hours as needed for pain; and [MEDICATION NAME]-[MEDICATION NAME] (narcotic pain medication) tablet 5-325 mg. Give 1 tablet by mouth every 6 hours as needed for pain. Continued review revealed [MEDICATION NAME] was administered to the resident on 8/2/17 at 4:49 PM for left hip pain rated a 5/10. Further review revealed no documentation of the effectiveness of the pain medication, no further assessment of pain to the left hip was present, and no further pain medication was administered to the resident while in the facility. Interview with the Director of Nursing (DON) on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed the facility failed to evaluate the effectiveness of pain medication administered at 4:49 PM on 8/2/17 and failed to assess for signs and symptoms of pain after that time until Resident #1 was discharged to the hospital on [DATE] at 8:30 AM. Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On admission to the facility Resident #28 was ordered [MEDICATION NAME] and Tylenol for pain. Medical record review of the Nursing Admission Data Collection document completed by Licensed Practical Nurse (LPN) #8 on 9/20/17 revealed no documentation of the left knee surgical incision and no documentation of sutures. Review of Nursing Daily Skilled Charting completed by LPN #9 on 9/27/17 revealed no documentation of the left knee surgical incision or sutures. Medical record review of Nurse Practioner (NP) #2 Physical Exams dated 9/21/17, 9/22/17, 10/4/17, 10/9/17, 10/17/17, 10/23/2017 10/31/2017 revealed history of present illness: .Surgical debridement . Continued review revealed no documentation of sutures. Interview with NP #2 on 10/31/17 in the conference room, when asked if she saw sutures present on exam stated, .it looked like a hair sticking out . Interview with LPN #10 on 10/31/17 in the conference room, revealed she was not aware of any sutures until 10/24/17. Telephone interview with Resident #28's insurance company nurse on 10/31/17 revealed she was visiting the resident on 10/24/17 at the facility when she was asked to look at the resident's knee by a family member who told the nurse Resident #28's knee was hurting. Continued interview with the nurse revealed, she had four stitches and they were embedded into her skin, and about 2 mm (millimeters) were sticking out of one of the stitches. Continued interview revealed the nurse stated, They should have come out a long time ago. Further interview revealed the insurance nurse reported the embedded sutures to the Charge Nurse. Medical record review of a Wound Note 10/24/17 revealed, .Total of 4 stitches removed. 2 on medial (inner) side of left knee and 2 on lateral (outer) side of left knee Sites cleaned and left open to air . Continued review revealed LPN #10 removed the first three sutures and then asked NP #2 to remove the last suture. NP #2 confirmed during interview on 10/31/17 in the conference room she removed one suture and LPN #10 removed three sutures on 10/24/17. Interview with Minimum Data Set (MDS) Coordinator #2 on 10/31/17 confirmed the MDS and the Nursing assessments were inaccurate and did not reflect the presence of the sutures for Resident #28. Further interview revealed the care plan was not updated after the residents first fall. Medical record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Medical record review of the Care Plan dated 10/3/17 revealed .Administer pain medication prior to treatments and therapy if indicated .Anticipate the resident's need for pain relief and respond immediately to any complaint of pain . Medical record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located in the secured unit on the 3rd floor of the facility. Medical record review of a Situation, Background, Assessment. Recommendation, (SBAR) Summary dated 9/7/17 at 10:35 AM revealed, .Resident fell down on his head, was unresponsive for a few minutes .increased confusion, decreased consciousness .unresponsiveness .labored breathing . Continued review revealed the resident was transported to a hospital. Medical record review of a hospital History and Physical dated 9/7/17 at 3:18 PM revealed, .He was found on the floor on the side of his bed this morning with evidence of trauma to the front of his head .more confused from baseline admitted in (MONTH) with heart failure exacerbation .started on .[MEDICATION NAME] for [MEDICAL CONDITION] and [MEDICAL CONDITION] . Continued review revealed a past surgical history of a permanent pacemaker with transvenous [MEDICATION NAME]; [MEDICAL CONDITION] and an active [DIAGNOSES REDACTED]. Further review of the physical exam revealed, .Large nodule on front of forehead .2 (plus) [MEDICAL CONDITION] to flanks . Continued review revealed, .he is chronically hypotensive related to [MEDICAL CONDITION] . Medical record review of the Comprehensive Care Plan dated 9/22/17 revealed a focus of [MEDICAL CONDITION] with interventions to check breath sounds and observe/document labored breathing; give cardiac medications as ordered; and observe input and output. Continued review revealed no identification or care of an ICD was noted on the Care Plan. Continued review revealed a focus dated 9/22/17 for Hypertension with interventions to educate the resident regarding exercise, limiting salt intake and medication and diet compliance; Give antihypertensive medications as ordered and observe for side effects such as orthostatic [MEDICAL CONDITION] and increased heart rate, observe and document any [MEDICAL CONDITION] and notify MD (Medical Doctor). Continued review revealed on 10/25/17 .late entry from fall on 9-7-17 patient sent out to ER (emergency room ) returned on 9-19-17 with noted changes [MEDICAL CONDITION](hypertension) medication . Continued review revealed no further interventions to monitor vital signs prior to administration of antihypertensive medication. Medical record review of the MAR indicated [REDACTED]. Continued review revealed no parameters were given when to hold/or administer the medications. Further review revealed no documentation of a heart rate or blood pressure prior to administration of either medication. Interview with the MDS Coordinator #2 on 10/30/17 at 3:30 PM in the conference room confirmed when asked if identification and care for an ICD was included on the comprehensive care plan stated, No, but we should have been monitoring it. We missed it. Continued interview confirmed the facility failed to provide interventions for monitoring blood pressure and heart rate prior to administration of cardiac medications to Resident #17. Interview with the DON on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed the facility failed to provide parameters for appropriate heart rate and or blood pressure values prior to the administration of [MEDICATION NAME] and [MEDICATION NAME] and failed to check and document a heart rate and blood pressure prior to administration of the medications to the resident. Continued interview confirmed the facility failed to provide care and services for Resident #17's highest practicable well-being. Medical record review revealed Resident #20 was admitted to the facility on [DATE], readmitted on [DATE] and 9/14/17, and was discharged to a psychiatric facility on 10/9/17 with [DIAGNOSES REDACTED]. Medical record review of a Discharge Return Anticipated MDS dated [DATE] revealed the resident was severely cognitively impaired and had behaviors of inattention, physical behaviors directed to others, and wandering. Continued review revealed she received antipsychotic, antianxiety and antidepressant medications. Medical record review of the Comphrensive Care Plan dated 4/22/16 revealed the following focus: (1) Receives antipsychotic medications related to dementia with behavior management; (2) Receives anti-anxiety medications as needed related to anxiety and agitation. Continued review revealed interventions included medication administration and monitoring for side effects and effectiveness of the medications. Further review revealed the Care Plan did not contain any non-pharmacological interventions and did not identify behaviors as a problem with interventions to address the resident's documented behaviors. Medical record review of a SBAR Summary dated 6/5/17 revealed Resident #20, .increased confusion and combative disorder observed .wandering everywhere, (patient) opened break room, linen room .stated that 'I have to get out of here. I will go home. If somebody touches me I will kill them' .kicking with agitation .transfer to hospital . Medical record review of a SBAR Summary dated 6/11/17 revealed, .Resident returned from hospital on [DATE] (with) same problems .lunch time she opened door and suddenly threw the food toward staff .when staff trying to control her behavior she hit, scratched staff and yelling out. After closed door she threw the food tray on the floor . Medical record review of a Behavior Note dated 7/26/17 revealed, .increasing agitation this pm. combative .(continues) back and forth between room & nurses station . Medical record review of a Behavior Note dated 8/4/17 revealed, .wandering hallway sometimes .entering other residents' room, (patient) has agitation. At 6 pm .in room and stood up from (wheelchair) (knocking on) window and stated that 'I have to get out of here' . Medical record review of a SBAR Summary dated 8/7/17 revealed, .Resident has been having psychiatric behavior recently pt (patient) (with) increased agitation, self-harming and others harming behavior, wandering kicking toward staff, verbally aggressive, restlessness noted . Medical record review of a Behavior Note dated 8/18/17 revealed, .Resident returned from hospital still pt has confusion, wandering, agitation observed pt trying to use elevator for get(ting) out of here and lay (laid) down in front of elevator . Medical record review of a SBAR Summary dated 8/24/17 revealed, .Resident has been having agitation, combative disorder, suicidal idea so multiple times pt transferred to psychiatric hospital. Today pt has significant behavior observed pt trying to jumping (jump) toward window for suicide and keeping razor to her abdomen also pt crying all day long . Medical record review of a Nurses Note dated 10/9/17 revealed, .Pt rolling around day room in (wheelchair) rolling up to pt striking at another pt. Pt rolling around reaching and try(ing) to hit at other residents. Interview with MDS Coordinator #2 on 10/30/17 at 3:30 PM in the conference room confirmed the resident's Care Plan did not address Resident #17's ongoing behaviors or develop interventions to care for the resident. Continued interview revealed the MDS Coordinator stated, Social Services does behavior Care Plans and it should have been in there. Interview with the DON on 10/30/17 at 6:40 PM in the conference room confirmed the facility failed to implement a Behavioral Care Plan for Resident #20 and the facility failed to provide the care and services required to meet the highest practicable well being and needs of the resident. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Behavior Note for Resident #22 written by LPN #5 dated 10/05/17 at 11:09 PM revealed .7:00PM (patient) became agitated. Went into a (resident's) room [ROOM NUMBER] and removed several of (the) blinds and carried (them) down (the) hall. Able to redirect but for short period. Attempted several times to get out of unit door. Patient later took and threw empty bucket. Able to be redirected. [MEDICATION NAME] administered with helpful results rendered. Patient put (back) to bed . Medical record review of a Care Conference Note written by Registered Nurse (RN) #5 dated 10/16/17 at 11:41 AM revealed .IDT (interdisciplinary team) in to discuss resident with son and daughter-n-law. Resident experienced a decline upon moving to third floor. Resident experiences many ups and downs with his medical/physical condition. Resident is doing better today with therapy. Family reported it was that way at home . Medical record review of a SBAR Summary by RN #4 dated 10/22/17 at 1:34PM revealed .Patient agitated. Additional Nursing Notes as applicable: Family health care agent notified at 11:00 AM on 10/22/17. Primary Care Clinician Notified: Nurse Practioner at 11:00 AM on 10/22/17 . Medical record review of a SBAR Summary dated 10/26/17 at 10:56 PM by LPN #4 revealed .agitated told son 'I want to go home' roaming this shift . Medical record review of a SBAR Summary for Resident #22 dated 10/27/17 3:38AM SBAR summary revealed .Resident is agitated , for no apparent reason. He has an long object in his hand, swinging it at staff and one of the residents. He grabbed a fire extinguisher off of the wall and began to spray it at me and a CNT (Certified Nurse Technician). We were unable to get the extinguisher from him. MD (Medical Doctor) was notified and gave order to send resident out for further evaluation, residents son was notified, as well as emergency room department. Resident was transferred via 911 ambulance service at 1:30AM . Interview with RN #2 at 10:50 AM by telephone with two Surveyors revealed she was informed of Resident #22 grabbing the arm of Resident #2. RN #2 stated .LPN #7 told me about it . RN #2 stated .One more time he have (had) those behaviors, he tried to hit resident in the hallway . Further interview revealed Resident #22 picked up the plastic planter and attempted to hit other residents. RN #2 was asked if she reported the assault and stated .no, I did not . Further medical record review revealed incident/accident report dated 10/27/17 at 1:00 AM written by LPN #3 revealed .Patient was yelling, this nurse went to her room and a male patient was in her room. She states that he was trying to kill her, she states that he grabbed her left arm, and she has a bruise on her left arm . Interview with RN #5 on 10/30/17 at 3:00 PM in the conference room revealed Resident #2 was grabbed and hit by Resident #22 around 1:15AM in Resident #7's room. RN #5 reported LPN #3 informed her of the .incident . Further interview revealed Resident #22 was transferred to the third floor due to elopement behavior. RN #5 stated .He has tried to hit her before; he is only up here because of his exiting behavior . Medical record review of the Psychiatric (Psych) Diagnostic Evaluation performed by Nurse Practitioner #2 dated, 9/11/17, .On exam patient is impulsive, anxious, and confused .9/18/17 .Psych visit after med changes last week for agitation, wandering, increased confusion and questionable [MEDICAL CONDITION] .9/29/17 .Increased confusion intermittently with negative urinanalysis (U/A) .10/17/17 .[MEDICAL CONDITION], trying to shoot others playfully but also paranoid and aggressive. Trying to get off of floor, took butter knife and tried to unscrew the elevator keypad. Resident #22 was attempting to get out of the secured doors. Verbally and physically aggressive towards other residents and staff members .10/24/17 .Patient reportedly tried to hit another resident with a fairly strong object .He continues to be psychotic with aggression and agitation was difficult to redirect. Patient threatening towards staff at times especially when they attempt to redirect . Interview with NP #1 on 10/30/17 at 10:40 AM revealed she was made aware of the incident with Resident #22 on 10/30/2017. NP #1 stated .Resident #22 was moved to the 3rd floor due to possible elopement. His son just doesn't get it, He tried to shoot at people with a plastic plant bottle, and tried to hit Resident # 21. I thought he might have a UTI so I sent his urine off . ANP confirmed the quality of care Resident is receiving on this secured unit was lacking in .consistency, I think it could be better with different staff, I know these residents, and when I only come twice a week I rely on the staff to inform me of changes . Medical record review revealed Minimum Data Set (MDS) assessments for Resident #22 dated 09/15/17, 9/22/17, 10/06/17, and 10/27/17, revealed Behavioral Symptom-Presence with Frequency and Physical behaviors directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) Behavior not exhibited . Based on medical record review, observation, and interview, the facility failed to protect Resident #2 from abuse by Resident #22. Further interview with the DON on 10/31/17 at 1:50 PM in the conference room confirmed the facility failed to investigate report and protect residents from physical abuse. Refer F224 K SQC",2020-09-01
5046,WESTMORELAND HEALTH AND REHABILITATION CENTER,445114,5837 LYONS VIEW PIKE,KNOXVILLE,TN,37919,2016-05-25,323,G,1,0,V91S11,"**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 effective interventions for the prevention of falls for 1 (#3) resident, of 3 residents reviewed for falls, of 17 residents reviewed, resulting in Harm to the resident. The findings included: Review of Falls and Fall Risk, Management Guidelines dated 12/13/14 revealed, based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk factors to try to prevent the resident from falling and to try to minimize complications from falling. Interventions should be individualized, according to the resident's needs. If falling recurs despite initial interventions, the interdisciplinary team will implement additional or different interventions, or indicate why the current approach remains relevant. Resident #3 was admitted on [DATE] and [DIAGNOSES REDACTED]. Medical record review of the care plan initiated on 2/23/15 for at risk for falls due to shuffling gait, listed these interventions: bed in lowest position, call light in reach, encourage the resident to ask for assistance with ADLs, and remind the resident to use the walker/wheelchair when in the hallway. Medical record review of the Fall Risk Evaluation dated 6/30/15 revealed the resident scored 19, with a score of ten or more placing the resident at a risk for falls. The eight Fall Risk Evaluations completed from 8/19/15 to 5/19/16 assessed the resident at a risk for falls. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 15, indicating no cognitive impairment, required extensive assistance with bed mobility transfers, walking, locomotion, dressing, toilet use, and personal hygiene. The resident was not steady but able to stabilize without staff assistance with moving from a seated to standing position, walking and surface to surface transfers; and not steady and only able to stabilize with staff assistance with turning around and moving on and off the toilet. The resident used a walker and a wheelchair, was frequently incontinent of urine and continent of bowel. The resident had two or more no injury falls since the previous assessment and received no therapy or restorative services. Medical record review revealed the resident had a fall on 10/9/15 at 9:11 AM. Staff found the resident lying on the floor between the beds and between the headboard and wall. Glasses were on and an indention was noted into the forehead. Staff sent the resident to the emergency room . The Resident Transfer Form dated 10/9/15 documented the resident was sent to the emergency room for evaluation of head trauma. There were no medical interventions and no documentation of additional falls interventions put in place. Medical record review revealed the resident had a fall on 10/12/15 at 9:00 PM. Staff found the resident lying prone on the floor between the beds and the resident received a one centimeter laceration to the right eye. The resident was sent to the emergency room and the laceration was superglued. Medical record review revealed no documentation of any falls interventions put in place. Medical record review revealed the resident had a fall on 1/8/16 at 7:05 PM. Staff found the resident lying on left hip on the floor next to the bed. Staff instructed the resident (who was cognitively impaired) to use the call light before attempting to transfer by self, and no other falls interventions were put in place. Medical record review of the annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 10, moderately cognitively impaired. The resident displayed inattention and disorganized thinking that fluctuated and displayed no behaviors. The resident required extensive assistance with bed mobility, transfers, ambulation, locomotion, dressing, toilet use, personal hygiene, and bathing. The resident was not steady but able to stabilize without staff assistance when moving from a seated to standing position, walking, and surface to surface transfers, and was not steady and only able to stabilize with staff assistance with turning around and moving on and off the unit. The resident utilized a walker and a wheelchair. The resident was always incontinent of bladder and always continent of bowel. The resident has had one non injury fall since the last assessment and did not receive therapy or restorative services. Medical record review of the care plan interventions dated 2/18/16 revealed interventions for history of falls due to shuffling gait: bed in lowest position, call light in reach, encourage the resident to ask for assistance with ADLs, remind resident to use walker/wheelchair when in hallway, not compliant with asking for assistance. Medical record review revealed the resident had a fall on 3/31/16 at 11:30 PM. Staff found the resident on the floor with an approximate one inch laceration to the chin. The resident was sent to the emergency room for a deep laceration and stitches were received. Staff instructed the resident (who was cognitively impaired) to call when needs help. Medical record review of the resident's care plan revealed it was updated for the 3/31/16 fall to include, .educated to use call light when transitioning to a different position . Observation on 5/24/16 at 1:28 PM, revealed the resident laid in bed with head at the foot of the bed and feet at the top of the bed. Observation on 5/24/16 at 2:15 PM, revealed the resident sat in a wheelchair in their room trying to put on shoes. Interview with direct care staff D on 5/25/16 at 3:05 PM, revealed the resident walked on their own, was a little unstable, and sometimes used a walker, but also had a wheelchair. This staff also stated the resident will use the call light when they needed something. Interview with licensed nurse B on 5/25/16 at 5:35 PM, revealed the resident was alert and oriented and does what he/she wants to. The facility failed to provide effective interventions for the prevention of falls for a cognitively impaired resident who required extensive assistance with activities of daily living and had emergency room visits resulting in glue and stitches.",2019-05-01
1528,GREEN HILLS CENTER FOR REHABILITATION AND HEALING,445267,3939 HILLSBORO CIRCLE,NASHVILLE,TN,37215,2017-10-31,224,K,1,0,EO0911,"**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 services to prevent neglect by failure to provide supervision and interventions to prevent falls for 5 residents (#1, #16, #17, #19, #28) of 7 residents reviewed; failed to assess pain for 2 residents (#1, #28) of 7 residents reviewed; failed to provide grooming and showers to 2 residents (#6, #7) failed to provide supervision to prevent ongoing violent behaviors for 2 residents (#20, #22). The resulting failure constituted an 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 District Director of Operations was notified of the Immediate Jeopardy on 10/30/17 at 3:00 PM in the Administrator's Office. F224 is Substandard Quality of Care (SQC) The findings included: Review of facility policy, Abuse and Neglect Prohibition, revised 8/2017 revealed, .Each resident has the right to be free from .neglect .To help ensure a resident's right to a safe and healthy environment .Neglect means a failure of the facility .to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Medical record review revealed Resident #1 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located in the secured unit on the 3rd floor of the facility. Medical record review of a Discharge Return Anticipated Minimum Data Set ((MDS) dated [DATE] revealed the resident was moderately cognitively impaired, ambulatory, occasionally incontinent of urine, and always continent of bowel. She had 1 fall without injury since the prior assessment. Medical record review of Fall Risk Assessments dated 1/9/17, 4/18/17 and 6/26/17 revealed Resident #1 was assessed to be at High Risk for falls. Medical record review of a Comprehensive Care Plan dated 1/18/17 and revised 4/18/17 revealed Resident #1 was at risk for falls with interventions to anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Continued review revealed a focus of at risk for pain related to decreased mobility with interventions to administer pain medications prior to treatments and therapy if indicated; anticipate the resident's need for pain relief and respond immediately; evaluate the effectiveness of pain interventions; and provide non-pharmacological interventions: repositioning; support; activities. Medical record review of Nursing Monthly Summaries dated 2/8/17, 3/8/17 and 5/8/17 revealed the resident was oriented to person only and was ambulatory most of the day. Medical record review of a SBAR (Situation, Background, Assessment, Recommendation) Summary and Progress Note dated 6/20/17 at 12:49 PM revealed, .Resident had a fall in hallway, housekeeping services alerted this writer .Resident has a skin tear on right arm and is complaining of right leg pain .Resident is being sent to (emergency room ) for evaluation and treatment . Medical record review of a Nurses Note dated 6/20/17 revealed no documentation regarding the circumstances of the fall, witness names, assessment of right lower extremity, pain level, or transferring and positioning information. Medical record review of a hospital History and Physical dated 6/20/17 revealed the resident had a medical history significant for Dementia, had a fall and .reported significant pain in the right lower extremity/right hip .awake, alert, but not oriented .she can follow simple commands, but not consistently .Image(s) (X-Ray) Hip 6/20/2017 (3:53) PM IMPRESSION: RIGHT femoral neck fracture . Continued review revealed the resident underwent [REDACTED]. Medical record review of a Nurse Practitioner (NP) Medical Progress Note dated 6/28/17 revealed, .readmitted .following acute hospitalization for fall with subsequent right femur fracture .She is no longer ambulatory at this time .She is self propelling (wheelchair) around hall, but is very slow and weak .General Appearance .Disheveled, Thin/frail . Medical record review of a NP Medical Progress Note dated 7/6/17 revealed, Pt (patient) requires frequent reorientation to environment and monitoring for falls .Since readmission from hospital, (patient) has been much more lethargic, weak .She is now non-ambulatory and is unable to self propel (wheelchair) due to [MEDICAL CONDITION] and cognitive impairment .General Appearance .Disheveled, Thin/frail .Continue close fall precautions and report any acute injuries . Review of an Incident/Accident Report form dated 8/2/17 at 2:00 PM revealed Resident #1 was found on the floor in the dining room and, .Resident was sitting in dining room after lunch. Got out of wheelchair and tried to walk . Medical record review of a Nurses Note dated 8/2/17 revealed no documentation regarding the circumstances of the fall, witness names, assessment of the left lower extremity, transferring, positioning, or activity level of the resident after the fall. Medical record review of a Radiology Report for Resident #1 dated 8/2/17 at 5:57 PM eastern time (4:47 PM central time) revealed, .Acute fracture, left femoral neck . Continued review revealed the report was faxed to the facility on [DATE] at 6:01 PM eastern time (5:01 PM central time). Medical record review of a NP Medical Progress Note dated 8/3/17 revealed, .(Patient) seen at staff request regarding fall .last evening resulting in pain to left hip. X-ray of hip ordered and has returned .with (positive) left femoral neck fracture. (Patient) was recently hospitalized for [REDACTED].according to staff thought she could walk .got up without assistance and fell . No further details of events surrounding fall know by the (Nurse Practitioner) at this time .General Appearance .Disheveled .(positive) pain with slight abduction (moving the leg away from the middle of the body) of (Left Lower Extremity) .Radiography .Testing Reviewed: Date 8/03/17 Test Results: Left femoral neck fracture .Administration to (evaluate) and investigate falls for any possible cause of recurrent falls and for future fall precautions interventions .(positive) pain during transfer to stretcher . Medical record review of the 8/2017 Medication Administration Record [REDACTED]. Continued review revealed no assessment to the effectiveness of the pain medication and no further assessment of pain to the left hip. Medical record review of a hospital History and Physical Report dated 8/3/17 at 11:11 AM revealed Resident #1 complained of left hip pain status [REDACTED].She underwent an x-ray which revealed a [MEDICAL CONDITION] femoral neck .she will not answer questions or really follow commands .Her urinalysis was felt to be consistent with a urinary tract infection .she is being admitted for further evaluation and treatment .Assessment/Plan [DIAGNOSES REDACTED].Acute UTI (urinary tract infection) . Interview with the NP #2 on 10/24/17 at 2:20 PM in the conference room confirmed she was notified of the fall of Resident #1 on 8/2/17 verbally by staff, but was unable to remember who told her. Continued interview confirmed she ordered an X-ray on 8/2/17. Further interview confirmed she was not notified of the X-ray results that revealed a fracture to Resident #1's left hip until 8/3/17 when she began rounding between 6:30 AM and 7:00 AM and found the results herself. Telephone interview with Registered Nurse (RN) #3 on 10/24/17 at 3:50 PM revealed the nurse was an agency nurse and was caring for Resident #1 when she had falls on 6/20/17 and 8/2/17. Continued interview revealed on 6/20/17 at approximately 12:15 PM the resident was found on the floor in another residents room by Housekeeper (HK) #1 who alerted the RN. Continued interview revealed RN #3 stated, We went down there and she was moaning and groaning. I got vital signs but didn't move her and alerted the Nurse Practitioner. Me and 2 techs assisted her back to bed. The Nurse Practitioner was already on the 3rd floor and she told us to call 911 and send her to the hospital. Further interview with RN #3 regarding the resident's fall on 8/2/17 revealed, It was in the dining room after dinner (lunch). She had oxygen on and was in the wheelchair. I think she tried to get up and walk and fell . She had tried to walk before and hadn't fallen. Continued interview revealed RN #3 could not remember who notified her the resident had fallen and stated, Maybe there was other staff and residents in the dining room. They heard a thump and then she was on the floor on her left side. I called the Nurse Practitioner and she said she'd be right there because there were so many falls on the 3rd floor. Continued interview revealed when asked how the resident was transferred, RN #3 stated, I don't know who did it or how she was transferred, but I had an inkling she had a fracture. Further interview with RN #1 revealed, They are staffed mostly with agency. They are short on techs a lot. I've worked with 3 techs on day shift when we needed 4 or 5. They need more on the dementia unit because they walk all the time. It's poorly staffed. Continued interview with RN #3 confirmed she did not receive any facility orientation prior to or while she worked in the facility. Interview with the Director of Nursing (DON) on 10/24/17 at 6:50 PM in the conference room when asked what the cause of the fall to Resident #1 was on 6/20/17 stated, More than likely a UTI. Continued interview revealed when asked what did the facility do to prevent a future fall the DON stated, We looked at our hydration program to encourage po (by mouth) fluids. Continued interview revealed when asked where was the documentation for the resident, the DON stated, There's not. It was more of a unit wide initiative. Further interview confirmed the facility had no fall prevention program or fall risk protocol in place for residents assessed to be at high risk for falls. Continued interview with the DON when asked what the facility could have done to prevent the second fall on 8/2/17 the DON stated, If we had our own staff it would have been easier for consistency and to notice any subtle changes with her. Interview with the Administrator and the DON on 10/24/17 at 6:55 PM in the conference room confirmed the facility had problems with staffing and used 6 different agencies to staff the facility with nurses and Certified Nurse Aides (CNAs). Continued interview revealed the Administrator stated when she began working at the facility in (MONTH) there were at least 20 agency staff working in the facility on a daily basis. Interview with Housekeeper (HK) #1 on 10/25/17 at 7:55 AM in the 3rd floor dayroom confirmed she found Resident #1 in the doorway of a resident room on 6/20/17. Continued interview revealed HK #1 stated she called for RN #3 and she came out of another resident's room, got a wheelchair, and I picked the resident up by myself under her arms. She was able to stand on her own some, cause the nurse checked her first. Then I sat her down in the wheelchair and the nurse wheeled her back to her room. Continued interview confirmed no other staff members were present or assisted HK #1 or RN #3. Interview with MDS Coordinator #2 on 10/30/17 at 3:30 PM in the conference room confirmed Resident #1 was not capable of using her call light and her Comprehensive Care Plan did not accurately reflect interventions to prevent falls. Interview with the DON on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed the facility failed to report X-ray results of a fracture to the Physician or Nurse Practitioner for 13 1/2 hours after receiving the x-ray results. Continued interview confirmed the facility failed to evaluate the effectiveness of pain medication administered at 4:49 PM on 8/2/17, and failed to assess for signs and symptoms of pain after that time until the resident was discharged to the hospital on [DATE] at 8:30 AM. Further interview with the DON confirmed the facility had no fall prevention program or fall risk protocol in place for residents assessed to be at high risk for falls and the facility failed to prevent neglect for Resident #1. Medical record review revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] and 8/1/17 with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located on the 3rd floor of the facility. Medical record review of a Comprehensive Care Plan dated 4/14/16 revealed a focus of .Has had an actual fall with no injury (related to) Unsteady gait, Psychoactive drug use, Poor Balance, Poor communication/comprehension . Continued review revealed the following interventions: 4/14/16 Place frequently used items and call light in reach; Offer/Assist to toilet frequently and as accepted; For no apparent acute injury, determine and address causative factors of the fall; Encourage resident to ask for assistance. Medical record review of a Quarterly MDS dated [DATE] revealed the resident was severely cognitively impaired, had no behaviors and required extensive assistance of 2 or more people for bed mobility and transfers, and ambulated in her room only once or twice with assistance of 1 person; was unsteady and only able to stabilize with staff assistance and used a wheelchair for mobility. Continued review revealed the resident was always incontinent of bladder and frequently incontinent of bowel. Further review revealed the resident had no previous falls. Review of a Quarterly MDS dated [DATE] revealed Resident #16 had behaviors of wandering 1-3 days of the previous 7 days, required extensive assistance of 1 person for bed mobility, ambulation in her room, and locomotion on and off the unit and used a wheelchair for mobility. Continued review revealed the resident had 1 fall with no injury and 2 falls with injury since the previous assessment. Medical record review of Fall Risk Assessments dated 7/11/17 and 10/10/17 revealed the resident was assessed to be at High Risk for falls. Medical record review of interventions on the at-risk plan dated 7/25/16 revealed Add anti-roll back to wheelchair; 8/4/17 Bedroom door to be ajar while patient in room alone. Landing strips to both side of bed; 8/30/17 8/24/17 Seating was adjusted with new cushion for wheelchair in place. Medical record review of an SBAR Summary dated 7/31/17 at 4:02 PM revealed, .found on floor in door hematoma and bleeding noted on forehead . Medical record review revealed no further documentation regarding the resident's fall or care she received. Medical record review of a hospital record dated 7/31/17 at 5:43 PM revealed .soft tissue swelling of the frontal scalp .Acute subcapital right femoral neck fracture . Continued review of a History and Physical revealed, .advanced dementia (nonverbal, mostly gets around with a wheelchair) presented to our (emergency room ) after being found on the floor at her nursing home. She had a laceration to her forehead .The (emergency room ) physician noticed her right leg was shorter than her left, and a hip xray showed a [MEDICAL CONDITION]. The patient is being admitted for further evaluation .laceration to forehead with steri strips (skin closure fore small cuts and wounds) in place .right leg short and externally rotated . Medical record review of a Medical Progress Note dated 8/2/17 revealed, .Re-admission assessment .seen .following acute hospitalization of fall with [MEDICAL CONDITION] and suspected right [MEDICAL CONDITION] .no surgical intervention was performed .non-ambulatory and sitting up in (wheelchair) .continues to pick at [MEDICAL CONDITION] and has caused increased bleeding .Appearance .Disheveled .large open shallow abrasion to forehead with active bleeding .monitor for falls .Administrative staff to assure appropriate fall prevention interventions are in place and that (patient) is in a safe environment . Medical record review of a SBAR Summary dated 8/24/17 at 7:17 PM revealed, .Resident found on floor in right lateral position (patient) has skin tear on right eyebrow area .Resident usually has wandering on hallway with (wheelchair) sometimes (patient) fall on floor with injury or without injury (patient) need special (wheelchair) for safety .skin tear site dressing done with steri strips . Medical record review of a SBAR Summary dated 9/6/17 at 11:57 AM revealed, .alert with some confusion was called to hallway noticed the resident was sitting on the floor on buttocks noticed blood from forehead clean with (normal saline) and apply bandage . Medical record review of a NP Medical Progress Note dated 9/11/17 revealed, .seen for (evaluation) and treatment of [REDACTED].indicating (positive) infection .labs obtained following recurrent fall with reopening of forehead abrasion .increased restlessness and anxiousness .Bruising and skin tears to upper extremities .Remains at a high risk of falls. Will hopefully improve with treatment of [REDACTED]. Medical record review of a SBAR Summary dated 9/27/17 at 3:01 PM revealed, .fall no injury . Continued review revealed no further documentation regarding the fall. Medical record review of a SBAR Summary dated 10/4/17 at 8:07 PM revealed, .Resident has a habit (holding others {wheelchair} or clothes) (patient) grasp fistful of (Resident #20's wheelchair) so (Resident #20) upset and smacking her face . Medical record review of a Nurses Note dated 10/6/17 at 8:53 PM revealed, .Resident up in (wheelchair) and wandering .observed redness on face (skin) almost disappeared . Observation of Resident #16 on 10/25/17 at 8:30 AM in the 3rd floor dining room revealed she was seated in a wheelchair with a cushion on it at a table waiting for breakfast with 3 other residents. Continued observation revealed she was alert, calm and nonverbal. Continued observation revealed no anti-roll back device to her wheelchair. Interview with the Administrator and the DON on 10/25/17 at 6:55 PM in the conference room confirmed the facility had problems with staffing and used 6 different agencies to staff the facility with nurses and Certified Nurse Aides (CNAs). Continued interview revealed the Administrator stated when she began working at the facility in (MONTH) there were at least 20 agency staff working in the facility on a daily basis. Interview with the DON on 10/30/17 at 9:20 AM in the conference confirmed she was not aware of a resident to resident altercation between Resident #16 and Resident #20. Continued interview confirmed the facility failed to report allegations of abuse. Interview with MDS Coordinator #2 on 10/30/17 at 3:30 PM in the conference room confirmed the resident was severely cognitively impaired and incapable of using a call light, unable to ask for assistance, was always incontinent of urine and unable to determine when to toilet. Continued interview revealed the MDS coordinator did not know what the intervention to continue interventions on the at-risk plan meant, and could not determine why changing the cushion to the resident's wheelchair aided in a fall prevention. Further interview confirmed the interventions to prevent falls for the resident were not applicable and/or were not specific for the type of falls the resident experienced. Interview with the DON on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed the facility failed to investigate the cause of multiple falls to the resident and place specific, individualized, interventions on the Care Plan to prevent future falls. Continued interview revealed when asked what the 'interventions on the at risk plan' were the DON stated, I have no idea. Further interview confirmed the resident did not have an anti-roll back device for her wheelchair, and the facility had no fall prevention program or a fall risk protocol in place for residents assessed to be at high risk for falls. Continued interview with the DON when asked what the facility could have done to prevent multiple falls for Resident #16, the DON stated, If we had our own staff it would have been easier for consistency and to notice any subtle changes. Further interview with the DON confirmed the facility failed to investigate the cause for multiple falls to the resident and failed to provide appropriate fall interventions to prevent accidents resulting in a forehead hematoma, a right femoral neck fracture, a right eyebrow laceration and multiple bruises to the resident. Continued interview confrmed the facility failed to prevent neglect to Resident #16. Medical record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located in the secure unit on the 3rd floor of the facility. Medical record review of a Discharge Return Anticipated MDS dated [DATE] revealed the resident was moderately cognitively impaired and had behaviors not directed to others for 1-3 days of the look back period. The resident required supervision for ambulation in his room and had only ambulated in the hallway 1or 2 times during the look back period. Medical record review of a Fall Risk assessment dated [DATE] revealed the resident was assessed to be at High Risk for falls. Medical record review of the Initial Care Plan dated 9/1/17 did not include safety or fall risk as a focus or potential problem and no interventions to prevent a fall. Medical record review of a SBAR dated 9/7/17 at 10:35 AM revealed, .Resident fell down on his head, was unresponsive for a few minutes .increased confusion, decreased consciousness .unresponsiveness .labored breathing . Continued review revealed the resident was transported to a hospital. Medical record review of a hospital History and Physical dated 9/7/17 at 3:18 PM revealed, .He was found on the floor on the side of his bed this morning with evidence of trauma to the front of his head .more confused from baseline admitted in (MONTH) with heart failure exacerbation .started on .[MEDICATION NAME] for [MEDICAL CONDITION] and [MEDICAL CONDITION] . Continued review revealed a past surgical history of a permanent pacemaker with transvenous [MEDICATION NAME]; [MEDICAL CONDITION] and an active [DIAGNOSES REDACTED]. Further review of the physical exam revealed, .Large nodule on front of forehead .2 (plus) [MEDICAL CONDITION] to flanks . Continued review revealed, .he is chronically hypotensive related to [MEDICAL CONDITION] . Medical record review of a Care Plan Note dated 9/20/17 revealed, .(Interdisciplinary Team) review of falls .sent out post fall and readmitted .has history of cardiac issues .patient to be out (in) day area as (frequently) as possible . Medical record review of the Comprehensive Care Plan dated 9/22/17 revealed a focus of [MEDICAL CONDITION] with interventions to check breath sounds and observe/document labored breathing; give cardiac medications as ordered; and observe input and output. Continued review revealed no identification or care of an ICD was noted on the Care Plan. Continued review revealed a focus dated 9/22/17 for Hypertension with interventions to educate the resident regarding exercise, limiting salt intake and medication and diet compliance; Give antihypertensive medications as ordered and observe for side effects such as orthostatic [MEDICAL CONDITION] and increased heart rate, observe and document any [MEDICAL CONDITION] and notify MD (Medical Doctor). Continued review revealed a focus dated 10/17/17 for At risk for falls related to confusion, gait/balance problems, incontinence, psychoactive drug use, unaware of safety needs with interventions as follows: Anticipate and meet the resident's needs; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; Ensure that the resident is wearing appropriate non skid footwear when ambulating, transferring, or mobilizing in (wheelchair). Continued review revealed on 10/25/17 .late entry from fall on 9-7-17 patient sent out to ER (emergency room ) returned on 9-19-17 with noted changes [MEDICAL CONDITION](hypertension) medication . Continued review revealed no further interventions to place Resident in the day area to prevent future falls, or any interventions to monitor vital signs prior to administration of antihypertensive medication. Medical record review of the MAR (Medication Administration Record) dated 9/2017 revealed an order for [REDACTED]. Further review revealed no documentation of a heart rate or blood pressure prior to administration of either medication. Interview with MDS Coordinator #2 on 10/30/17 at 3:30 PM in the conference room confirmed Resident #17 was a high fall risk and failed to identify Resident #17's increased risk for falls with interventions on the initial Care Plan dated 9/1/17. Further interview with the MDS Coordinator when asked if identification and care for an ICD was included on the Comprehensive Care Plan stated, No, but we should have been monitoring it. We missed it. Continued interview confirmed the facility failed to identify the resident as at risk for actual falls, failed to provide interventions to prevent a fall, failed to provide an intervention after an actual fall, and failed to provide interventions for monitoring blood pressure and heart rate with administration of cardiac medications for Resident #17. Interview with the DON on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed the facility failed to provide parameters for appropriate heart rate and or blood pressure values prior to the administration of [MEDICATION NAME] and [MEDICATION NAME] and failed to check and document a heart rate and blood pressure prior to administration of the medications to Resident #17. Continued interview confirmed the facility had no fall prevention program or fall risk protocol in place for residents assessed to be at high risk for falls. Continued interview confirmed the facility failed to investigate the cause of the fall and failed to prevent neglect to Resident #17. Medical record review revealed Resident #19 was admitted to the facility on [DATE] and discharged to hospital on [DATE] with [DIAGNOSES REDACTED].#2, History of Falling, Head Injury, Weakness, Hypertension, Anorexia, Lack of Coordination, and Difficulty Walking. Medical record review of an Admission MDS dated [DATE] revealed the resident was cognitively intact, required extensive assistance of 1 person for bed mobility, transfers, and ambulation in her room. Continued review revealed she was not steady on her feet and was only able to stabilize with staff assistance. Medical record review of a Fall Risk assessment dated [DATE] revealed the resident was assessed to be at High Risk for falls. Medical record review of an Initial Care Plan dated 9/26/17 revealed a focus of Safety/Fall Risk related to History of Falls and decreased safety awareness with interventions to observe for placement and function of devices per facility protocols; and initiate safety checks as indicated. Medical record review of a Care Conference Note date 9/28/17 revealed, .Resident is a high fall risk . Medical record review of a SBAR Summary dated 10/8/17 at 5:19 AM revealed the resident had a fall and, .resident was getting up from bed to go walk to rest room when she slipped . Medical record review revealed no further documentation regarding the fall was present. Medical record review of a Nurses Note dated 10/15/17 at 9:00 PM revealed, .notified .while assisting patient to the commode, the patient sat down quickly on her own, and bumped her back against the rail next to the commode. At the time the patient stated she hit her head, but (CNA) denies witnessing patient hit her head .will notify the MD if any acute (symptoms) observed or patient expressess pain . Medical record review of a SBAR Summary dated 10/16/17 at 12:13 AM revealed, .fell (complained of) (left) hip pain .resident was transferring self with walker to restroom, staff heard loud noise, enter room observe resident lying on floor on back in front of toilet, stated she hit her head, staff assisted resident up and to bed. (Complained of) pain to (left) hip while walking, notified MD (Medcial Doctor) on call orders received to send to hospital for (evaluation) . Interview with MDS Coordinator #2 on 10/30/17 at 3:30 PM in the conference room confirmed the Initial Care Plan for Resident #19 had no interventions to prevent falls as the resident did not have any medical devices and there was no protocol for safety checks. Interview with the DON on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed Resident #19 was still in the hospital due to the fall on 10/16/17 with a left [MEDICAL CONDITION]. Continued interview confirmed the facility had no fall prevention program or fall risk protocol in place for residents assessed to be at high risk for falls. Further interview with the DON confirmed the facility failed to prevent falls resulting in a fracture, and failed to prevent neglect for Resident #19. Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a History and Physical dated 9/13/17 revealed, .She apparently fell the other weekend she has had ongoing pain and discomfort in her left knee .and significant swelling . Medical record review of an Admission MDS dated [DATE] revealed the resident had no previous falls in the last six months prior to admission to the facility. Medical record review of a SBAR Summary dated 10/6/17 revealed, .10/5/17 Resident was found on the floor .Resident was sent to (hospital) as requested by family . Continued reveiw revealed the resident was evaluated by the Emergency Department and discharged with [DIAGNOSES REDACTED]. Medical record review of an Interdisciplinary (IDT) Post Fall Review dated 10/20/17 revealed Resident #28 fell and was found in her room. Continued review revealed the fall was unwitnessed and no injuries documented. Further review revealed no assessment of neurological assessment was performed after the fall. Medical record review of a Comprehensive Care Plan dated 9/25/17 revealed interventions were not initiated until 10/25/17 after the resident sustained [REDACTED].",2020-09-01
1535,GREEN HILLS CENTER FOR REHABILITATION AND HEALING,445267,3939 HILLSBORO CIRCLE,NASHVILLE,TN,37215,2017-10-31,280,E,1,0,EO0911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, observation, and interview, the facility failed to revise the comprehensive care plan related to fall interventions for 3 residents (#1, #16, #17) of 7 residents reviewed for falls and failed to revise the code status and foley catheter status for 1 resident (#6) of 28 residents reviewed. The findings included: Review of facility policy, Comprehensive Care Plan, revised 8/2017 revealed, The care plan is reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes, or change in condition . Medical record review revealed Resident #1 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] to the hospital with a [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. Medical record review of a Discharge Return Anticipated Minimum Data Set ((MDS) dated [DATE] revealed the resident was moderately cognitively impaired and ambulatory. Medical record review of Fall Risk Assessments dated 1/9/17, 4/18/17 and 6/26/17 revealed Resident #1 was assessed to be at High Risk for falls. Medical record review of a Comprehensive Care Plan dated 1/18/17 and revised 4/18/17 revealed a focus of at risk for falls with interventions to (1) anticipate and meet the resident's needs, and (2) be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Continued review revealed on 6/26/17 an intervention to ensure the resident is wearing appropriate non skid footwear when ambulating, transferring or mobilizing in the wheelchair; and 7/27/17 for Physical Therapy and Occupational Therapy to evaluate and treat. Medical record review revealed Resident #1 had a fall on 6/20/17 and was sent to the hospital for surgical repair of a right femur fracture. Continued review revealed the resident returned to the facility on [DATE]. Further review revealed the resident received Physical Therapy from 6/28/17--7/31/17 and Occupational Therapy from 6/28/17--7/28/17. Medical record review of a Medical Progress Note dated 7/6/17 revealed, Pt requires frequent re-orientation to environment and monitoring for falls .Since re-admission from hospital, (patient) has been much more lethargic, weak .She is now non-ambulatory and is unable to self-propel (wheelchair) due to [MEDICAL CONDITION] and cognitive impairment . Interview with Minimum Data Set (MDS) Coordinator #2 on 10/30/17 at 3:30 PM in the conference room confirmed Resident #1 was not capable of using her call light, could not ambulate, transfer or self-propel in the wheelchair unassisted and her Comprehensive Care Plan did not accurately reflect interventions to prevent falls. Medical record review revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] and 8/1/17 with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] revealed the resident was severely cognitively impaired, had no behaviors, required extensive assistance of 2 or more for bed mobility and transfers, and ambulated in her room only once or twice with assistance of 1 person; was unsteady and only able to stabilize with staff assistance and used a wheelchair for mobility. Continued review revealed the resident was always incontinent of bladder and frequently incontinent of bowel. Further review of a Quarterly MDS dated [DATE] revealed Resident #16 had behaviors of wandering 1-3 days of the previous 7 days, required extensive assistance of 1 person for ambulation in her room and locomotion on and off the unit and used a wheelchair for mobility. Further review revealed the resident had 1 fall with no injury and 2 falls with injury since the previous assessment. Medical record review of Fall Risk Assessments dated 7/11/17 and 10/10/17 revealed the resident was assessed to be at High Risk for falls. Medical record review of a Comprehensive Care Plan dated 4/14/16 revealed a focus of .Has had an actual fall with no injury (related to) Unsteady gait, Psychoactive drug use, Poor Balance, Poor communication/comprehension . Continued review revealed the following interventions: 4/14/16 Place frequently used items and call light in reach; Offer/Assist to toilet frequently and as accepted; For no apparent acute injury, determine and address causative factors of the fall; Encourage resident to ask for assistance; Continue interventions on the at-risk plan; 7/25/16 Add anti-roll back to wheelchair; 8/4/17 Bedroom door to be ajar while patient in room alone. Landing strips (Fall Mats) to both side of bed; 8/30/17 8/24/17 Seating was adjusted with new cushion for wheelchair in place. Medical record review of a hospital record dated 7/31/17 at 5:43 PM revealed, .advanced dementia (nonverbal, mostly gets around with a wheelchair) presented to our (emergency room ) after being found on the floor at her nursing home. She had a laceration to her forehead .The (emergency room ) physician noticed her right leg was shorter than her left, and a hip xray showed a [MEDICAL CONDITION]. The patient is being admitted for further evaluation .laceration to forehead with steri strips (adhesive strips used to hold together cuts) in place .right leg short and externally rotated . Medical record review of a Situation, Background, Assessment, Recommendation, (SBAR) Summary dated 8/24/17 at 7:17 PM revealed, .Resident found on floor in right lateral position (patient) has skin tear on right eyebrow area .Resident usually has wandering on hallway with (wheelchair) sometimes (patient) fall on floor with injury or without injury (patient) need special (wheelchair) for safety .skin tear site dressing done with steri strips . Medical record review of a SBAR Summary dated 9/6/17 at 11:57 AM revealed, .alert with some confusion was called to hallway noticed the resident was sitting on the floor on buttocks noticed blood from forehead clean with (normal saline) and apply bandage . Medical record review of a SBAR Summary dated 9/27/17 at 3:01 PM revealed, .fall no injury . Continued review revealed no further documentation regarding the fall. Observation of Resident #16 on 10/25/17 at 8:30 AM in the 3rd floor dining room revealed she was seated in a wheelchair at a table waiting for breakfast with 3 other residents. Continued observation revealed she was alert, calm and nonverbal. Continued observation revealed no anti-roll back implement device to her wheelchair. Interview with the Director of Nursing (DON) on 10/30/17 at 4:50 PM in the conference room with the District Director of Operations present confirmed the facility failed to investigate the cause of multiple falls for the resident and place specific, individualized, interventions on the care plan to prevent future falls. Continued interview revealed when asked what the 'interventions on the at risk plan' were the DON stated, I have no idea. Continued interview confirmed the resident did not have an anti-roll back device to her wheelchair. Further interview confirmed the facility failed to revise the Care Plan to prevent falls and failed to develop a plan to improve Quality of Life for Resident #16. Medical record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident's room was located in the secured unit on the 3rd floor of the facility. Medical record review of a Discharge Anticipated Return MDS dated [DATE] revealed the resident was moderately cognitively impaired and had behaviors not directed to others for 1 to 3 days of the look back period. The resident required supervision for ambulation in his room and had only ambulated in the hallway 1 or 2 times during the look back period. Medical record review of a Fall Risk assessment dated [DATE] revealed the resident was assessed to be at High Risk for falls. Medical record review of the Initial Care Plan dated 9/1/17 did not include safety or fall risk as a focus or potential problem and no interventions to prevent a fall. Medical record review of a SBAR Summary dated 9/7/17 at 10:35 AM revealed, .Resident fell down on his head, was unresponsive for a few minutes .increased confusion, decreased consciousness .unresponsiveness .labored breathing . Continued review revealed the resident was transported to a hospital. Medical record review of a Care Plan Note dated 9/20/17 revealed, .(Interdisciplinary Team) review of falls .sent out post fall and readmitted .has history of cardiac issues .patient to be out (in) day area as (frequently) as possible . Medical record review of the Comprehensive Care Plan dated 10/17/17 revealed a focus of Risk for falls related to confusion, gait/balance problems, incontinence, psychoactive drug use, unaware of safety needs with interventions as follows: (1)Anticipate and meet the resident's needs; (2) Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; (3) Ensure that the resident is wearing appropriate non skid footwear when ambulating, transferring, or mobilizing in (wheelchair). Continued review revealed no further interventions to place in the day area as frequently as possible. Interview with MDS Coordinator #2 on 10/30/17 at 3:30 PM in the conference room confirmed Resident #17 was a high fall risk and had no focus of increased risk for falls with interventions on the Initial Care Plan dated 9/1/17. Continued interview confirmed the resident was inconsistent with his use of the call light due to his [DIAGNOSES REDACTED].#2 confirmed the facility failed to provide an appropriate intervention after an actual fall and failed to revise the Care Plan with specific, individualized interventions to prevent a fall for Resident #17. Resident #6 was admitted on [DATE] from the hospital with [DIAGNOSES REDACTED]. The resident was transferred to the Hospital Emergency Department from another facility after he sustained a fall. Medical record review of the Care Plan dated 10/9/17 revealed, .family choose to have resident remain on full code status . Medical record review on 10/25/17 at 8:30 AM revealed Resident #6 has a POST form dated 10/23/17 revealed Tennessee Physician order [REDACTED]. Interview with Director of Nursing (DON) on 10/30/17 at 5:45 PM in the conference room confirmed Resident #6's POST form in his medical record and the Care Plan dated 10/9/17 did not match for code status. Interview with the DON on 10/30/17 in the conference room at 6:15 PM confirmed the facility failed to accurately identify the correct code status of Resident #6's care plan and the facility failed to revise the Comprehensive Care Plan for falls and catheter status.",2020-09-01
1057,RAINTREE MANOR,445216,415 PACE STREET,MC MINNVILLE,TN,37110,2019-06-04,609,D,1,0,IKUY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, observation, and interviews, the facility failed to follow their abuse policy for reporting allegations of abuse for 1 Resident (#1), and failed to report 2 allegations of abuse within federally required time frame for 1 Resident (#1) of 4 residents reviewed for abuse. The findings included: Review of the facility abuse policy Abuse Prevention Policy & Procedure, revised 10/1/17, revealed .All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the Administrator and Director of Nursing . All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the state survey agency, adult protective services and to all other agencies as required, per state and federal guidelines . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. Observation of Resident #1 on 6/4/19 at 7:50 AM, in her room, revealed the resident was lying in bed, she was awake and alert. Continued observation revealed no anxious or fearful behaviors were identified. Interview with the Social Service Director (SSD) on 6/4/19 at 9:45 AM, in the conference room, revealed she (Resident #1) went to the doctor on 4/29/19, and during that visit she reported to the doctor she had been raped. The Physician's Social Worker called me and she said she had to follow up on the concerns .(Resident #1) had reported to the doctor, while the resident was still at the doctor's office. She said she had been raped at the facility. I told her she had a care plan of making sexual allegations that had been unsubstantiated regarding male staff. I told her in the past if a male walked by her room she would yell out that they had raped her, and I know what you did, you raped me. I told the Director of Nursing (DON) as soon as I got off the phone that she was at the doctor's office making sexual allegations. Continued interview revealed she has been making these allegations for some time and is care planned for sexual inappropriate behavior. On 4/5/19 she was calling from her room at the Maintenance Assistant stating he was the one who raped her. As far as I know 4/5/19 was the first time she had mentioned anything about rape in the facility. Interview with the DON on 6/4/19 at 10:40 AM, in the conference room, revealed I remember the SSD telling me the resident was at the doctor's office and had made sexual allegations. In my mind she was reporting the resident was stating the same things she says here, and the SSD didn't say anything about .(Resident #1) reporting she had been raped at the facility. We did not report the allegation, because I didn't take it as she was saying anything new, she had reported she had been raped in the past. I didn't know at that point she was making the allegation she had been raped in the facility. Today is my first knowledge of the resident stating she had been raped in the facility. Continued interview revealed I don't recall being informed she had yelled at the Maintenance Assistance from her room that he was the one who raped her, so no we did not report the allegation. Interview with the Administrator on 6/4/19 at 12:30 PM, in the conference room, revealed the report I received is the Maintenance Assistant was walking down the hall and she yelled out to him, 'you did it, you did it' which is a lot different than accusing him of rape. Continued interview revealed, I am unaware of her reporting during her doctor's appointment on 4/29/19, that she was raped in the facility Interview with the Maintenance Assistance on 6/4/19 at 12:43 PM, in the conference room revealed, I was walking down the hall and she yelled at me from her room. I didn't know what she said so I went back to her door way and asked what she had said. She said it is a good thing you admitted it, and I said what and she said admitted to raping me. I didn't say anything I just walked away and told . (SSD) and .(Admissions Coordinator) was in the office when I reported it. Continued interview revealed I didn't report it to the Administrator because I reported it to .(SSD). Interview with the Administrator on 6/4/19, at 3:01 PM, in the conference room, confirmed the facility failed to follow their policy for reporting 2 allegations of abuse for 1 Resident (#1) occurring on 4/5/19 and on 4/29/19. Continued interview confirmed the facility failed to report the allegations of abuse to the State Agency as required.",2020-09-01
413,SIGNATURE HEALTHCARE OF PUTNAM COUNTY,445136,278 DRY VALLEY RD,COOKEVILLE,TN,38506,2018-08-22,761,D,1,0,JFHZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, observations, and interviews, the facility failed to ensure narcotics were stored under lock and key for one resident (#8) of 8 residents reviewed for medication storage and failed to follow procedures during narcotic reconciliation on 1 of 5 medication carts on 1 of 5 wings of the facility observed for narcotic reconciliation. The findings included: Review of facility policy Controlled Medication and Drug Diversion, last revised 7/24/18, revealed .2. At each shift change or when keys are rendered a physical inventory of all controlled medication is conducted by two staff .this is completed as follows .a. the nurse .surrendering the keys will read from the controlled substance accountability book the name of the resident and the medications to be accounted .oncoming nurse .will locate the medication .count the remaining medication and report .the amount of medication remaining .6. Controlled medications remaining in the facility after the order has been discontinued are retained in the facility in a securely locked area with restricted access until .destroyed by the facility's director of nursing, administrator, and consultant pharmacist . Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged home 8/1/18. Medical record review of a physician's orders [REDACTED].[MEDICATION NAME] (narcotic) .10 (milligrams) .give one tablet by mouth four times a day as needed .pain . Interview with the Assistant Director of Nursing (ADON) on 8/20/18 at 2:30 PM, in the chapel, revealed on the evening of 8/1/18 she was given Resident #8's [MEDICATION NAME] for destruction by Licensed Practical Nurse (LPN #3), who had removed them from the medication cart after Resident #8 was discharged . Continued interview revealed the ADON did not immediately secure the narcotics in the secure medication storage lock box, but instead placed them in an unlocked desk drawer in her unlocked office and on 8/3/18 when the ADON attempted to retrieve the [MEDICATION NAME], the narcotics were missing from the desk drawer. Interview with the DON on 8/20/18 at 6:00 PM, in the chapel, confirmed the facility failed to secure Resident #8's discontinued narcotics under lock and key in a secure area and failed to follow facility policy. Observation of a narcotic drug reconciliation (narcotic count) with LPN #8 and LPN #9 on 8/21/18 at 12:03 AM, of the D wing medication cart, revealed LPN #8 and LPN #9 completed the narcotic count without naming the resident or the name of each narcotic and did not simultaneously verify the remaining quantity of each narcotic medication compared to the narcotic inventory control card. Interview with the DON on 8/20/18 at 6:00 PM, in the chapel, confirmed the facility failed to ensure narcotics were verified and reconciled during a narcotic count and the facility failed to follow facility policy.",2020-09-01
768,SMITH COUNTY HEALTH AND REHABILITATION,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2017-10-26,333,D,1,0,KCFU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, resident observation and interview, the facility failed to ensure residents are free of any significant medication errors for 1 resident (#12) of 13 reviewed for medications with parameters. The findings included: Review of facility policy (undated), Suggested Medication Administration, Assistance or Observation Procedures, revealed .Resident Right's and Dignity must be preserved during medication administration/observation . Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physicians Order Sheet (POS) revealed an order dated 3/7/17 .[MEDICATION NAME] (Antihypertensive) 100 mg (milligram) give 1 tablet by mouth 1 time a day at 7:00 AM [MEDICAL CONDITION](Hypertension). Hold if pulse is 60 or below . Continued review of the POS revealed a second order for [MEDICATION NAME] 200 mg, give 1 tablet 1 time a day at 8:00pm for HTN, re written on 5/24/17 to include, hold if pulse is 60 or below . Medical record review of the Medication Administration Record (MAR) revealed Resident #12 received [MEDICATION NAME] 100 mg 7:AM dose and 200mg PM dose on the following dates with the pulse documented at 60 or below. 4/2/17 pulse 54, medication documented as administered. 4/9/17 pulse 60, medication documented as administered. 4/28/17 pulse 60, medication documented as administered. 6/8/17 pulse 60, medication documented as administered. 6/24/17 pulse 60, medication documented as administered. 7/22/17 pulse 60, medication documented as administered. 7/26/17 pulse 60, medication documented as administered. 7/31/17 pulse 60, medication documented as administered. 8/1/17 pulse 56, medication documented as administered. 8/2/17 pulse 60, medication documented as administered. 8/15/17 pulse 56, medication documented as administered. 8/16/17 pulse 60, medication documented as administered. 9/17/17 pulse 60, medication documented as administered. 10/15/17 pulse 60, medication documented as administered. Resident observation on 10/23/17 at 12:35 PM revealed Resident #12 sitting at bedside, call light in reach, well-groomed and dressed appropriately, conversing with roommate. Further observation on 10/23/17 at 7:45 PM revealed Resident #12 sitting at bedside conversing on the telephone. Interview with Licensed Practical Nurse #2 on 10/23/17 at 7:45 PM on the 700 hall revealed .when the pulse check of Resident #12 is 60 or below the nurse was to hold the medication . Interview with the Nurse Practitioner on 10/24/17 at 11:30 AM in the conference room revealed she .expected the nurses to follow the parameters .and was .concerned .the resident had received [MEDICATION NAME] with heart rate 60 or below .The Nurse Practitioner reviewed the MAR and confirmed the medication was given with a pulse check of 60 and below . Interview with the Medical Director on 10/24/17 at 11:10 AM on the 800 hallway revealed that he .expects the nurses to follow parameters and not to administer [MEDICATION NAME] to (Resident #12) if pulse is 60 or below. Interview with the Director of Nursing (DON) on 10/25/17 at 3:15 PM in her office confirmed .the [MEDICATION NAME] was given to (Resident #12) with pulse documented at 60 and below . The DON confirmed the facility failed to prevent a significant medication error for Resident #12.",2020-09-01
1648,GRACE HEALTHCARE OF WHITES CREEK,445281,3425 KNIGHT DRIVE,WHITES CREEK,TN,37189,2018-03-02,580,J,1,1,GWBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of Emergency Department records, review of a facility investigation, and interview, the facility failed to notify the Physician in a timely manner for changes in residents' condition for 2 residents (#24, #61) of 29 residents reviewed. The facility's failure to notify the Physician timely resulted in a delay in treatment and placed Resident #24 and #61 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements 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 4:05 PM in the Administrator's office. An Acceptable Allegation of Compliance which removed the immediacy of the jeopardy was received and corrective actions were validated through review of documents, observations, and staff interviews conducted onsite on [DATE]. The Immediate Jeopardy was effective from [DATE] through [DATE]. The findings included: Review of facility policy, Change in a Resident's Condition or Status, undated revealed .To insure the proper and timely reporting and documentation of any changes in a resident's condition or status .Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status .Nursing services will notify the resident's attending physician when .The resident is involved in any accident or incident; including injuries of an unknown source .The nurse will record in the resident's medical record any changes in the resident's medical condition or status . Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #24 scored 9 on the Brief Interview Mental Status (BIMS) indicating she was moderately cognitively impaired. Continued review of the MDS revealed Resident #24 required extensive assistance of 2 people for transfers and dressing; extensive assistance of 1 person for grooming and bathing; and was always incontinent of bowel and bladder. Further review revealed Resident #24 was non-ambulatory; was placed in a wheelchair; and was unable to propel the wheelchair. Medical record review of Wound Care Notes revealed Resident #24 was admitted to the facility with a Stage IV pressure ulcer (full thickness tissue loss) to the right heel, measuring 1.2 centimeters (cm) x (by) 1.5 cm x 1.3 cm with undermining (wound beneath healthy tissue) of 2 cm at 11:00 (anatomically speaking the wound is located at the 11:00 position on the face of a clock). Continued review of the Nurses' Notes revealed Resident #24 went to the Wound Clinic weekly for treatment of [REDACTED]. Review of a facility investigation dated [DATE] revealed Resident #24 had an appointment at the Wound Clinic on [DATE] at 7:45 AM for treatment of [REDACTED].#1 and CNA #17 were getting Resident #24 up and dressed for her appointment, she complained of leg pain. Further review revealed CNA #1 notified Licensed Practical Nurse (LPN) #9 who assessed the resident but took no further action. Review of the facility investigation revealed upon return to the facility, CNA #3 observed the resident's knee appeared swollen with the knee cap leaned over and reported her observations to LPN #3. Continued review revealed LPN #3 assessed the resident who complained of heel pain when questioned. Further review revealed CNA #1 later transferred the resident who complained of leg pain; LPN #3 was notified and assessed the resident, but did not observe excessive swelling to the leg. Continued review of the facility investigation dated [DATE] revealed CNA #5 was showering the resident on [DATE] and noted the resident's .right knee was swollen and the knee was not sitting straight up the way it was on [DATE] . Continued review revealed CNA #3 informed LPN #5 of the swollen knee who agreed the knee was swollen and stated she would have Physical Therapy (PT) look at it. Further review revealed LPN #5 observed the knee to be swollen, painful to move, warm to touch, and notified the Charge Nurse (LPN #4). Review revealed LPN #4 assessed the right knee of Resident #24 and agreed it was swollen, warm, painful and notified the Physician who gave an order for [REDACTED]. Review of the ED record dated [DATE] at 12:02 AM revealed Resident #24 had a history of [REDACTED]. Continued review of the ED records revealed a statement the Resident had no trauma and was non-ambulatory according to facility records. Review of the ED records revealed the resident suffered a .comminuted interarticulated displaced angulated distal femoral fracture extending into the knee joint . (fracture of femur (long bone of thigh) into many parts and extending into the knee separating the surface of the bone into many parts). Review of the ED information sheet revealed .Elderly people typically have poor bone quality and a fall from a standing position can cause such a fracture. Symptoms of this type of fracture include pain with weight bearing, swelling and bruising; tenderness to touch; knee may look out of place and the leg may appear shorter and crooked . Medical record review of Nurses' Notes dated [DATE] revealed no documentation of an assessment, pain level, or the status of the resident's knee by LPN #9 or LPN #3. Medical record review of Nurses' Notes dated [DATE] at 5:39 PM revealed Resident #24 was noted to have a right swollen knee per LPN #5 and LPN #4 agreed the knee was swollen, warm, and painful to touch. Continued review revealed the Physician was notified and gave orders for the resident to be transferred to the hospital. Interview with CNA #3 on [DATE] at 2:30 PM on the 100 hall revealed when Resident #24 returned from the Wound Clinic her knee was swollen. Continued interview revealed she notified the Charge Nurse (LPN #3) the resident's knee was swollen on [DATE]. Further interview revealed CNA #3 took Resident #24 to her room and assisted her to bed. Further interview revealed CNA #3, who initially saw the knee upon return from the Wound Clinic knew something was wrong and told LPN #3 but no action was taken. Further interview revealed LPN #3 saw Resident #24 and decided there was nothing wrong so took no action. Continued interview revealed from [DATE] - [DATE] there was no documentation of observation of the resident's knee and no action was taken. Interview with CNA #5 on [DATE] at 6:20 AM in the conference room revealed when Resident #24 returned from the Wound Clinic on [DATE], her legs looked different. Continued interview revealed she asked the LPN #5 to look at the resident's legs. CNA #5 continued to state the knee was turned inward and the resident was in severe pain. Continued interview with CNA #5 revealed LPN #5 resident's knee was not right and she would notify the Charge Nurse (LPN #4). Further interview revealed the LPN #5 asked Physical Therapy (PT) if they could help with positioning. The therapist stated not to bother doing anything because the (Resident's) leg didn't look right. Interview with CNA #1 on [DATE] at 6:35 AM in the conference room revealed Resident #24 had an appointment at the Wound Clinic on [DATE] at 7:45 AM and (CNA #1) asked a co-worker to assist the resident with getting dressed and into a wheelchair for pickup. Continued interview revealed the resident had no complaints or abnormalities. Further interview revealed about 2:00 PM Resident #24 complained of leg pain and LPN #3 assessed the leg but found no concerns. Interview with the Director of Nursing (DON) on [DATE] at 4:03 PM in her office revealed Resident #24 had a right heel pressure ulcer which was treated at the Wound Clinic and complained of foot pain regularly. Continued interview revealed CNA #9 notified LPN #1 of the knee swelling who thought a PT consult was needed. Further interview revealed when the swelling was reported a second time the resident was transferred to the ED and the femur fracture was diagnosed . Interview revealed Resident #24 returned to the facility in late ,[DATE] from the hospital with a right above the knee amputation and gastric tube (feeding tube in stomach) and was in poor health at the time. Continued interview revealed a few days later the resident's blood pressure and blood glucose became elevated so she was sent to the hospital again. Further interview revealed Resident #24 returned to the facility on [DATE]; her heart stopped on [DATE]; and died . Continued interview revealed there was no conclusion as to the cause of the fracture. Further interview revealed the DON called the Wound Clinic to find out how the resident was transferred and interviewed CNA #2 who accompanied the resident to the appointment, stated Resident #24 was transferred using a stand-pivot method. Interview with the DON confirmed there was a delay in notifying the Physician so medical treatment could be obtained for Resident #24 when she had pain and swelling of her knee. Telephone interview with CNA #2 on [DATE] at 5:35 PM revealed there was no problem observed with the van ride or getting (Resident #24) in and out of the clinic. Continued interview revealed once inside the staff stood the resident up and eased her to the treatment bed using the stand-pivot method of transfer; eased her legs onto the bed; and propped her right leg on a pillow. Further interview with CNA #2 revealed she accompanied Resident #24 to and from the Wound Care Clinic in the van and offered to assist with the resident's transfer at the clinic but was not needed. In summary, Resident #24 was admitted to the facility on [DATE] with a right heel Stage IV pressure ulcer. The resident had co-morbidities of Diabetes Mellitus and [MEDICAL CONDITION]. On [DATE] upon return from the Wound Clinic, CNA #3 noted the resident's right knee was swollen. LPN #3 assessed the knee; felt there was no significant swelling; and failed to document her assessment. CNA #3 stated she told the Nurse about Resident #24's swollen knee and pain but the Nurse failed to document any assessment of the resident's knee and failed to notify the Physician. On [DATE] Nurses' Notes revealed the first documentation of the resident's knee being swollen, painful, and warm to touch. There is no documentation the Physician was notified from [DATE]-[DATE] when CNAs stated they reported the resident had pain. Resident #24 was sent to the ED where a comminuted interarticulated displaced angulated distal femoral fracture extending into the knee joint was identified. During this time the pressure ulcer on the heel deteriorated and the resident required surgical intervention with a right above the knee amputation and insertion of a feeding tube, by which she received her nutrition. The resident subsequently developed pneumonia and a systemic infection, her heart stopped, and died . The facility failed to notify the Physician timely of Resident #24's complaints of pain and change in condition and a delay of care resulting in Immediate Jeopardy for Resident #24. Medical record review revealed Resident #61 was admitted to the facility on [DATE] and readmitted on [DATE] and [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged to the hospital on the evening of [DATE]. An additional [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #61 had a BIMS score of 1 indicating the resident was severely cognitively impaired. Continued review revealed Resident #61 required extensive assistance with bed mobility and was totally dependent for transfer, dressing, toilet use, personal hygiene and bathing. Continued review revealed the resident had a range of motion limitation in the upper and lower extremities on both sides. Further review revealed the resident received PRN (as needed) pain medication. Review of a witness statement signed by CNA #10 dated Saturday, 9, (YEAR) revealed .(Resident #61) was in the bed .This morning, ([DATE]) she said her knee was hurting .As I was changing her she complain(ed) of pain in her knee . Continued review of the witness statement revealed an addendum dated [DATE] at 8:21 PM and signed by the Director of Nursing (DON) who documented .CNA reported that nurse on ,[DATE] (night shift) was made aware around 5 AM of resident's complaint of pain to right knee . Review of a witness statement signed by Licensed Practical Nurse (LPN) #9 dated [DATE] included in the facility investigation revealed, .When I went in resident's room to give pain med (medication) for rt (right) leg (CNA #10) told me she was hurting she mentioned that man dropped me .This occurred between 5:30 AM and 6:00 AM (night shift) on [DATE] . Medical record review of the Nurses' Notes for [DATE] revealed no documentation by LPN #9 regarding the resident's voiced pain, a man had dropped her, or any pain medication was given. Medical record review revealed a Physician's Telephone Order dated [DATE] at 12:30 PM Stat (immediately) right knee x-ray due to swelling and pain . signed by LPN #7. Medical record review of a Nurses' Note dated [DATE] at 12:43 PM by LPN #7 revealed .resident complain(ed) of R (right) knee pain stated she was drop(ped) by a man last night right knee noted to be swollen painful to touch or move MD (medical doctor) made aware order to have x-ray done and call him .will continue to monitor waiting on (mobile x-ray) to come to facility for x-ray . Interview with the DON on [DATE] at 3:50 PM in the Assistant Director of Nursing's (ADON) office, confirmed the facility did not follow their policy on promptly notifying the resident's Physician when Resident #61 reported to LPN #9 around 5:30 AM to be in pain and someone had dropped her, resulting in a delay of treatment until it was reported to the Physician approximately 7 hours later. Interview with the Administrator on [DATE] at 5:08 PM in the ADON's office, regarding the delay in reporting of a change in status in the resident's condition, stated You're not telling us anything we didn't know, that's why we fired them (LPN #9, CNA #10). The surveyor verified the Allegation of Compliance by: 1. On [DATE] the on-call Nurse who failed to notify the DON of the incident for 3 days was in-serviced on timely reporting and quality of care. 2. On [DATE] all staff were educated on Incidents, Accidents, Abuse, Reporting, Customer Service, and Quality of Care. 3. On [DATE] all cognitively impaired residents underwent a head-to-toe skin assessment with no concerns apparent. 4. On [DATE] all cognitively intact residents were interviewed regarding abuse with no concerns elicited. 5. On [DATE] all staff were educated on Notification of Change and Condition. 6. On [DATE] staff were educated on Transfers, ADLS (Activities of Daily Living), How to Care for Residents, Knowing Your Residents, Abuse, Neglect, and Reporting all Resident Claims. 7. On [DATE] licensed staff were educated on Incomplete Data on the Medication Administration Records and Treatment Administration Records. 8. From [DATE] - [DATE] all staff were educated again on the Abuse Policy and Procedure, notification, and Reporting. 9. Review of daily audits on [DATE] and [DATE], of resident observations for change in pain, change or decline in condition, assessment as indicated with Physician and/or Nurse Practitioner notification, and follow-up revealed audits were completed with Licensed Staff and CNAs assigned to each resident. 10. Interview with staff members on [DATE] regarding education received on abuse, transfers, notification, knowing residents, reporting resident claims revealed they were able to discuss each of the topics. Noncompliance continued at a scope and severity of D for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance Committee. The facility is required to submit a plan of correction.",2020-09-01
957,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,323,G,1,0,SMVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of Event Report, review of hospital record, interview, and observation, the facility failed to provide an environment free of accident hazards and the supervision needed to prevent accidents for 5 residents (#2, #4, #7, #8, #9) of 11 residents reviewed. Resident #2 sustained HARM (laceration to head which required stitches) during a fall when the facility failed to follow his care plan by using 2 staff to provide care. In addition, the facility failed to provide assistive devices such as low beds, fall mats, and call lights in reach to prevent falls for 4 residents (#4, #7, #8, #9). The facility failed to ensure devices to prevent accidents, such as geri-sleeves to prevent skin tears, were provided for Resident #7. The facility failed to ensure interventions resulting from an investigation were acted upon for 4 residents (#2, #4, #7, #9). The facility failed to ensure the environment was free of accident hazards such as side rails for which there was no assessment and were a factor in Resident #4's fall from the bed. The findings included: Review of facility policy, Fall Risk Reduction and Management, revised 9/16 revealed .A 'fall' is when a resident comes to rest unintentionally on the floor. An intercepted fall is a fall. A fall without injury is a fall. When a resident is found on the floor, the conclusion is that a fall has occurred. If a resident rolls or 'scoots' off a bed or mattress on the floor, this is a fall .Complete side rail assessment at time of admission, quarterly, at time of significant change Interventions appropriate to individual resident and their risk for falls will be implemented based on recognized standards of practice .MDS (Minimum Data Set)/Care Plan Coordinator is responsible for updating care plan related to fall risks, interventions and/or injury related to falls .Interdisciplinary staff will make suggestions for appropriate interventions to decrease likelihood of recurrent fall/fall with injury .The MDS/Care Plan Coordinator will be responsible for making sure that the care plan is updated accordingly .If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant .If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable . Review of a facility policy, Incident/Accident, revised 9/10/16, revealed .Incidents, accidents, or injury of unknown origin will be investigated and appropriate interventions taken as needed .Residents are assessed through the routine assessment and care planning process for factors that may place them at risk for incidents or accidents. Interventions will be implemented based on the assessment findings .The facility will investigate the incident, accident or injury to identify potential contributing factors .Based on investigative findings, the care plan will be reviewed and revised to include preventative interventions to decrease potential for recurrence . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident had a tracheostomy and was dependent on supplemental oxygen. Review of an Event Report dated 1/1/16 revealed the resident was lowered to floor. Review of the facility investigation revealed staff stated while she was giving him a bed bath, resident coughed violently multiple times that had him leaning off bed. For safety, resident was lowered to floor to keep from falling off bed .Care Plan to reflect x2 (2 person) assist for all care. Continued review of the note, staff were educated to use x2 assist for ADLs (Activities of Daily Living) and turning. Review of hospital records dated 11/2/16, revealed the resident was admitted to the hospital with [REDACTED]. Review of Progress Notes revealed the resident was readmitted to the facility on [DATE]. Review of an admission Fall Risk assessment completed on 11/9/16 revealed the resident was at risk for falls based on factors including decreased muscular coordination, impaired mobility, continent, medication use, length of stay, and his neuromuscular/functional status. Review of an Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 continued to require total assistance of 2 staff for ADLs including bed mobility, transfer, dressing and toilet use. Continued review of the assessment revealed the resident was bedfast, severely cognitively impaired, and had no recent falls. Review of Resident #2's fall risk Care Plan last updated on 12/4/16, revealed upon his return to the facility, the documentation remained the resident at risk for falls r/t (related to) impaired mobility, need for 2 staff members with ADL assistance. Review of an Event Report dated 12/4/16 revealed at 6:00 AM staff had resident turned twards (towards) herself as she was providing incontinent (incontinence) care. Resident began to forcefully cough multiple times. Resident's body came off the bed and (staff) was unable to stop him from falling due to weight. The Event Report noted the resident had a 2-inch gash above the right eye. Review of the Progress Notes attached to the facility investigation revealed swelling was present to the area and neurochecks were started due to suspected head trauma. Review of the fall investigation revealed the resident was transferred to the hospital at approximately 9:15 AM, at the sister's request. Review of the 12/4/16 hospital record revealed the resident had stitches applied to the laceration above his right eye. Continued review of a computerized tomography (CT) scan of the resident's head revealed there was a small amount of new intraventricular hemorrhage within the atria of both lateral ventricles, greatest on the left. Review of the 12/4/16 Progress Notes dated 12/4/16 revealed the resident returned from the Emergency Department at approximately 2:30 PM. Review of Progress Notes on 12/5/16, revealed the resident continues to have edema (swelling) to right side of face and eye (the same side of the head as the craniectomy). Continued review of the Progress Notes revealed the Resident is noted to have blood present in trachea and is present when being suctioned, that was initially noted after returning from hospital. Review of a CNA (Certified Nurse Aide) Observation form dated 12/4/16 and a witness statement from the CNA that was present at the time of the fall revealed, I was turning (Resident #2) towards the window .to reposition him and change him. (Resident) coughed and coughed very hard two - 3 times. He threw himself out of the bed and I was unable to catch him. He fell out and had hurt himself. Review of her statement revealed that she had marked Yes to the question, Were all intervention(s) in place? Interview with the Director of Nursing (DON) on 9/19/17 at 10:48 AM on the first floor administrative wing revealed the Quality Assurance (QA) Nurse completed the investigation of this fall with injury, and she would be able to answer questions about it. The DON related the CNA involved in the incident had been disciplined for failing to follow the resident's Care Plan a second time in (MONTH) (YEAR), and no longer worked at the facility. Interview with the QA Nurse on 9/19/17 at 11:04 AM revealed the CNA's witness statement was not accurate. She stated all interventions were not in place, as the Care Plan called for 2 staff to be present whenever ADL care was given. The QA Nurse confirmed There were supposed to be 2 staff present at the time of the fall. She stated the CNA was aware of the resident's Care Plan and knew that there were supposed to be 2 people in the room but she was in a hurry. She made a big mistake. Medical record review revealed Resident #4's was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed the resident was cognitively impaired and required limited assistance with bed mobility, transfers and walking in her room. Continued review revealed the resident had no functional limitations to range of motion, but was not steady in transfers and was only able to stabilize herself during transfers with staff assistance. She was assessed as at risk for falls and the problem was Care Planned. Review of Resident #4's clinical record revealed no Physician Orders for any type of restraints, including side rails. Review of x-ray results dated 5/19/17 revealed Resident #4 was diagnosed with [REDACTED]. Review of Progress Notes dated 5/19/17 revealed the resident required hospitalization and a hip replacement. Review of the facility investigation revealed the facility was unable to determine the etiology of this fracture. Resident #4 returned to the facility on [DATE] and remained at risk for falls and the problem continued to be Care Planned. Fall 1 - Review of an Event Report dated 6/20/17 revealed at 11:00 PM the resident had an unwitnessed fall, and was found sitting next to bed on floor. Patient still had blankets on. Continued review of the Event Report revealed bilateral hip and sacral x-rays were ordered on [DATE] due to the resident's increased pain after the fall; however, no new fractures were found. The Probable Cause of the fall was listed as resident attempted to ambulate without assistance. Review of the Event Report revealed the Care Plan was updated; however, review of the Care Plan, initiated on 4/19/17, revealed no interventions were added to the Care Plan. Review of hospital records revealed the resident was hospitalized from [DATE] - 7/3/17, when she required a below the knee amputation (BKA) of her left leg due to a gangrenous great toe. Resident #4 returned to the facility on [DATE]. The resident's Comprehensive Care Plan continued to indicate she was at risk for falls. Medical record review of a comprehensive assessment dated [DATE], was completed for a significant change in the resident's condition. After the amputation, the resident no longer walked, and needed extensive staff assistance with bed mobility and transfers. After completion of the Comprehensive Assessment, the resident's Comprehensive Care Plan was updated and a Care Conference was held on 7/19/17. Review of Resident #4's Care Plan revealed approaches were not revised to reflect the resident's current status. Review of the Care Plan revealed the resident was at risk for infection r/t Left BK[NAME] Approaches to meet the goal of remaining free of infection revealed the resident was to have Shoes on only during therapy r/t L (left) heel blister. The care plan also noted the resident is a fall risk r/t S/P (status [REDACTED]. Both of these approaches had previously been on the resident's Care Plan and were not revised/deleted after the amputation of the resident's leg. Fall 2 - Review of an Event Report dated 7/13/17 revealed the resident's next fall occurred on 7/13/17 at 1:35 AM. The resident was found by staff Sitting on floor at bedside with legs extended in front of her. Resident stated she slid out of bed once her leg went over the side. Medical record review of a x-ray Report of the resident's left hip (which was previously fractured and replaced) revealed no new fractures. Review of Physician Orders attached to the Event Report revealed, on 7/13/17, the Physician gave new orders for Fall mats beside pt's (patient's) bed. Bed in lowest position at ALL times. Continued review of the Event Report revealed the resident's Care Plan was updated in response to the fall on 7/13/17. Further review of the Care Plan revealed the approach of the bed in the lowest position was not added to the Care Plan until 8/1/17. Continued review of the Care Plan revealed, as of 9/18/17, the approach of fall mats at the bedside had never been added to Resident #4's Care Plan. Fall 3 - Review of an Event Report dated 8/1/17 revealed, at approximately 4:30 PM, the resident was found sitting on the floor .When asked what happened, the resident stated, I just wanted to get in the chair. Continued review of the Event Report revealed the Probable cause of the fall was the Resident has intermittent confusion, is a fall risk, and doesn't always remember to use call light. Although the investigation identified the resident's [DIAGNOSES REDACTED]. Fall 4 - Review of an Event Report dated 8/25/17 revealed at 4:15 PM, the resident attempted to transfer herself from the chair to the bed without assistance and fell , did not call and ask for help. The root cause was described as transferring without assistance, not using call light. The Care Plan was updated on 8/25/17 with an intervention for, Remind resident to use the call light for assistance. Continued review revealed there was no evidence of identification that the use of the call light was already on the Care Plan and was not successful in preventing this fall. Further review revealed there was no evidence of an investigation as to why the previous intervention of the call light was not successful, and the facility did not assess factors such as whether the call light was out of reach, or if the resident could not remember to use it due to cognitive function. Fall 5 - Review of an Event Report dated 9/11/17 revealed at 11:20 AM, staff walked into resident's room to find resident at the end of bed with legs hanging off bed touching floor. Resident began to slide, (staff) assisted resident to floor. Review of the Probable Cause was listed as resident scooted to foot of bed and lost her balance and fell off bed. Continued review revealed there was no evidence the facility assessed the root cause of why the resident scooted to the foot of the bed. Medical record review of the resident's Care Plan revealed, since 7/26/17, the resident was to have a lower bedrail raised on the amputation side (left side) of the bed. Further review of the Care Plan revealed with the use of the one lower side rail, the resident will still be able to get OOB (out of bed) to her strong side. Review revealed there was no evidence the facility investigated whether one (or more) side rails were in use at the time of this fall and whether their use restricted normal exit from the bed, forcing the resident to scoot to the end to try and get out of bed. Although the Event Report indicated there were no injuries noted from this fall, review of the facility investigation revealed the resident complained of pain to the left leg stump on 9/12/17 and 9/13/17, as well as knee pain on 9/14/17. Fall 6 - Review of Progress Notes dated 9/17/17 revealed at approximately 5:30 AM the resident was found sitting on floor on knee/stump, claims she forgot she only has one leg. Medical record review revealed the resident's stump was bleeding and she had a small bruise to the right knee. Continued medical record review revealed at 7:16 PM, the resident was complaining of pain in her right ankle from the fall and the nurse observed bruising across the top of the ankle. X-rays were obtained on 9/18/17, and no fracture was identified. Observation on 9/18/17 at 8:35 AM revealed Resident #4 was asleep in bed. The resident's Physician Orders for fall mats and the bed to be in the lowest position were not followed. Observation revealed the resident's bed was not lowered and the fall mats were not in use. The resident's Care Plan called for one lower side rail to be up when the resident was in bed. However,observation revealed all 4 one-half side rails were raised, creating the effect of 2 full side rails which restrained the resident in bed. Although the Care Plan called for the resident to use her call light to prevent falls, observation revealed the call light cord was looped through the middle bar of the top side rail, and was dangling under the bed, out of the resident's reach. Further observation on 9/18/17 at 1:49 PM revealed the resident was asleep in bed with the bed in the lowest position closest to the floor with no fall mats in use and the 4 side rails raised. Observation on 9/19/17 at 8:08 AM revealed Resident #4's right foot was bruised and purple-grey in color. The bruising extended over the top of the resident's foot from the ankle to the toe and around the back and side of the ankle. The resident was moaning, and when Licensed Practical Nurse (LPN) #1 asked Resident #4 if her foot hurt, she responded, Yes. Interview with CNA #3 on 9/18/17 at 1:52 PM, confirmed all 4 side rails were raised, and there were no fall mats in place. CNA #3 stated, She doesn't use any fall mats; not that I know of. CNA #3 stated the bed was always supposed to be in the lowest position; however, it had to be raised for meals to get the over-bed table in place. When told of the observation on 9/18/17 at 8:08 AM, she stated staff, may have forgotten to lower the bed after the resident's meal was finished. During the interview on 9/18/17 at 1:52 PM, CNA #3 stated she always used all 4 side rails for the resident when she was in bed. She stated the resident had a leg amputation earlier this year, and After she came back from the hospital, we was (were) told to use all 4 side rails with her because she's a fall risk. Further interview with CNA #3 revealed the resident doesn't try to climb over - she goes out the end (of the bed) instead. CNA #3 stated she was the staff who witnessed Fall #5 on 9/11/17, saying, Just last week, I found her sliding out the end of the bed when she could not exit the bed in a normal fashion because all 4 side rails were raised. Further interview with CNA #3 revealed each resident had a Care Plan posted in their closet and this information was used to know what type of assistance and devices were needed. She went to Resident #4's closet and showed there was a Care Plan posted on the left door of the resident's closet. Review of the documents which CNA #3 referred to revealed the Safety care plan included only one intervention - Mattress stops in place to prevent mattress from sliding down. CNA #3 reviewed the Safety Care Plan and confirmed it did not show the need for fall mats, low bed, and only 1 side rail to the lower left side of the bed. Interview with the DON about Resident #4 on 9/18/17 at 2:10 PM, the DON stated, She's fallen more times than you can count. When informed the Safety Care Plan provided by CNA #3 did not include multiple interventions which had been identified to prevent falls, the DON provided another document titled Safety Careplan and stated this was also posted in the resident's closet (on the right door of the closet.) Review of this Safety Careplan revealed the resident was supposed to have: Bed in lowest position at all times. Fall mats. Remind her to use call light. Raise Lower Bedrail on bed to help with safe sleep. Further interview with the DON at this same time revealed she was unaware staff were not consistently using a low bed and were not using fall mats when the resident was in bed. The DON stated historically the facility did not assess for the use of side rails. She stated, although the facility was in the process of adding side rail assessments to the admission packet, Resident #4 did not have a side rail assessment completed. The DON stated she had no evidence the facility had conducted a thorough assessment of the safety of this equipment relative to the resident's condition. Continued interview with the DON revealed after the fall in (MONTH) (YEAR), the fall team decided the resident should only have 1 side rail (lower left) raised when she was in bed. She stated she was unaware staff were using all 4 side rails when the resident was in bed. The DON added she was unaware all 4 side rails were in use at the time of the 9/11/17 fall, and confirmed the investigation should have addressed this as a possible root cause and determined if the fall from the end of the bed occurred because all 4 side rails were raised and Resident #4 could not get out of bed in a routine manner. The DON was interviewed about other interventions listed on the investigations and care plans to prevent further accidents. She stated the repeated addition of the call light was not appropriate, based on the resident's cognition, which she stated had declined since admission. Interview with the Care Plan Coordinator on 9/19/17 at 9:50 AM revealed if the call light was already listed on the Care Plan, the Care Plan should have been revised with a different intervention - Not one that was already on there. Further interview with the Care Plan Coordinator on 9/19/17 at 4:35 PM revealed Anyone can update the Care Plan when the falls team meets. He could provide no explanation as to why Care Plan approaches were not updated per the Event Report documentation, and stated, It should have been done. Medical record review revealed Resident #7's with [DIAGNOSES REDACTED]. Review of the resident's most recent assessment, a Quarterly MDS dated [DATE], revealed the resident was moderately cognitively impaired, was totally dependent on staff for transfer, and required extensive assistance with bed mobility. The resident did not walk and required either supervision or limited assistance from staff with locomotion in her wheelchair. Medical record review revealed Resident #7 had a history of [REDACTED]. -11/10/16 skin tear to left lower extremity during transfer to wheelchair by staff -1/3/17 skin tear to back of right calf during transfer by staff -2/18/17 skin tear to right thigh -3/23/17 skin tear to left forearm -4/30/17 skin tear to right hand -6/22/17 skin tear to left upper extremity (x2) -7/19/17 skin tear to left lower extremity -7/19/17 skin tear to right lower extremity -8/6/17 skin tear to left wrist -8/21/17 skin tear to second knuckle of right hand Review of Resident #7's Comprehensive Care Plan, dated 9/7/17, revealed that since 11/30/15, the resident has impaired/potential for impaired skin integrity r/t impaired mobility, incontinence of bowel and bladder, age related skin changes, ASA (aspirin) in use. Venous insufficiency, chronic edema. Approaches to help the resident meet the goal of avoidable skin breakdown included 8/21/16 - Geri-sleeves to be in place. Review of the Safety Care Plan used by direct care staff and posted in the resident's closet also revealed the instructions: Geri-sleeves to be in place at all times d/t (due to) frequent STs (skin tears) - 8/21/16. Observation of Resident #7 on 9/18/17 at 8:48 AM, 3:00 PM, 5:06 PM, and 9/19/17 at 8:10 AM, 8:26 AM, and 3:15 PM revealed the resident was not wearing geri-sleeves. Bruising was noted on the resident's right hand, which extended from the index finger to the thumb, across the back of the hand. Interview on 9/19/17 at 8:26 AM with CNA #1 confirmed the resident was not wearing geri-sleeves at that time, and her arms were bare from below her elbow. CNA #1 stated, No, she doesn't use them. Interview with CNA #1 revealed she was unaware that the resident's Care Plan called for the use of geri-sleeves at all times. Interviews on 9/19/17 at 3:15 PM with LPN #1 and on 9/19/17 at 3:22 PM with UM #1 both confirmed that the facility had geri-sleeves available for use. Each confirmed that this assistance device to prevent injuries should have been used per Resident #7's care plan. Review of Resident #8's most recent Comprehensive Assessment (admission MDS of 11/17/16) revealed the resident was cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The resident was bedfast and totally dependent on staff for all ADLs, including bed mobility and turning/repositioning. Review of a readmission History and Physical, dated 5/17/17 revealed the resident had a tracheostomy, and was ventilator and dialysis dependent. Demographic information revealed the resident also had [DIAGNOSES REDACTED]. Review of the most recent Fall Risk assessment form, completed 8/31/17, revealed the resident was at risk for falls based on intermittent confusion/poor recall/judgement/safety awareness, decreased muscular coordinator, incontinence, medication use, and neuromuscular//functional status. Resident #8's Comprehensive Care Plan, initiated 11/10/16, was reviewed on 9/18/17. The Care Plan stated the resident is at risk for falls r/t dependent on staff for ADLs, limited mobility, antihypertensive and psychotropic medications in use. To meet the goal of no avoidable falls, interventions since 12/20/16 included Floor mats at bedside. Observation on 9/18/17 at 5:34 PM revealed Resident #7 was in his bed, which was in a high position. A fall mat was observed on the left side of the bed. However, no fall mat was present on the right side of the bed. A fall mat was noted on the floor in the bathroom, underneath a reclining chair in storage. Additional observations on 9/19/17 at 8:30 AM and 10:04 AM also revealed, while the resident was in bed, there was no fall mat on the right side of the bed, which was in a high position. Interview on 9/19/17 at 10:04 AM with CNA #2 confirmed there was no fall mat on the right side of the resident's bed. She stated, I think it's family preference that there was no mat on one side of the bed. She stated if a Care Plan intervention was not being used, it should be reported to the nurse; however, she had not done so. CNA #2 was also asked about the height of Resident #7's bed, which increased the potential for injury, should a fall occur. She stated, Oh, he wants it that way. You can ask him. When interviewed at this time, Resident #7 responded No, he did not want his bed to be in a high position. When asked if he wanted his bed lower, he replied, Yes. CNA #2 then stated, Oh, well and did not lower the resident's bed before she left the room. Further review of Resident #8's Care Plan on 9/19/17 revealed the intervention of fall mats, which had been in effect since (YEAR), was no longer on the Care Plan. Review of the Care Plan History revealed the intervention of fall mats was deleted on 9/18/17 after surveyor intervention. The reason for the discontinuation of the mats on the Care Plan was listed as prior admit. Interview with the Care Plan Coordinator on 9/19/17 at 4:45 PM revealed he had deleted the intervention of fall mats after the survey team left the faciity on [DATE] because, I was just trying to make the Care Plans right and the fall mats had been in place on the Care Plan since the resident's last admission. He confirmed that each of the other interventions listed on the Care Plan were also in place since the last admission, and could provide no explanation as to why he had discontinued the one intervention on the Care Plan which the survey team identified was not being implemented by staff. Interview with a corporate representative who was present during this interview revealed the Care Plan approach of fall mats should not have been removed without an assessment of the resident's current needs and ongoing fall risk. Review of Resident #9's Admission Notes dated 8/7/17 revealed the resident was admitted to the facility with [DIAGNOSES REDACTED]. The admission note documented the resident's right side was flaccid, but he could move his left arm within the functional limitation. Demographic information revealed additional [DIAGNOSES REDACTED]. An Admission Fall Risk assessment completed 8/7/17 revealed the resident was at risk for falls, based on his incontinence, use of multiple medications, neuromuscular/functional status, and length of stay in the facility. Resident #9's admission MDS, dated [DATE] revealed the resident was moderately cognitively impaired, was bedfast, and was totally dependent on staff for all care, including transfers and bed mobility. Review of Resident #9's Comprehensive Care Plan revealed it was initiated on 8/23/17. The Care Plan noted the resident was at risk for falls r/t weakness S/P CVA (cerebrovascular accident - stroke). In response, 4 standard nursing interventions were listed as interventions - administer medications per orders, anticipate needs proactively, get assistance with ADLS to ensure safety as needed and observe for unsafe actions - intervene immediately. Review of Resident #9's Progress Notes revealed on 9/2/17, Nursing staff have had to assist resident back into proper position multiple times this shift. Resident has been found with legs out of bed. Progress Notes on both 9/8/17 and 9/9/17 documented the resident was in a low bed with call light in reach. Progress Notes on 9/15/17 documented the resident was noted with more activity, movement in legs, reaching, turning self from side to side .Bed currently in low position for patient safety. However, review of the Care Plan revealed it was not revised to reflect the fall risk related to the resident being found with portions of his body out of bed, his increased mobility and movement in legs, or the need for a low bed and call light that was identified by staff. Review of an Event Report revealed on 9/17/17 at 2:20 AM, a staff was walking hallway, noted resident OOB (out of bed) and yelled for assistance. Upon entering room, resident noted on R (right) side on floor between A and B bed. The report noted injuries from the fall, as the resident was decannulated (tracheostomy tube came out), complained of pain after the fall and had to have a .new trach placed . Per the Event Report, the facility was unable to determine the root cause of the fall, noting the resident was non-verbal/clean and dry. In response to this fall, the Care Plan was updated for a .Low bed when unattended . Observation on 9/18/17 at 5:24 PM revealed the resident was asleep in bed, with his tracheostomy in place, and nutrition infusing via gastrostomy tube. No staff were present in the room. The resident's bed was not in a low position. Interview on 9/18/17 at 5:29 PM with LPN #3 revealed, although he was aware Resident #9 had fallen from bed the previous day, he did not know the resident had been injured or required trach placement in response to the fall. He stated, He's been trying to get out of bed again today, especially this morning. LPN #3 stated, although the resident was totally dependent on staff for turning and repositioning, the resident had limited use of one arm and one foot, which he was using to wriggle himself across the bed. LPN #3 stated We put some pillows in to help keep the resident's position in the center of the bed to prevent further falls. Further observations of Resident #9 in bed on 9/18/17 at 5:33 PM, and on 9/19/17 at 8:33 AM and 2:03 PM revealed there were no pillows being used to",2020-09-01
2150,ROGERSVILLE CARE & REHABILITATION CENTER,445359,109 HWY 70 NORTH,ROGERSVILLE,TN,37857,2019-05-08,609,D,1,0,Y08Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility grievance document, and interview, the facility failed to report an allegation of sexual abuse to the State Survey Agency for 1 resident (#1) of 3 residents reviewed for Abuse. The findings included: Review of the facility policy Abuse, Neglect and Misappropriation of Property, undated, revealed .Reporting Guidelines: Any abuse allegation must be reported to State within 2 hours from the time the allegation was received . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 13 (cognitively intact). Continued review revealed the resident required limited assistance with transfers and toilet use with 1 person assist. Further review revealed the resident was occasionally incontinent of urine. Review of a facility grievance document dated 3/25/19 revealed Resident #1 reported to the Director of Nursing (DON) .a man took her to the bathroom while wiping her, he stuck his fingers 'back there' .Plan .female care givers only for personal care . Interview with the Administrator on 5/8/19 at 9:30 AM, in the conference room, revealed she was unaware of the allegation of abuse reported by Resident #1 until a representative from Adult Protective Services (APS) advised them on 5/3/19. Continued interview confirmed she was advised by the corporate offices there was no need to report the allegation to the State survey agency. In summary, Resident #1 reported an allegation of sexual abuse on 3/25/19 and APS informed the facility of the allegation on 5/3/19. As of 5/8/19 the facility had failed to report the incident to the State Survey Agency.",2020-09-01
2151,ROGERSVILLE CARE & REHABILITATION CENTER,445359,109 HWY 70 NORTH,ROGERSVILLE,TN,37857,2019-05-08,610,D,1,0,Y08Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility grievance report, and interview, the facility failed to investigation an allegation of Abuse for 1 resident (#1) of 3 residents reviewed for Abuse. The findings included: Review of the facility policy Abuse, Neglect and Misappropriation of Property, undated, revealed .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain or mental anguish .conducting a reasonable investigation: date and time of incident; the nature and circumstances of the incident; the location of the incident; a description of any injury; the condition of any injured person; the disposition of the injured person; names of witnesses and their accounts of the incident; time and date of notification of the resident's physician and family .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 entire Facility, as appropriate; shall conduct an appropriate physical assessments of residents who are not capable of being interviewed . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 13 (cognitively intact). Continued review revealed the resident required limited assistance with transfers and toilet use with 1 person assist. Further review revealed the resident was occasionally incontinent of urine. Review of a facility Grievance document dated 3/25/19 revealed Resident #1 reported to the Director of Nursing (DON) .a man took her to the bathroom while wiping her, he stuck his fingers 'back there' .Plan .female care givers only for personal care . Interview with the DON on 5/8/19 at 12:00 PM, in the conference room, revealed .was told she (Resident #1) wanted to talk to me around noon .She told me a man (Certified Nursing Assistant (CNA) #1) took her to the shower room and while he was wiping me he stuck his fingers back there .she could not tell me who or when .felt like the concern was a man giving care so implemented females only to provide care . Continued interview confirmed the facility was again notified of the allegation by an outside agency on 5/3/19. Further interview confirmed the facility did not begin their investigation until 5/3/19 (40 days after Resident #1 reported the incident). Telephone interview with Resident #1 on 5/9/19 at 1:40 PM revealed .told that woman in charge (DON) that (CNA#1) took my clothes off in the shower .put his fingers in my private areas and jerked .I talked with (outside agency) and told her the same thing I told (DON) .he didn't take care of me after that and I was glad . In summary, Resident #1 reported an allegation of abuse to the DON on 3/25/19. The DON assumed Resident #1 was uncomfortable with personal care provided by a male and did not investigate the allegation per facility policy until reported to the facility by an outside agency on 5/3/19.",2020-09-01
1692,WILLOW RIDGE CENTER,445284,215 RICHARDSON WAY,MAYNARDVILLE,TN,37807,2018-11-20,609,D,1,0,PGOW11,"**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 timely for 2 residents (#1 and #2) of 9 residents reviewed for abuse. The findings included: Review of the facility policy Abuse Prohibition, last revised on 7/1/18 revealed .will prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents 5.1.1.the notified supervisor will report the suspected abuse immediately to the Center Executive Director (CED) or designee and other officials in accordance with state law .If the suspected abuse is resident-to-resident, the resident who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed .6.Upon receiving information concerning a report of suspected or alleged abuse , mistreatment, or neglect, the CED or designee will perform the following: .report allegations involving abuse (physical, verbal, sexual, mental) not later than two hours after the allegation is made . Medial 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 Mental Status (BIMS) score of 12 (moderate cognitive impairment). Further review revealed the resident required extensive assistance for bed mobility, transfers, and activities of daily living (ADLs) with 1-2 person assist. 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 a BIMS score of 14 (cognitively intact). Continued review revealed the resident required extensive assistance with bed mobility, transfers, and ADLs with 1-2 person assist. Review of a facility investigation dated 11/8/18 at 9:00 PM revealed Resident #1 hit Resident #2 on the back of the head. Continued review revealed the residents were roommates. Further review revealed a nurse informed the Assistant Director of Nursing Services (ADNS) of the incident. Interview with Resident #1 on 11/20/18 at 1:40 PM, in his room, revealed .smacked him on the back of his head . Interview with Resident #2 on 11/20/18 at 1:50 PM, in his room, revealed .we got into he hit me on the head and I hit him on the head .Don't remember what it was about . Interview with ADNS on 11/20/18 at 2:45 PM, in the admissions office, revealed the staff nurse called her around midnight (3 hours later) and reported the resident-to-resident altercation. Continued interview revealed .I was told they were already in bed sleeping. I knew neither could get out of bed without assistance .told the nurse to check on the residents every 15 minutes and to move (Resident #1) first thing in the morning . Interview with the CED and Director of Nursing (DON) on 11/20/18 at 3:30 PM, in the CED's office, confirmed they were not notified of the incident the morning of 11/9/18 (approximately 11 hours later). In summary, the incident was not reported to the state survey agency until 11/9/18 at 8:55 AM (approximately 12 hours after the incident occurred) and the facility failed to follow facility policy.",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
1212,CHURCH HILL CARE & REHAB CTR,445237,701 WEST MAIN BLVD,CHURCH HILL,TN,37642,2017-07-19,223,D,1,0,HH0711,"**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 3 residents (#5, #6, and #8) were free from verbal abuse of 8 residents reviewed for abuse. The findings included: Review of the facility policy Abuse and Event Management Standard dated 10/2014, revealed .Abuse - A basic definition describes abuse as the harmful treatment of [REDACTED].Verbal abuse .any use of oral, written or gestured language that willfully includes the disparaging and derogatory terms to residents, their families or within hearing distance regardless of their age, ability to comprehend or infirmities .Reporting .All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint, allegation, observation or suspicion of resident abuse, mistreatment or neglect so that the resident's needs can be attended to immediately and investigation can be undertaken promptly . 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 3/10/17 revealed .has adjustment issues/potential for adjustment issues related to admission .give the resident control over the resident's environment and care delivery . Medical record review of Resident #5's Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 (moderate cognitive impairment). Continued review revealed the resident required extensive to total assist for transfers, dressing, and personal hygiene with 1-2 person assist, and was always incontinent of bowel and bladder. Review of a facility investigation dated 4/9/17 revealed a witness statement written by Certified Nursing Assistant (CNA) #3. Further review revealed .Date of incident 4/8/17 .reported 4/9/17 .(CNA #8) and I were changing resident yesterday during change (CNA #8) spoke to resident in a hateful manner .aggravated because resident wouldn't let go of (lift used for transfers) .repeatedly told resident to let go in a hateful voice .(CNA #8) gets hateful with resident (s) if they don't do what she tells them .(Resident #5) told (CNA #8) 'maybe if you treat people different they would treat you different' .(Resident #5) called the (CNA #8) a 'hateful [***] ' .told (CNA #8) she wanted to 'smack the[***]out of her' .(CNA #8) didn't respond or apologize for being hateful .but she (CNA #8) did calm down .the resident also mentioned (CNA #8's) foul language .(CNA #8) said to (Resident #5) 'yes I have a potty mouth' .I don't remember exact curse words she used but she (CNA #8) does it all the time .I'm just used to it . Continued review of a witness statement by Licensed Practical Nurse (LPN) #1. Further review revealed . I heard (CNA #8) being very loud in the hall at approx. (approximately) 8:00 AM .as I walked down the hallway two CNA's were in (Resident #5's room) and I could hear (CNA #8) talking rude. I knocked on the door and ask if everything was ok? (CNA #8) said 'yes, why' .I said it sounded like she (CNA #8) was not talking very nice .(CNA #8) said 'she (Resident #5) is complaining already and I am not dealing with it today' . Further review revealed the Assistant Director of Nursing (ADON) interviewed Resident #5 and the resident stated .if that hateful (CNA #8) would be friendlier, people would be friendlier to her. She is always hateful and acts mad towards me .(CNA #8) was using bad language .I ask her not to be rough .She (CNA #8) is hateful to me all the time because I'm the one she has to get up and help with everything . Continued review of a statement from CNA #8 revealed .(Resident #5) kept calling me (wrong name) .that I didn't love her, I was hurting her and was mean to her. Resident got upset yesterday and pulled my scrub shirt .I said 'don't rip my shirt.' When she got a hold of (lift) I told her she was going to pull her shoulder out of place. Resident told me if I was nicer, that other people would be nicer .Resident called me 'hateful [***] ' .I did tell resident that 'I do have a potty mouth' . Telephone interview with CNA #4 on 7/12/17 at 10:30 AM revealed .we were getting her (Resident #5) up .she (CNA #8) was hateful .resident told her if she would be nicer maybe people would be nicer to her .(CNA #8) said 'Come on (Resident #5) roll' and then used foul language .reported to LPN #1 that morning (4/8/17) . Interview with LPN #1 on 7/12/17 at 10:50 AM, in the treatment nurse's office, revealed .I was outside the door and I could hear (CNA #8) yelling .knocked on the door and asked what was going on and (CNA #8) said 'that's how she had to deal with her (Resident #5)' .had heard (CNA #8) cuss in front of resident many times .every day I worked with her .had told her she shouldn't use that kind of language .reported to ADON .she (ADON) would talk to her (CNA #8) .she would do better for a little while .the resident's couldn't tell you anything .I think she should have been removed immediately, but I'm just an LPN .yes ADON told me I should remove someone immediately and call RN/DON (Registered Nurse/Director of Nursing) if it happened again . Continued interview revealed CNA #8 was allowed to continue her shift and was not removed from providing resident care. Interview with Resident #5 on 7/13/17 at 9:15 AM, in her room, revealed .I don't remember a CNA named (#8). I remember one CNA being hateful and rude, but don't remember her name .don't remember what she said .I think she didn't like me because I am fat . Telephone interview with CNA #8 on 7/19/17 at 9:15 AM revealed .we had a good relationship when she (Resident #6) was having a good day .yes, I said words that were not good that day .don't remember what . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 7 (severe cognitive impairment). Further review revealed the resident required extensive assist with transfers, dressing, and personal hygiene with 2 person assist. Further review revealed the resident was always incontinent of bladder and frequently incontinent of bowel. Medical record review of the care plan revised on 3/16/17 revealed .potential to demonstrate physical behaviors r/t (related to) Dementia, Poor impulse control .When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later . Review of a facility investigation dated 4/9/17 revealed a witness statement completed by CNA #9. Further review revealed .(CNA #8) takes (Resident #6) to shower room and tells her that she cannot stand her, she looks like a troll, you disgust me or you are disgusting, states to resident you know why I cannot stand you. (Resident #6 stated) to me that she doesn't know why that woman (CNA #8) stays so mad all the time .CNA (#8) uses foul language in front of residents all day long every day . Continued review revealed RN #5 attempted to interview Resident #6, but the resident mumbled unintelligible comments. Interview with the Central Supply Clerk on 7/12/17 at 2:00 PM, in the treatment nurse's office, revealed .was the weekend manager (on 4/8/17- 4/9/17) .don't remember who reported it .sometime after lunch on Sunday (4/9/17) .had them write statements .called ADON .then me and (RN #4) took (CNA #8) into the conference room and questioned her. (CNA #8) was crying .asked her what was wrong and told her we had complaints of her being mean .told her she needed to go home . Observation and interview with Resident #6 on 7/12/17 at 3:05 PM, in her room, revealed the resident was unable to answer questions. Interview with CNA #5 on 7/12/17 at 3:25 PM, in the treatment nurse's office, revealed . (Resident #6) requires two person assist because she is claiming everyone is trying to kill her .she knows who she is but is confused and delusional . Interview with CNA #6 on 7/12/17 at 3:45 PM, in the treatment nurse's office, revealed . (Resident #6) will try to hit, she sometimes gets hysterical, try to calm her, but may have to walk away . Telephone interview with CNA #8 on 7/19/17 at 9:15 AM revealed .she (Resident #6) had done something sexually inappropriate to me .you know these people have dementia so you try to overlook things like that .Yes, I know I used words that were inappropriate for the work place . Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #8 was discharged to the hospital on [DATE] and did not return to the facility. Medical record review of the 14 Day MDS dated [DATE] revealed the resident had a BIMS score of 99 (unable to complete). Continued review revealed the resident required total to extensive assistant with transfers, dressing, eating, and personal hygiene with 1-2 person assist. Further review revealed the resident was always incontinent of urine and frequently incontinent of bowel. Medical record review of Resident #8's care plan dated 4/4/17 revealed .potential to demonstrate physical behaviors r/t (related to) Dementia .Intervene before agitation escalates; guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later . Review of a facility investigation revealed a witness statement by CNA #4. Further review revealed .(CNA #8) and I were doing care on (Resident #8) and going to get her up .When getting resident out of bed, (CNA #8) got more aggravated and began to curse .resident was slapping and resident got a hold of (CNA #8's) scrub top while sitting on side of bed and (CNA #8) yanked scrub top out of the resident's hand .(CNA #8) began to curse out using 'F .and G D .Are you f serious' .(CNA#8) always curses in front of residents .does this on regular basis but does not curse the resident .(CNA #8) just uses foul language no matter the resident .I went out of room to get help from (LPN #1) .(CNA #8's) behavior stopped when the LPN came in the room to help us . Continued review revealed RN #5 interviewed Resident #8 and the resident did not report any concerns with staff members. Telephone interview with CNA #8 on 7/19/17 at 10:10 AM, in the treatment nurse's office, revealed .they said I used words in front of her (Resident #8) but I don't remember . Interview with the Administrator on 7/19/17 at 10:30 AM, in the Administrator's office, confirmed the facility failed to ensure Resident #5, #6, and #8 were free from verbal abuse and the facility failed to follow facility policy.",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
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
2241,NORTHSIDE HEALTH CARE NURSING AND REHABILITATION C,445373,202 EAST MTCS ROAD,MURFREESBORO,TN,37130,2017-11-30,684,E,1,1,Z9P511,"**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 medications were administered according to Physician order [REDACTED].#6, #8, #15, #24, #35, #37) of 37 residents reviewed. The findings included: Review of facility policy, Preventing Medication Errors and Medication Administration, effective 11/28/17, revealed .Medications may only be administered by licensed medical or nursing personnel acting within the scope of their license as per the Physician order [REDACTED].Medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescription order; the manufacturer's specifications regarding preparation and administration; accepted professional standards and principals which apply to professionals providing services . Review of facility policy, Controlled Medication Policy, effective 11/28/17, revealed .The facility will have safeguards in place to prevent loss, diversion, or accidental exposure .Any discrepancies that cannot be resolved must be reported immediately: notify the DON immediately and the Pharmacy; complete an investigation detailing the discrepancy; steps taken to resolve it; and names of all licensed staff working when the discrepancy was noted .Staff may not leave the area until discrepancies are resolved or reported as unresolved discrepancies . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) revealed Resident #6 scored 8 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. Medical record review of the Medication Administration Record (MAR) for (MONTH) (YEAR) revealed it was documented Resident #6 was administered [MEDICATION NAME] (pain) 50 milligrams (mg) at 9:00 PM on 10/30/17 by Licensed Practical Nurse (LPN) #4. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #8 scored 15 on the BIMS indicating she was alert, oriented, and able to make her needs known. Medical record review of the (MONTH) MAR revealed documentation Resident #8 was administered [MEDICATION NAME] 5 mg at 9:00 PM on 10/31/17. Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #15 scored 10 on the BIMS, indicating she had moderate cognitive impairment. Medical record review of the (MONTH) MAR revealed documentation Resident #15 was administered Atorvastatin 20 mg at 9:00 PM on 10/31/17. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #24 was severely impaired cognitively. Medical record review of the (MONTH) MAR revealed documentation Resident #24 was administered a [MEDICATION NAME] (pain) patch 50 micrograms per hour to be changed every 3 days on 10/31/17. Medical record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #35 was severely impaired cognitively. Medical record review of the (MONTH) MAR revealed documentation Resident #35 was administered [MEDICATION NAME] (pain) 100 mg at 9:00 PM on 10/31/17. Medical record review revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #37 was moderately impaired cognitively. Medical record review of the (MONTH) MAR revealed documentation Resident #37 was administered Atorovastatin 40 mg at 9:00 PM on 10/31/17. Continued review of the MAR and Narcotic Sign-Out Record revealed on 10/30/17 and 10/31/17 [MEDICATION NAME] (antianxiety) 0.5 mg were signed out and 0.25 mg were wasted each night. Review of the facility investigation revealed staff spoke with the Director of Nursing (DON) the morning of 10/31/17 regarding concerns LPN #4 was not administering medications on the 7:00 PM - 7:00 AM shift. Continued review revealed the DON conducted a count of all medications due to be administered to residents on the 7:00 PM - 7:00 AM shift on 10/31/17. Further review revealed the staff stated medications were not administered on 10/31/17 and LPN #4 was frequently absent from the nurses' station and the building. Continued review revealed the DON recounted the medications on 11/1/17 and found discrepancies with medications for Residents #6, #8, #15, #24, #35, and #37. Further review revealed the medication count was the same on 11/1/17 as it was on 10/31/17, indicating the medications were not given. Continued review revealed the residents who had discrepancies received their medications from LPN #4. Further review revealed the narcotic sign-out sheet for [MEDICATION NAME] for Resident #37 had the signature of LPN #4 as administering the medication but also had the signature of RN #2 as observing/confirming the wasting of 0.25 mg of [MEDICATION NAME] on 10/30/17 and 10/31/17. Continued review revealed the signature did not appear to be that of RN #2 and when questioned she denied it was her signature. Review of a written statement from CNA #7 dated 11/1/15 revealed at 10:15 PM a resident asked for his medications. Continued review revealed CNA #7 went to the car of LPN #4 and found her asleep with the car running Review of a written statement by the Assistant Director of Nursing (ADON) dated 10/31/17 revealed one resident stated she had to ask for pain medications during the night and the nurse (LPN #4) made her feel insecure about the medications she was administering. Continued review revealed another resident stated she had to ask for her medications quite awhile after they were due and the nurse (LPN #4) appeared sleepy. Further review revealed this resident was concerned for those residents who could not ask for their medications. Review of the facility investigation revealed the DON determined LPN #4 did not administer the medications but documented them as being administered. Continued review revealed the DON and ADON telephoned LPN #4 to notify her she was terminated. Interview with the DON and ADON on 11/30/17 at 1:50 PM in their office revealed on 10/31/17 the CNAs came to them to say they did not think LPN #4 was administering medications to residents. At that point the DON counted the medications that would be administered on the 7:00 PM - 7:00 AM shift. On the morning of 11/1/17 the staff again stated they felt medications were not administered and they couldn't find LPN #4 most of the night. When residents would ask for medications she would say she had already given them. At one point during the night one of the CNAs had to knock on the car window of LPN #4 because she was asleep in the car. The DON did another count of medications on 11/1/17 and found all narcotics counts were correct. Sporadic drugs were documented as administered but the medications were still in the blister packs, indicating they were not administered. Both the DON and ADON viewed the video surveillance from the night of 10/31/17 and noted LPN #4 to be absent from the building for periods of time as well as in a camera blind spot which was the beauty shop. They also noted LPN #4 to be sleeping at the nurses' station. At this point they called LPN #4; informed her of the findings; and told her she was terminated. Interview with the DON confirmed LPN #4 documented medications as being administered but they were not. In summary, on the nights of 10/30/17 and 10/31/17, LPN #4 documented medications for 6 residents as being administered when they were not as evidenced by the count remaining the same for both days. On those two nights LPN #4 signed out 2 narcotics; wasted part of the tablet; and signed the name of another nurse. Review of the video surveillance for 10/31/17 revealed LPN #4 missing from the building for periods of time as well as sleeping at the nurses' station. Staff reported they had to go out to her car to wake her up to give medications to residents.",2020-09-01
4487,CUMBERLAND HEALTH CARE AND REHABILITATION INC,445262,4343 ASHLAND CITY HWY,NASHVILLE,TN,37218,2016-09-21,225,D,1,0,KCHW11,"**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 follow their policy for occurrence investigations and failed to complete a thorough investigation for allegations of abuse for 2 residents (#1, #3) of 8 residents reviewed for abuse. The findings included: Review of facility policy, Abuse, dated 6/14 revealed, .The policy provides the procedure and practice in the event of an incident of actual or suspected abuse. The Administrator must lead the facility and oversee the investigation of all incidents of abuse .The important thing to remember is that all reports are treated in the same fashion. The first and most important step is ensuring the safety of the patients. The next step is to conduct a THOROUGH investigation that is well documented .Investigation Checklist .Is there a detailed accounting of the incident .or injury documented in the nurses notes? Social services notes should also document any 'patient to patient' altercation .Was the Nurse Event Note completed with no blanks and follow up done for 72 hours or until resolved? .Were preventative measures taken to prevent similar incidents .or injuries from occurring again? . Review of facility policy, Occurrences, Patient, dated 9/14 revealed, .An occurrence is any happening, which is not consistent with the routine .care of a particular patient .It might be an .unusual happening, or situation .Upon discovery of a patient occurrence, the charge nurse must complete the Nurse's Event Note. The original is to be filed in the patient's chart .All areas of the note must be completed .The investigation area .must also be completed .Nursing Administration should also complete the Post Occurrence Analysis Report and attach report to the Occurrence Investigation .An appropriate intervention must be implemented by the charge nurse immediately to prevent recurrence. Observe the patient for the next 72 hours .Document observations each shift emphasizing pertinent problems that might occur from the occurrence .it is important to get accurate information in a thorough investigation that will help uncover the cause of the occurrence, which in turn will hopefully prevent similar occurrences from happening .An injury (including bruises .) that was not observed by any person .is considered an injury of unknown origin and requires a thorough investigation .The investigation must include all personnel who have had contact with the patient during the past 48 hours, or more if indicated . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility investigation dated 8/5/16 revealed Resident #1 claimed an allegation of abuse by a female night shift staff member who grabbed her arm and left a bruise in the early morning of 8/2/16.The resident was unable to name the alleged perpatrator. The facility investigation included statements from 1 male nurse, Certified Nurse Aide (CNA) #2, Resident #1's roommate, and a resident across the hall from the resident; a statement from the resident, and a skin assessment dated [DATE] indicating a fading bruise to the resident's right upper forearm. Review of a Daily Assignment Sheet dated 8/2/16 revealed the male nurse was not working on 8/2/16 and 2 female nurses worked the 11 PM - 7 AM shift that night. Continued review revealed 4 other CNA's and CNA #2 worked the night shift. Medical record review revealed no Nurse's Event Note in the clinical notes, no Post Occurrence Analysis Report completed by nursing administration, no detailed accounting of the incident documented in the nurse notes, and no 72 hour documentation of observations of the resident after the alleged occurrence in the clinical notes. Continued review revealed a nursing note dated 8/5/16 regarding restorative range of motion and the next nursing note was dated 8/17/16. There was no documentation of a Social Service follow up visit. Interview with the Director of Nursing (DON) on 8/31/16 at 1:30 PM, in the Conference Room revealed she had no knowledge of a bruise to Resident #1 until today when the Assistant Director of Nursing (ADON) mentioned it to her. The DON confirmed there was no Nurse's Event Note in the clinical notes for Resident #1; no Post Occurrence Analysis Report; no 72 hour documentation of observations of the resident after knowledge of the alleged abuse occurred and no follow up visit or notes from Social Services. Continued interview revealed the DON stated she would have completed head to toe skin assessments on all cognitively impaired residents in the care of CNA #2, and interviewed all cognitively intact residents. The DON stated she would have notified Psych Services and Social Services to visit Resident #1. Continued interview with the DON confirmed the facility failed to fully investigate the allegation of abuse and a bruise of unknown origin for Resident #1. Interview with the Administrator on 9/1/16 at 1:00 PM, in the Conference Room confirmed the facility failed to complete a thorough investigation for allegations of abuse for Resident #1. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility investigation dated 8/2/16 revealed an incomplete Nurse's Event Note dated 8/1/16, hand written statements from CNA #1, and Licensed Practical Nurse (LPN #4), regarding a witnessed physical altercation between Resident #2 and Resident #3. Continued review of LPN #4's statement revealed, .The techs noticed (Resident #2) standing at the head of the bed of (Resident #3) .I instructed everyone in the room to back off of (Resident #2) .Once patient (Resident #2) walked out of the room [ROOM NUMBER] staff members tried to prevent (Resident #2) from falling .while other staff was instructed to stay with (Resident #3) .Continued review revealed no names or statements from the 3 staff members present, or the staff member who stayed with Resident #3 who had knowledge of the resident to resident altercation as reported by LPN #4 were present in the facility investigation. Medical record review revealed no Post Analysis Occurrence Report and no follow up with Social Services. Interview with the DON on 8/31/16 at 1:30 PM, in the Conference Room confirmed the facility investigation for Resident #3 was incomplete and not thoroughly investigated. The DON confirmed the facility failed to thoroughly investigate the resident to resident altercation for Resident #3.",2019-09-01
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
5646,"SUMMIT VIEW OF FARRAGUT, LLC",445258,12823 KINGSTON PIKE,KNOXVILLE,TN,37923,2016-01-26,226,D,1,0,EUNZ11,"**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 implement its abuse policy for one Resident (#6) of 9 residents reviewed. The findings included: Review of facility policy, Guidelines for Abuse Investigations (effective (MONTH) 2007) revealed, .All reports of resident abuse .shall be promptly and thoroughly investigated by facility management .review .Unusual Occurrence Report .interview the persons reporting the incident .interview any witnesses .interview the resident .reports will be obtained in writing .with signature and date .employees .who have been accused .will be immediately reassigned .or suspended from duty until results have been reviewed .Administrator will provide a written report of the results of all abuse investigations and appropriate actions taken to the state agency .as required by .law . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident with a Brief Interview of Mental Status Score (BIMS) of 14/15 (cognitively intact) and the resident was independent in decision making. Review of the Patient Grievance Forms from 3/1/15 to 3/30/15 revealed an entry dated 3/14/15 (late entry) signed by the Social Services Worker on 3/17/15 that noted an investigation of allegations of verbal abuse and neglect of the resident made by a staff Certified Nursing Assistant (CNA #8) against CNA (#9) on 3/14/17. Continued review revealed the resident was interviewed and did not recall the incident as alleged in the grievance and no staff or resident witnesses were identified related to the incident. Review of a type written statement dated 7/23/15 and signed by the Social Services Worker revealed .investigation results revealed that this allegation may have been the result of a conflict that (CNA #8) had with (CNA #9) .The unit nurses noticed that (CNA #8) had a problem with (CNA #9) .(CNA #9) and the resident were not aware of the allegations . Review of the facility investigation revealed the incident was reported to the Department of Health on 8/12/15 (148 days after the alleged incident was to have occurred). Continued review revealed the facility investigation did not identify any of the floor nurses interviewed during the investigation, nor did it include written documentation of interviews with the alleged victim, other potential staff witnesses or interviews with the alleged perpetrator or accuser. There was no documentation of an Unusual Occurrence Report and no written, signed or dated statements by any of the involved staff members included in the investigation. Review of the personnel file for CNA #9 (alleged perpetrator) revealed no indication the CNA had been temporarily suspended or reassigned during the abuse investigation. Interview and review of the facility investigation with the current Administrator on 1/25/16 at 2:00 PM in the conference room, revealed the Administrator reported when she arrived and assumed oversight of the facility in 6/2015 she began a routine review of facility operations which included reviews of incident investigations and the grievance logs for the prior year and upon completion of her audit several weeks later determined the facility's documentation of the investigation was incomplete and the incident had not been reported to the Department of Health. Continued interview confirmed the facility had failed to implement its abuse policy and immediately report abuse allegations to the Administrator or his/her designee upon their discovery, failed to report abuse allegations to the Department of Health within 5 days as required by law, confirmed the facility failed to thoroughly document the investigation and confirmed the facility failed to suspend or reassign the alleged perpetrator to duties that did not involve resident contact until the outcome of the investigation was determined.",2019-01-01
1007,SPRING CITY CARE AND REHABILITATION CENTER,445209,331 HINCH STREET,SPRING CITY,TN,37381,2018-09-25,607,D,1,0,15FE11,"**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 intervene promptly during an alleged incident and failed to report an allegation of abuse timely for 1 resident (#1) of 5 residents reviewed for abuse and neglect. The findings included: Review of the facility policy, Abuse, Neglect and Misappropriation of Property, undated, revealed .Every Stakeholder .must intervene immediately, to the extent feasible and consistent with personal safety .and training .to prevent or interrupt an incident of abuse . 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 the resident scored an 8 (moderate cognitive impairment) on the Brief Interview for Mental Status. Review of a facility investigation dated 9/3/18 revealed Licensed Practical Nurse (LPN) #2 alleged she observed LPN #1 roughly handle and verbally demean Resident #1. Continued review revealed LPN #2 did not intervene promptly during the incident and waited until LPN #1 clocked out at the end of the shift (approximately 2 hours) before she reported the incident to the Director of Nursing (DON). Interview with LPN #2 on 9/24/18 at 2:16 PM, in the conference room, confirmed she witnessed the alleged incident between Resident #1 and LPN #1, but did not intervene immediately. Further interview confirmed LPN #2 did not report the incident timely to the DON. Interview with the DON on 9/24/18 at 3:30 PM, in the conference room, confirmed the facility failed to follow facility policy.",2020-09-01
5645,"SUMMIT VIEW OF FARRAGUT, LLC",445258,12823 KINGSTON PIKE,KNOXVILLE,TN,37923,2016-01-26,225,D,1,0,EUNZ11,"**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 investigate allegations of abuse, and to report allegations of abuse to the State Survey and Certification Agency in accordance with Federal Requirements for 1 Resident (#6) of 9 residents reviewed. The findings included: Review of facility policy, Guidelines for Abuse Investigations (effective (MONTH) 2007) revealed, .All reports of resident abuse .shall be promptly and thoroughly investigated by facility management .review .Unusual Occurrence Report .interview the persons reporting the incident .interview any witnesses .interview the resident .reports will be obtained in writing .with signature and date .employees .who have been accused .will be immediately reassigned .or suspended from duty until results have been reviewed .Administrator will provide a written report of the results of all abuse investigations and appropriate actions taken to the state agency .as required by .law . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident with a Brief Interview of Mental Status Score (BIMS) of 14/15 (cognitively intact) and the resident was independent in decision making. Review of the Patient Grievance Forms from 3/1/15 to 3/30/15 revealed an entry dated 3/14/15 (late entry) signed by the Social Services Worker on 3/17/15 that noted an investigation of allegations of verbal abuse and neglect of the resident made by a staff Certified Nursing Assistant (CNA #8) against CNA (#9) on 3/14/17. Continued review revealed the resident was interviewed and did not recall the incident as alleged in the grievance and no staff or resident witnesses were identified related to the incident. Review of a type written statement dated 7/23/15 and signed by the Social Services Worker revealed .investigation results revealed that this allegation may have been the result of a conflict that (CNA #8) had with (CNA #9). The unit nurses noticed that (CNA #8) had a problem with (CNA #9) .(CNA #9) and the resident were not aware of the allegations . Review of the facility investigation revealed the incident was reported to the State Survey and Certification Agency on 8/12/15 (148 days after the alleged incident was to have occurred). Continued review revealed the facility investigation did not identify any of the floor nurses interviewed during the investigation, nor did it include written documentation of interviews with the alleged victim, other potential staff witnesses or interviews with the alleged perpetrator or accuser. Further review revealed no documentation of an Unusual Occurrence Report and no written, signed or dated statements by any of the involved staff members included in the investigation. Review of the personnel file for CNA #9 (alleged perpetrator) revealed no indication the CNA had been temporarily suspended or reassigned during the abuse investigation. Interview with the Staff Development Coordinator (SDC) on 1/25/16 at 11:45 AM, in the conference room revealed she was formerly employed as the Social Services Worker and investigated the incident noted in the facility documentation. The SDC reported at the time of the occurrence she was assigned to perform the witness interviews and document findings by the former Administrator who was the facility abuse coordinator and coordinated the investigation under the supervision of the former Director of Nursing (DON). Continued interview revealed the SDC reported she learned of the allegations on Tuesday 3/17/15 in the morning, shortly after arriving to work when a staff nurse whose name she could not recall reported CNA #8 had accused CNA #9 of verbal abuse of Resident #6 on Friday 3/14/15 on the evening shift (3 days prior). The SDC reported the nurse informed her that the allegations had not been reported to the DON or Administrator at the time they were alleged to have occurred and the nurse who reported the allegations to her informed the SDC she had not witnessed the incident herself but heard peers discuss CNA #9's allegations against CNA #8 in the nursing station the night before. Further interview revealed the SDC reported she immediately took a written statement from the reporting nurse and informed both the former DON and former Administrator of the allegations and an investigation of the incident was launched on 3/17/15. Interview revealed the SDC reported she interviewed both the alleged perpetrator and accuser during her investigation, took written statements from both and interviewed the staff nurses on duty at the time the incident was alleged to have occurred and all staff interviewed except for CNA #8 denied knowledge of any incident that involved Resident #6 or the alleged perpetrator. Continued interview revealed the SDC reported she interviewed Resident #6 and the resident denied any abuse had occurred. The SDC reported both Resident #6 and the accused person appeared unaware of the allegations. Continued interview revealed the SDC reported the findings of her investigation and provided copies of all written statements to both the former DON and former Administrator for review. The SDC stated once the former DON took possession of the documents her role in the investigation was completed and the former DON and former Administrator were responsible for implementation of any responses to the alleged incident. Interview and review of the facility investigation with the current Administrator on 1/25/16 at 2:00 PM, in the conference room revealed the Administrator reported when she arrived and assumed oversight of the facility in 6/2015 she began a routine review of facility operations which included reviews of incident investigations and the grievance logs for the prior year and upon completion of her audit several weeks later determined the facility's documentation of the investigation was incomplete and the incident had not been reported to the State Survey and Certification Agency. The Administrator reported she required the SDC to add her typewritten statement to the documents on hand as part of her corrective actions in response to the incident prior to submission of the report to the Department of Health on 8/12/15. The Administrator confirmed the investigation presented to the surveyor was missing documentation of the witness interviews conducted by the SDC and stated the facility had attempted to locate them without success. Continued interview confirmed the facility investigation presented to the surveyor was incomplete. The Administrator confirmed the facility had failed to immediately report abuse allegations to the Administrator or his/her designee upon their discovery. The Administrator confirmed the facility had failed to thoroughly document the investigation and confirmed investigations were to include interviews of all witnesses or involved parties and documentation of suspension or reassignment of accused persons and confirmed the facility failed to reassign or suspend the alleged perpetrator to duties that did not involve resident contact until the outcome of the investigation was determined. The Administrator confirmed the facility had failed to investigate and report allegations of abuse to the State Survey and Certification Agency within 5 days in accordance with Federal Law.",2019-01-01
2659,MT JULIET HEALTH CARE CENTER,445439,2650 NORTH MT JULIET ROAD,MOUNT JULIET,TN,37122,2017-06-07,514,D,1,0,W48711,"**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 an accurate medical record for 1 resident (#4) of 3 residents reviewed for medication administration on 3 of 4 halls of 18 sampled residents. The findings included: Review of the facility's policy Controlled Drug Accountability Procedure dated 4/22/14 revealed .Each dose administered is to be signed out by the nurse on the controlled drug record and on the patient's eMAR (electronic Medication Administration Record) .The count of each controlled substance must be audited at every shift change by the nurse coming on duty and the nurse going off duty. Visual checks of the entire medication card for missing medications and the record sheet must be done by both nurses .Both nurses must sign the Narcotic Control Record .indicating that the count has been completed; the date, time, number of medication cards and the number of controlled drug record sheets must be documented . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 scored 08/15 (severely cognitive impaired) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required limited assistance for transfer and hygiene/bathing with extensive assistance for dressing. Medical record review of the Patient Medication Profile dated 7/23/16 revealed a physician's orders [REDACTED]. Medical record review of the Administration History (computer documentation) of the [MEDICATION NAME] Patch for Resident #4 revealed it was documented as given on 5/7/17, 5/13/17, and 5/16/17. Medical record review of the Controlled Drug Receipt/Record/Disposition Form (paper form) revealed the [MEDICATION NAME] Patch 25 mcg/hr was administered on 5/7/17, 5/11/17, 5/13/17, and 5/16/17. Review of a facility investigation dated 5/30/17 revealed .(named nurse) on (MONTH) 11th, (YEAR) .signed out a [MEDICATION NAME] Patch for a resident but did not document the administration in Vision (computerized system) . Interview with the Interim Director of Nursing (DON) on 6/5/17 at 3:25 PM, in the Social Services office, confirmed the facility signed the medication out on the narcotic controlled drug sheet, but failed to document the administration of the medication in the electronic medical record. Further interview confirmed the facility failed to maintain an accurate medical record for Resident #4.",2020-09-01
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
4490,CUMBERLAND HEALTH CARE AND REHABILITATION INC,445262,4343 ASHLAND CITY HWY,NASHVILLE,TN,37218,2016-09-21,323,D,1,0,KCHW11,"**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 prevent a resident to resident altercation for 1 resident (#3) of 8 residents reviewed for abuse. The findings included: Review of facility policy, Resident Rights, dated 9/14 revealed, .Listing of Resident Rights .To be free from mental and physical abuse . Review of facility policy, Abuse, dated 6/14 revealed, .This facility practices the concept of 'zero tolerance' for patient abuse. Nurse management must strive to ensure that the patients are free from verbal, sexual, physical and mental abuse .Abuse may involve patients .all reports are treated in the same fashion. The first and most important step is ensuring the safety of the patients .Policy .To operate the facility where all patients are free from verbal, sexual, physical and mental abuse .Facility will identify patients whose personal history renders them at risk for abusing other patients. The facility will assess, develop intervention strategies, monitor for changes and reevaluate interventions as needed . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Medical record review of an Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 5/15 on the Brief Interview for Mental Status (BIMS) indicating Resident #2 was severely cognitively impaired. The resident had physical and verbal behavioral symptoms directed toward others, for 1-3 days of the 7 day look back period. The resident significantly intruded on the privacy of others and was significantly disruptive to the care and living environment. He rejected care and had behaviors of wandering 1-3 days of the 7 day look back period. Continued review revealed the resident was ambulatory and required supervision of 1 person. Medical record review of Clinical Notes dated 6/2/16 at 12:48 AM revealed, .patient noted to be completely naked standing in front of sleeping roommate . 6/2/16 at 9:04 AM notes revealed, .pacing, rummaging through other resident belongings especially foods .disrobing in public, wandering, seeking exits .easily agitated high anxiety .resistant at times from redirection . 6/2/16 at 10:31 PM documented .Resident wandering into rooms and was asked to come out. Upon guiding resident out of the room, resident tried to hit @ (at) me by balling fist and flexing toward me .Resident can become combative easily when being redirected . Continued review on 6/5/16 at 5:55 PM revealed, .Resident is wandering in hallway nude; numerous attempts to put clothes on resident but resident resistive .swinging out at staff members .7/10/16 at 12:09 AM clinical notes documented, .Patient found in his room pulling his roommate by the feet towards the floor .several redirection techniques with no effectiveness .Resident then began to take off his pants and get into bed with roommate . 7/28/16 at 5:51 PM clinical notes documented .disrobing in public, grabbing items from other resident's .grabbing water pitcher off cart .urinating in hallway in corners .approached female table and started pulling off tablecloth .then he proceeded around the table and pinched a female resident's upper right arm .becomes aggressive pulls away aggressive stance acts like he's going to hit staff when he was separated from female resident . Review of clinical notes dated 8/1/16 at 12:14 AM documented, .Resident .in the roommates area holding the roommates (Resident #3) right wrist tightly with his left hand. This writer and another staff member tried to remove the patients hand from his roommates arm and patient reached down and grabbed the roommates gown with right hand at the area of roommates neck. After several unsuccessful attempts to detach the roommates arm from patients hand .patient let the roommate go and walked out of the room . Medical record review of the comprehensive care plan dated 6/14/16 revealed a problem of wandering. Interventions included, .Check location/whereabouts of (Resident #2) every 30 minutes on each shift . Medical record review revealed 1:1 hourly monitoring of Resident #2 on 6/27/16 from 1:00 PM-6/28/16 at 6:00 AM; 6/28/16 from 7:00 AM-3:00 PM, and from 11:00 PM to 6/29/16 at 6:00 AM; 6/29/16 at 7:00 AM-11:00 PM; 6/30/16 from 7:00 AM- 3:00 PM; 7/28/16 from 4:00 PM-6:00 PM; 7/29/16 from 7:00 AM-1:00 PM, and 3:00 PM-7/30/16 at 6:00 AM; 7/30/16 at 7:00 AM-3:00 PM; and 7/31/16 from 7:00 AM-3:00 PM. Interview with Licensed Practical Nurse (LPN #2) on 8/23/16 at 11:11 AM, in the Conference Room confirmed the wandering and behaviors of Resident #2 and his need for constant observation and redirection. When asked if the facility was able to meet the needs of the resident with adequate supervision, the LPN stated, No I do not. Our staff is already lacking and we needed to watch him all of the time. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission MDS dated [DATE] revealed a BIMS score of 5/15 indicating the resident was severely cognitively impaired. Resident #3 required extensive assistance of 2 people for transfers and extensive assistance of 1 person for locomotion. He had bilateral lower extremity impairments and used a wheelchair at all times. Review of a handwritten statement in a facility investigation by Certified Nurse Aide (CNA #1) dated 8/1/16 revealed, .On 7/30/16 I observed (Resident #2) a resident in room 502A walked toward the resident in room 502B bed and grabbed his hand very tightly .I have seen him many times trying to get in the bed of (Resident #3) 502B resident his roommate. Many times I have separated him from his room (mate) trying to grab him . Medical record review of Clinical Notes dated 8/1/16 at 1:24 AM revealed, Resident in bed 502B noted to be laying in bed with arm being held tightly by roommate 502A .attempted multiple times to remove arm from roommates hands but was not successful. 502A grabbed 502B by the gown in (front) by neck tightly. Staff able to lure the patient away from 502A .Patient in bed 502B appeared frightened . Interview with the DON on 8/31/16 at 1:30 PM, in the Conference Room confirmed the facility failed to follow the comprehensive care plan and check on the whereabouts of Resident #2 every 30 minutes thus resulting in a resident to resident altercation with Resident #3. The DON confirmed the facility failed to protect Resident #3 from the physical behaviors of Resident #2.",2019-09-01
1751,BEECH TREE HEALTH AND REHABILITATION,445292,"240 HOSPITAL LANE, PO BOX 300",JELLICO,TN,37762,2018-10-26,600,D,1,0,I1LH11,"**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 prevent abuse for 2 residents (#1 and #2) of 5 residents reviewed for abuse. The findings included: Review of the facility policy Abuse, Neglect, Exploitation and Misappropriation of Resident Property, not dated, revealed .(Facility) will not tolerate Abuse, Neglect, Exploitation of its residents .Willful means the individual must have acted deliberately .Prevention .monitoring of residents with needs and behaviors which might lead to conflict .such as residents with a history of aggressive behaviors . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Review of Resident #1's Care Plan dated 8/8/16 and last revised on 9/7/18 revealed .9/7/18 Altercation with another resident . Medical record review revealed Resident #3 was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. Review of a Quarterly MDS dated [DATE] revealed a BIMS score of 7, indicating severe cognitive impairment. Continued review revealed the resident experienced verbal behaviors 1 to 3 days during the period reviewed. Review of Resident #3's Care Plan dated 2/12/16 and revised on 9/7/18 revealed .altercation with another resident . Continued review revealed the resident was placed on every 15 minute checks until seen by psychiatric services. Further review of the care plan updated on 10/12/18 revealed .place on close observation 1 on 1 when smoking . Review of the facility investigation dated 9/7/18 revealed Resident #1 was involved with an altercation with Resident #3 on 9/7/18. Further review revealed the residents were in the dayroom and were overheard yelling at each other. Continued review revealed an employee entered the dayroom and witnessed Resident #3 hit Resident #1 on the right side of the face. Further review revealed the two residents were separated and placed on 15 minute checks until seen by the psychologist. Review of a Health Status Note dated 9/7/18 at 4:30 PM revealed .it appears that (Resident #1) and (Resident #3) were both in the dayroom and (Resident #1) is telling .(Resident #3) about a chair in a loud voice .(Resident #3) who is also hard of hearing, apparently felt .(Resident #1) was raising his voice at him and became agitated .(Resident #3) wheels his chair closer to the couch where .(Resident #1) is sitting and both residents begin to attempt to get to the standing position (Certified Nursing Assistant #1) enters and gets between the two .(Resident #3) however, does manage to swing at .(Resident #1) through the CNA's (Certified Nursing Assistant) arms and makes contact with .(Resident #1) . Interview with CNA #1 on 10/23/18 at 2:00 PM, in the conference room, revealed .I was at the nurses' station .heard voices getting loud .I went into the day room and .(Resident #1) was standing up and .(Resident #3) stood up. I got between them, one was on each side of me .(Resident #3's) left arm went between my arms and hit .(Resident #1) on the right side of his face on his chin .(Resident #3) took his left arm and intentionally hit (Resident #1) on the right side of his face .oh yeah he meant to hit him . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of a Quarterly MDS dated [DATE] revealed a BIMS score of 6, indicating severe cognitive impairment. Review of a care plan dated 7/17/13 and last revised on 10/12/18 revealed .10/12/18 Altercation with another resident . Review of the facility investigation dated 10/12/18 revealed Resident #3 had an altercation with Resident #2. Continued review revealed after returning to the building from a smoking break Resident #3 yelled at Resident #2 .'you pulled your car out in front of me' . Further review revealed Resident #3 then stood up from his wheelchair and struck Resident #2 on the face and put his hands around Resident #2's neck. Continued review revealed the residents were separated by staff. Interview with Licensed Practical Nurse (LPN) #4 on 10/23/18 at 12:15 PM, in the conference room, revealed .(Resident #3) grabbing (Resident #2's) wheelchair handles .he said something then he stood up and hit .(Resident #2) on his face . Interview with LPN #3 on 10/23/18 at 4:45 PM, in the conference room, revealed .I was at the med (medication)cart with .(LPN #1) and I saw .(Resident #2's) feet shuffling .I turned around to see what was going on. I saw .(Resident #3) had his arms around .(Resident #2's) neck .had him in a head lock .at the time he knew what he was doing; he knew he had his hands around his neck .it was deliberate . Interview with the Director of Nursing on 10/26/18 at 9:30 AM, in the conference room, confirmed Resident #3 had a known history of resident to resident altercations and the facility failed to prevent abuse to Resident #1 and Resident #2 by Resident #3.",2020-09-01
1408,SUMMIT VIEW OF ROCKY TOP,445259,204 INDUSTRIAL PARK RD,ROCKY TOP,TN,37769,2020-02-12,600,D,1,0,7H4S11,"**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 prevent abuse for 2 residents (Resident #5 and Resident #1) of 5 residents reviewed for abuse, resulting in Resident #5 and Resident #1 being physically abused by Resident #2. The findings include: Review of the facility's policy titled, Abuse Prevention Program, dated 12/2016, showed .Our residents have the right to be free from abuse.this includes but is not limited to.physical abuse. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] showed Resident #5 had short and long term memory problems. 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. Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a significant change MDS dated [DATE] showed Resident #2 scored a 1 (severe cognitive impairment) on the Brief Interview for Mental Status (BI[CONDITION]) and had no behavioral symptoms directed toward others during the look back period. Review of Resident #2's care plan dated 3/29/2018 showed .Redirect resident when displaying behaviors. The care plan was updated on 1/14/2020 to show .resident was placed on one on one watch until ambulance arrived.was discharged to hospital. The care plan was updated on 1/29/2020 to show .resident was placed closer to the nurses station.private room.was placed on one on one on 1/30/2020. Review of a facility investigation dated 1/14/2020 showed Resident #2 was observed hitting Resident #5 in the face. No injuries were noted to either resident. The resident was sent to the hospital on [DATE] and was admitted to a gero-psychiatric unit. The resident was discharged from the hospital back to the facility on [DATE]. Review of a facility investigation dated 1/30/2020 showed Resident #2 was observed hitting Resident #1 on the left side of his mouth and cheek, causing a laceration to Resident #1's lower lip. During an interview on 2/12/2020 at 3:00 PM, the Assistant Administrator stated .with the first incident he (Resident #2) hit him (Resident #5) in the face.they (Resident #2 and Resident #5) didn't have any injuries.with the second incident he (Resident #2) hit (Resident #1) in the face causing an injury to his (Resident #1's) lip. The Assistant Administrator confirmed the facility failed to prevent abuse to Resident #1 and Resident #5.",2020-09-01
1260,GREYSTONE HEALTH CARE CENTER,445242,181 DUNLAP ROAD,BLOUNTVILLE,TN,37617,2019-07-02,600,D,1,0,49DX11,"**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 prevent verbal abuse for 1 resident (#4) of 4 residents reviewed for abuse of 8 sampled residents. The findings included: Review of the facility policy, Abuse Prevention Program, revised date 2/22/18 revealed .Our residents have the right to be free from abuse .'verbal abuse' is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents . Medical record review revealed Resident #4 was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. Medical record review of Resident #14's Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 15 (cognitively intact). Continued review revealed the resident was totally dependent on staff for bed mobility, transfers, and activities of daily living with 1-2 person assist. Further review revealed the resident was verbally aggressive towards staff. Review of a facility investigation dated 6/28/19 revealed Resident #4 was overheard cursing Certified Nurse Assistant (CNA) #7 and the CNA then in turn cursed the resident and said .(expletive) you (Resident #4) . Further review revealed Licensed Practical Nurse (LPN) #2 immediately removed CNA#7 from resident care and notified the Director of Nursing (DON). Continued review revealed CNA #7 and the facility notified the Physician and local and state agencies. Further review of an undated hand written statement signed by CNA #7 confirmed she had cursed Resident #4. Interview with Hospitality Aide #1 on 7/1/19 at 1:00 PM, in the conference room, revealed Resident #4 .gets upset if someone is not in his room right away (to answer the call light) . Interview with LPN #1 on 7/1/19 at 1:15 PM, in the conference room, revealed .(Resident #7) has his picks .he will cuss staff sometimes if he doesn't like you . Telephone interview with LPN #2 on 7/1/19 at 5:00 PM confirmed she overheard CNA #7 cursed Resident #4. Interview with the DON on 7/2/19 at 11:45 AM, in her office, confirmed CNA #7 was terminated by the facility for verbal abuse of Resident #7.",2020-09-01
1797,LIFE CARE CENTER OF ATHENS,445298,"1234 FRYE STREET, PO BOX 786",ATHENS,TN,37371,2019-06-19,600,D,1,0,BEBO11,"**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 prevent verbal abuse to 1 resident (#1) of 3 residents reviewed for abuse or neglect, of 5 residents sampled. The findings included: Review of facility policy, Protection of Residents: Reducing the Threat of Abuse & Neglect, revised 2/1018, revealed .Residents must not be subjected to abuse by anyone .verbal abuse .the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of their age, ability to comprehend or disability . 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 scored a 7 (severe cognitive impairment) on the Brief Interview for Mental Status and required assistance of one or two persons for all activities of daily living (ADL). Review of a facility investigation dated 5/27/19 revealed on 5/27/19 at approximately 2:29 PM Certified Nursing Assistant (CNA) #1 observed an incident between Housekeeper #1 and Resident #1. Further review revealed Resident #1 was seated in a wheelchair near the doorway of her room and Housekeeper #1 attempted to direct the resident away from the doorway so the housekeeper could enter the room; which agitated Resident #1. Continued review revealed the Housekeeper became angry at the agitated resident and then yelled at Resident #1 .get out of my damn way . Further review revealed the housekeeper then stomped her foot at Resident #1 from a distance of about 2-3 feet away from Resident #1, as staff members moved to intervene. Continued review revealed CNA #2 heard the housekeeper curse and yell at Resident #1 .I don't have to take this[***]. Further review revealed Housekeeper #1 was questioned about the incident by the Administrator and the housekeeper admitted she had cursed the resident. Interview with CNA #1 on 6/19/19 at 1:45 PM, in the training room, revealed she observed the housekeeper curse Resident #1 and she considered Housekeeper #1's actions to be willful and aggressive. Interview with the Director of Nursing (DON) on 6/19/19 at 3:00 PM, in the training room, confirmed the facility failed to protect Resident #1 from verbal abuse and the facility failed to follow facility policy.",2020-09-01
4167,BETHESDA HEALTH CARE CENTER,445427,444 ONE ELEVEN PLACE,COOKEVILLE,TN,38501,2016-12-07,431,D,1,0,GGMZ11,"**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 promptly dispose of discontinued medications for 2 Residents (#5, #6) of 6 residents reviewed and failed to safely secure medications on 2 of 5 medication carts reviewed. The findings included: Review of the facility policy Controlled Medications effective 7/2014 revealed .management of controlled medications is a matter of utmost importance . irregularities in the drug count cannot be tolerated .upon receipt of controlled substances .nurse must ensure .the drugs are secured in the proper drawer of the medication cart .count of each controlled substance is audited at every shift change .visual checks of the entire medication card must be done by both nurses .whenever the number of cards or sheets in the narcotic drawer will be effected due to discontinuing a medication or if a card is empty .two nurses are required to verify the change .if the count is incorrect the DON must be notified immediately .no exchange of med cart keys should be done and the off going nurse should not leave the facility .when an irregularity is noted .the nurse on duty at the time is accountable .whenever .medication is discontinued or a patient discharged .the medication must be removed from the cart and placed in a designated area in the med prep room .controlled medications must be .destroyed by the DON or designee . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Medication Administration Record [REDACTED]. Further review revealed the resident's Hydrocodone was increased to 10 mg tablets on 11/29/16. Review of a facility investigation dated 11/29/16 revealed the discontinued Hydrocodone (7.5 mg tablets) was placed in the back of the narcotics drawer in the 500 Hall medication cart to await disposal. Continued review revealed on 11/30/16 Licensed Practical Nurse (LPN) #9 had control of the 500 Hall medication cart on the day shift (7:00 AM to 3:00 PM). Further review revealed all narcotic reconciliation counts were documented as accurate and correct at the beginning and end of the LPN's shift and the discontinued Hydrocodone 7.5 mg tablets were documented as present on the cart. Continued review revealed on 11/30/16 LPN #7 assumed control of the medication cart at 3:00 PM and maintained sole control of the cart until approximately 8:47 PM when she turned over the control of the medication cart to LPN #8. Further review revealed LPN #8 reported she performed a narcotic reconciliation with LPN #7 around 8:45 PM on 11/30/16 and no irregularities in narcotic counts were noted. Continued review revealed LPN #8 conducted an audit of the narcotic count prior to the end of her shift (11:00 PM) and discovered the narcotic control inventory sheet and narcotic blister (dispensing) cards for Resident #5's discontinued Hydrocodone were missing. Further review revealed LPN #8 did not immediately report the missing medications or inaccurate reconciliation to the Director of Nursing (DON) until 12/1/17 at 2:30 PM. Telephone interview with LPN #8 on 12/6/16 at 6:30 PM confirmed both LPN #8 and #7 signed off the narcotic count before the count was started. Continued interview revealed neither nurse pulled narcotic cards from the cart during the count, nor did they check the name of each resident, name of any drug or dosage present, or cross check one another during the count. Further interview confirmed the missing medication was unaccounted for and she failed to report the discrepancy immediately upon discovery to the DON. Further interview confirmed LPN #8 had failed to follow facility policy. Telephone interview with LPN #7 on 12/6/16 at 8:45 PM confirmed she signed off on the narcotic count prior to the actual narcotic count and she failed to follow facility policy. Interview with the DON and Administrator on 12/6/16 at 2:45 PM, in the Human Resources Coordinator's office, confirmed the facility failed to follow facility policy. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a MAR indicated [REDACTED]. Review of a facility investigation dated 9/27/16 revealed the facility received 30 tablets of Oxycodone 20 mg tablets from the facility pharmacy service the evening of 9/27/16. Further review revealed on the morning of 9/27/16 at 5:30 AM LPN #20 discovered the Oxycodone and the narcotic inventory sheet were missing from the 100 hall medication cart during the morning narcotic reconciliation. Continued review revealed the missing Oxycodone was documented as present on the medication cart on 9/26/16. Further review revealed on 9/26/16 the narcotic storage boxes, located on the medication cart, were filled to capacity and LPN #21 removed an unknown number of narcotic blister cards and placed them in a bottom drawer of the medication cart, which was secured by one lock. Continued review revealed the narcotic count was inaccurate on 9/24/16, 9/25/16, and 9/26/16 and staff nurses continued to pass medications and document the narcotic inventory count as accurate during shift change reconciliations. Further review revealed the DON was not immediately notified of the discrepancies. Interview with LPN #16 on 12/7/16 at 1:00 PM, in the conference room, revealed on 9/23/16 she assisted the DON with removal of a large quantity of discontinued medications, including narcotics, from the 100 hall medication cart. Further interview revealed LPN #16 discovered the discrepancy in the narcotic control sheet inventory count on 9/23/16 and advised the DON. Continued interview confirmed she was aware an unknown number of narcotic blister cards for an unknown number of residents were stored in the bottom drawer of the narcotic cart and the cart was not secured by two locks per facility policy. Interview with the DON on 12/7/16 at 11:00 AM, in the conference room, confirmed the DON was aware of the discrepancies in the narcotic inventory on the 100 hall medication cart after removal of discontinued medications from the cart on 9/23/16. Continued interview confirmed the facility had stored narcotics in the bottom drawer of the medication cart, the cart was not secured with two locks, and the facility failed to follow facility policy.",2019-11-01
2088,SIGNATURE HEALTHCARE OF SOUTH PITTSBURG REHAB & WE,445343,201 EAST 10TH STREET,SOUTH PITTSBURG,TN,37380,2018-11-29,600,D,1,0,CUY711,"**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 protect 1 resident (#3) from abuse of 3 residents reviewed for abuse, of 5 residents sampled. The findings included: Review of the facility policy Abuse, Neglect and Misappropriation of Property revealed, not dated, revealed .It is .policy to prevent the occurrence of abuse .the policy applies to all residents without respect to the resident's cognitive condition, awareness, or ability to understand the event at the time .abuse is the willful infliction of injury .intimidation .includes .verbal abuse .for purposes of this policy 'willful' means non-accidental .means the individual acted deliberately .not that the individual must have intended to inflict injury or harm . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 5 (severe cognitive impairment) on the Brief Interview for Mental Status. Continued review revealed the resident had a history of [REDACTED]. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's 14 day MDS dated [DATE] revealed the resident scored a 4 (severe cognitive impairment) on the BIMS. Continued review revealed the resident had no history of behaviors and was dependent upon moderate to maximum assistance of others for all ADLs. Review of a facility investigation dated 11/26/18 revealed Resident #2 wandered into Resident #3's room on the secured memory care unit and sat on Resident #2's bed. Continued review revealed Licensed Practical Nurse (LPN) #1, who was at the nurses' station, heard a commotion, entered the resident's room and observed Resident #3 pull on Resident #2's pants leg. Further review revealed LPN #2 observed Resident #2 tell Resident #3 to stop and then slap Resident #3 on the right cheek with an open hand. Interview with LPN #1 on 11/29/18 at 1:25 PM, in the dietary office, revealed she heard a commotion from Resident #3's room at the far end of the unit and when she responded she observed Resident #3 tug on Resident #2's leg and then she observed Resident #2 slap Resident #3. Interview with the Director of Nursing (DON) on 11/29/18 at 3:35 PM, in the dietary office, revealed the DON confirmed Resident #2 willfully slapped Resident #3 on the face and the facility failed to protect Resident #3 from abuse.",2020-09-01
1020,SPRING CITY CARE AND REHABILITATION CENTER,445209,331 HINCH STREET,SPRING CITY,TN,37381,2018-12-14,580,D,1,0,DJ7L11,"**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 a change in resident condition timely to the Physician for one resident (#5) of 4 residents reviewed for change in condition of five sampled residents. The findings included: Review of the facility policy Change of Condition, undated, revealed .The facility will evaluate and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner, to relay information to the physician and to document actions to include but not limited to .significant change in the residents physical .status .need to alter treatment .decision to transfer .accident which results in injury .or has potential .requiring physician intervention .document in the medical record the physician .notification .notify the resident's representative .of change .and follow through completed .in the medical record .follow up documentation by the licensed nurse .should continue .following onset of the change or as ordered by the physician .address .change on the 24 hour report .update the care plan . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 had short and long term memory loss, was chair or bedfast, and required maximum assistance of 2 persons for all activities of daily living. Review of a facility investigation dated 11/30/18 revealed on 11/29/18 at approximately 2:00 AM Resident #5 was noted by Certified Nurse Aide (CNA) #3 to have increased discomfort during personal care. Continued review revealed CNA #3 noted [MEDICAL CONDITION] in the resident's right leg above the knee joint and a dried spot of blood on the resident's left shin. Further review revealed CNA #3 reported the symptoms Licensed Practical Nurse (LPN) # 2 and LPN #2 assessed the resident's and noted the findings on the 24 hour report form. Continued review revealed LPN #2 did not notify the Physician of the resident's change in condition. Further review revealed at approximately 4:00 AM CNA #3 noted the resident's right knee had increased swelling and the resident had increased discomfort. Continued review revealed CNA #3 reported the resident's condition to LPN #2 who assessed the resident again, but did not report the change in condition to the physician. Further review revealed the resident's condition was not immediately reported to the Director of Nursing (DON) or Administrator by the oncoming nurse, but the resident's change in condition was discussed in the daily morning meeting which included Assistant Directors of Nursing (ADON) #1 and #2. Continued review revealed ADON #1 and ADON #2 completed the morning meeting but did not assess Resident #5 or notify the Physician of Resident #5's condition until around 1:30 PM on 11/29/18 (11.5 hours later) when staff reported Resident #5 exhibited increased swelling to her right leg and had abrasions on her left knee. Further review revealed ADON #1 notified the physician and obtained an order for [REDACTED]. Interview with the Administrator and Director of Nursing (DON) on 12/17/18 at 6:00 AM, in the conference room, confirmed the facility failed to notify Resident #5's physician timely of the change of condition and the facility failed to follow facility policy.",2020-09-01
1333,RIVER GROVE HEALTH AND REHABILITATION,445253,1520 GROVE ST BOX 190,LOUDON,TN,37774,2019-04-18,609,D,1,0,3SWQ11,"**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 allegations of abuse to the State Agency within 2 hours for 1 resident (#2) of 3 residents reviewed for abuse. The findings included: Review of the facility policy, Abuse, effective date 11/28/17 revealed .The center reports any alleged violations involving verbal, sexual, physical and mental abuse .to .officials in accordance with State regulations through established procedures including to the State Survey and certification agency . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 was severely cognitively impaired, had verbal and physical behaviors directed at others, had impaired thought processes and confusion, limited mobility in both lower extremities, urinary and fecal incontinence, and required moderate to maximum assistance of one or two persons for all activities of daily living. Review of a facility investigation dated 3/16/19 revealed the facility received notification from local law enforcement that Resident #2's spouse contacted them on 3/16/19 alleging Resident #2 had been sexually assaulted in the facility. Continued review revealed no evidence the State Survey Agency was notified of the alleged incident by the facility. Interview with the Director of Nursing (DON) on 4/18/19 at 4:53 PM, in the DON's office, confirmed the facility failed to notify the State Survey Agency of the allegation.",2020-09-01
259,"HEALTH CENTER AT STANDIFER PLACE, THE",445111,2626 WALKER RD,CHATTANOOGA,TN,37421,2019-05-01,609,D,1,0,22N711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, and interview, the facility failed to report an allegation of abuse within 2 hours to the State Survey Agency for 1 resident (#4) of 3 residents sampled for abuse, of five sampled residents. The findings included: Review of facility policy, Abuse, (undated) revealed .if you have reasonable suspicion that a crime has occurred against a resident .Federal Law Requires that you report your suspicion directly to .the State Survey Agency . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 scored a 14 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Medical record review of a Nursing Note dated 3/26/19 at 10:00 PM revealed .Pt (patient) A&O (alert and oriented) .some confusions (at) times . Medical record review of a Nursing Note dated 4/11/19 at 4:00 AM revealed .went to check on pt .not responding in usual manner .very lethargy .speech sluggish . Continued review revealed the resident was transferred to a local hospital with altered mental status and a urinary tract infection [MEDICAL CONDITION]. Review of the facility investigation dated 4/24/19 revealed a caseworker with Adult Protective Services (APS) contacted the facility on 4/24/19 and advised them while Resident #4 was in the hospital the resident alleged she was sexually abused by an unidentified male staff member at the facility sometime prior to her hospitalization on [DATE]. Further review revealed the facility did not report the allegation to the State Survey Agency. Interview with the Director of Nursing and the Risk Manger on 4/30/19 at 6:00 PM, in the conference room, confirmed the facility failed to report an allegation of abuse to the State Agency within 2 hours of notification of the allegation. In summary, the facility was aware of an allegation of abuse on 4/24/19 and as of 4/30/19, the facility had not reported the allegation of abuse to the State Survey Agency (7 days).",2020-09-01
1213,CHURCH HILL CARE & REHAB CTR,445237,701 WEST MAIN BLVD,CHURCH HILL,TN,37642,2017-07-19,225,D,1,0,HH0711,"**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 thoroughly investigate an allegation of abuse and failed to report the allegation to the state agency within 2 hours for 2 residents (#2 and #5) of 8 residents reviewed for abuse. The findings included: Review of the facility policy Abuse and Event Management Standard dated 10/2014, revealed .Abuse .Reporting .All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint, allegation, observation or suspicion of resident abuse, mistreatment or neglect so that the resident's needs can be attended to immediately and investigation can be undertaken promptly . 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 the resident had a Brief Interview for Mental Status (BIMS) score of 5 (cognitive impairment). Continued review revealed the resident required extensive assistance with transfers, dressing, and personal hygiene with 1 person assist. Further review revealed the resident was always incontinent of bowel and bladder. Medical record review of a nurse's note dated 6/2/17 completed by Licensed Practical Nurse (LPN) #5 revealed .Resident told staff that she had been raped by a man she did not know. Resident has not had any male visitors. Before resident spoke with male staff about the situation resident was escorted to bathroom by male staff but also had female nurse in room. Resident was placed in hall with nurse until resident went to bed. Resident had no other complaints of this situation. Resident showed no s/sx (signs/symptoms) of distress . Medical record review of a nurse's note dated 7/5/17 (34 days after the alleged incident) completed by LPN #4 revealed .This nurse present during Dr (doctor) .assessment of resident (r/t (related to) incident 06.02.17) .conducted in resident's room. Dr .questioned resident asking X (times) 2 if resident remembered making statement (rape allegation) .she replied yes X 2 when asked X 2 if resident remembered incident, she replied yes X 2 when asked X 2 if she could describe the incident or tell what happen, resident did not respond X 2 .Dr .asked if resident would prefer to speak to a female MD (Medical Doctor). Resident did not respond X 2. Dr .explained there would probably be no benefit in the exam since the incident occurred on 06.02.17. Dr .also told resident he would prefer not to put her through the exam. Resident responded ok Dr .asked resident if she understood the questions he was asking and she said yes .He further explained that he would discuss this with his attending and would speak to resident again. Resident said ok . Medical record review of a nurse's note dated 7/7/17 completed by Registered Nurse #2 revealed .late entry/follow-up note on 6/2/17: Staff notified me that resident had made remarks regarding inappropriate activity. I assessed resident who at this time was alert to name only. No bleeding was noted on brief changed by staff. Resident did not show any signs of distress. She has a flat affect which is WNL (within normal limits) for her. Resident stated a man had inappropriate sexual activity with her, 'but he didn't hurt me' .there were only two male staff members that worked this night and she stated it was not either one of them. No male residents had been out of their rooms after bedtime. Resident was up in wheelchair at nurse's desk the rest of the morning with staff member close by at all times until shift change . Interview with Resident #2's Primary Care Physician on 7/13/17 at 10:50 AM, in the medical records office, revealed .was made aware .suspicion is it happened in her previous life .the facility did a terrible job with follow up but when they figured out what had happened they did follow up . Interview with LPN #5 on 7/18/17 at 6:05 PM, in the treatment nurse's office, revealed .I reported to my supervisor .she (supervisor) told me to keep her with me until she went to bed . Interview with CNA #7 on 7/18/17 at 6:20 PM, in the treatment nurse's office, revealed .she (Resident #2) was hollering help .went in room .said I've been raped .ask by who .she didn't know . Interview with RN #2 (supervisor) on 7/18/17 at 6:45 PM, in the treatment nurse's office, revealed .should have called the nurse on call and/or called the Director of Nursing (DON) . Interview with the DON on 7/19/17 at 10:00 AM, in her office, confirmed she was not informed of the allegation until 7/5/17 (34 days later). Continued interview confirmed she would have expected to have been notified of the allegation of rape by Resident #2. Interview with the Administrator on 7/19/17 at 10:15 AM, in her office, confirmed the facility failed to investigation an allegation of abuse timely and failed to report the allegation to the state agency within 2 hours. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #5's Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Mental Interview Status (BIMS) score of 10 (moderate cognitive impairment). Continued review revealed the resident required extensive to total assist for transfers, dressing, and personal hygiene with 1-2 person assist, and was always incontinent of bowel and bladder. Review of a facility investigation dated 4/9/17 revealed a witness statement written by Certified Nursing Assistant (CNA) #3. Further review revealed .Date of incident 4/8/17 .reported 4/9/17 .(CNA #8) and I were changing resident yesterday during change (CNA #8) spoke to resident in a hateful manner .aggravated because resident wouldn't let go of (lift used for transfers) .repeatedly told resident to let go in a hateful voice .(CNA #8) gets hateful with resident (s) if they don't do what she tells them .(Resident #5) told (CNA #8) 'maybe if you treat people different they would treat you different' .(Resident #5) called the (CNA #8) a 'hateful [***] ' .told (CNA #8) she wanted to 'smack the[***]out of her' .(CNA #8) didn't respond or apologize for being hateful .but she (CNA #8) did calm down .the resident also mentioned (CNA #8's) foul language .(CNA #8) said to (Resident #5) 'yes I have a potty mouth' .I don't remember exact curse words she used but she (CNA #8) does it all the time .I'm just used to it . Continued review revealed a witness statement by Licensed Practical Nurse (LPN) #1. Further review revealed . I heard (CNA #8) being very loud in the hall at approx. (approximately) 8:00 AM .as I walked down the hallway two CNA's were in (Resident #5's room) and I could hear (CNA #8) talking rude. I knocked on the door and ask if everything was ok? (CNA #8) said 'yes, why' .I said it sounded like she (CNA #8) was not talking very nice .(CNA #8) said 'she (Resident #5) is complaining already and I am not dealing with it today' . Further review revealed the Assistant Director of Nursing (ADON) interviewed Resident #5 and the resident stated .if that hateful (CNA #8) would be friendlier, people would be friendlier to her. She is always hateful and acts mad towards me .(CNA #8) was using bad language .I ask her not to be rough .She (CNA #8) is hateful to me all the time because I'm the one she has to get up and help with everything . Continued review of a statement obtained from CNA #8 revealed .(Resident #5) kept calling me (wrong name) .that I didn't love her, I was hurting her and was mean to her. Resident got upset yesterday and pulled my scrub shirt .I said 'don't rip my shirt.' When she got a hold of (lift) I told her she was going to pull her shoulder out of place. Resident told me if I was nicer, that other people would be nicer .Resident called me 'hateful [***] ' .I did tell resident that 'I do have a potty mouth' . Further review revealed the facility failed to report the incident to the state agency until 4/9/17 at 2:12 PM ( 30 hours after the allegation). Telephone interview with CNA #4 on 7/12/17 at 10:30 AM revealed .reported( the incident) to LPN #1 that morning (4/8/17) . Interview with LPN #1 on 7/12/17 at 10:50 AM, in the treatment nurse's office, revealed .I think she (CNA #8) should have been removed immediately, but I'm just an LPN .yes ADON told me I should remove someone immediately and call RN/DON (Registered Nurse/Director of Nursing) if it happened again . Interview with the ADON on 7/18/17 at 10:20 AM, in the treatment nurse's office, confirmed the facility failed to investigate an allegation of abuse timely, failed to report an allegation of abuse to the state agency timely, and the facility failed to follow facility policy.",2020-09-01
1022,SPRING CITY CARE AND REHABILITATION CENTER,445209,331 HINCH STREET,SPRING CITY,TN,37381,2018-12-14,842,D,1,0,DJ7L11,"**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 document significant changes in resident medical conditions into the medical record for one Resident (#5) of 5 medical record reviewed. The findings included: Review of the facility policy Change of Condition, undated, revealed .The facility will evaluate and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner, to relay information to physician and to document actions to include but not limited to .significant change in the residents physical .status .need to alter treatment .decision to transfer .resident .accident which results injury .or has potential .requiring physician intervention .document in the medical record the physician .notification .notify the resident's representative .of change .and follow through completed .in the medical record .follow up documentation by the licensed nurse .should continue .following onset of the change or as ordered by the physician .address .change on the 24 hour report .update the care plan . Review of a facility investigation dated 11/30/18 revealed on 11/29/18 at approximately 2:00 AM Resident #5 was noted by Certified Nurse Aide (CNA) #3 to have increased discomfort during personal care. Continued review revealed CNA #3 noted [MEDICAL CONDITION] in the resident's right leg above the knee joint and a dried spot of blood on the resident's left shin. Further review revealed CNA #3 reported the symptoms Licensed Practical Nurse (LPN) # 2 and LPN #2 assessed the resident's and noted the findings on the 24 hour report form. Continued review revealed at approximately 4:00 AM CNA #3 noted the resident's right knee had increased swelling and the resident had increased discomfort. Continued review revealed CNA #3 reported the resident's condition to LPN #2 who assessed the resident again. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 had short and long term memory loss, was chair or bedfast, and required maximum assistance of 2 persons for all activities of daily living. Medical record review revealed no documentation of the swelling and pain to Resident #5's leg. Telephone interview with LPN #2 on 12/11/18 at 7:00 PM confirmed she was made aware of Resident #5's symptoms of swelling and pain in the resident's right leg, but she had become distracted and failed to complete the nursing documentation. Interview with the Director of Nursing (DON) on 12/17/18 at 6:00 AM, in the conference room, confirmed there was no documentation of the resident's injury in the medical record.",2020-09-01
106,CLAIBORNE HEALTH AND REHABILITATION CENTER,445071,1850 OLD KNOXVILLE ROAD,TAZEWELL,TN,37879,2019-01-07,609,D,1,0,Y9FF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, and interviews, the facility failed to ensure allegations of abuse were reported timely to the facility's Administrator and to the state survey agency for 4 residents (#1, #2, #3, and #4) of 8 residents reviewed for abuse on 1 of 4 nursing units. The findings included: Review of facility policy titled Reporting Allegations of Abuse/Neglect/Exploitation, last reviewed 6/2018, revealed .policy of this facility to report all allegations of abuse/neglect/exploitation to appropriate agencies in accordance with current state and federal regulations . Medical Record Review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical Record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored 3/15 (severely cognitive impaired) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident exhibited physical and verbal behaviors directed toward others and required total care for bed mobility, transfer, toilet use, and personal hygiene. Medical record review of Resident #1's care plan dated 11/16/18 revealed the resident was care planned for episodes of combativeness during care. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #2 was assessed as severely cognitive impaired and was unable to complete the BIMS. Further review revealed the resident required total assistance for bed mobility, toilet use, dressing, and personal hygiene. Medical record review of Resident #2's care plan dated 9/19/18 revealed the resident would smack at staff during care received for Activities of Daily Living (ADL). Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #3 was severely cognitive impaired and required extensive assistance for bed mobility, transfer, toilet use, and personal hygiene. Medical record review of Resident #3's care plan dated 10/17/18 revealed the resident was care planned for resistance to care during ADLs and smacks and yells out when care was provided. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual MDS dated [DATE] revealed Resident #4 was severely cognitive impaired and was unable to complete the BIMS. Further review revealed the resident had episode of physical behavioral directed toward others. Continued review revealed the resident required total assistance for bed mobility, transfer, toilet use, and personal hygiene. Medical record review of Resident #4's care plan revealed the resident was at risk for episodes of [MEDICAL CONDITION] and changes in behaviors and moods. Review of a facility investigation dated 12/14/18 revealed Certified Nursing Assistant (CNA) #1 notified Licensed Practical Nurse (LPN) #1 the morning of 12/14/18 of an allegation of abuse, which occurred on the day shift of 12/13/18 (prior day). Further review revealed CNA #1 alleged she witnessed CNA #2 abuse 4 residents during care. Continued review revealed CNA #1 alleged CNA #2 held her hands over the mouth of Resident #2 and #4 and hit Resident #1 in the head with a pillow because he called the CNAs the B word. Further review revealed CNA #1 stated, during ADL care for Resident #3, CNA #2 was holding the resident's hands tightly because the resident was trying to put her hands in the incontinent episode and when Resident #3 started to cry CNA #2 put her hand over the resident's mouth and told her to be quiet. Continued review revealed CNA #1 stated she was afraid to report the incidents, but after she thought about it over night she reported the incidents to LPN #1. Further review revealed CNA #2 denied the incidents, but she was terminated on 12/18/18 due to .recent investigation has determined that on Thursday, (MONTH) 13th while performing her CNA assignments (CNA #2) provided care and assistance which did not meet an acceptable standard of care . Continued review revealed . a recent investigation determined (CNA #1) observed a number of inappropriate interactions demonstrated by a fell ow coworker (CNA#2). Standard practices were not followed as there was a delay in reporting these events . Interview with CNA #1 on 1/7/19 at 1:30 PM, in the Director of Nursing's (DON) office, confirmed the CNA was aware she was required to report any allegation of abuse immediately. Telephone interview with CNA #2 on 1/7/19 at 1:45 PM revealed the CNA denied the abuse occurred. Interview with the Administrator on 1/7/19 at 3:15 PM, in the Administrator's office, confirmed CNA #1 was aware she should have reported the allegation of abuse immediately, but failed to do so.",2020-09-01
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
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
3574,SERENE MANOR MEDICAL CTR.,4.4e+252,970 WRAY ST,KNOXVILLE,TN,37917,2020-01-08,600,D,1,0,245H11,"**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 sexual abuse to 2 residents (#1 and #2) of 8 residents reviewed for abuse. The findings included: Review of the facility policy Resident Abuse, Neglect, Theft of Personal Property, Unusual Incident/Accidents, undated, revealed .Abusive residents will be identified by previous history and procedures established for: intervention to prevent occurrences .identify, correct and intervene in risk areas . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's Admission MDS dated [DATE] revealed a Brief Interview Mental Status score of 14 (cognitively intact). The resident required supervision for bed mobility, transfers, and ambulation. Medical record review of Resident #1's care plan dated 10/28/2019 revealed the resident had demonstrated previous inappropriate sexual behaviors on 10/27/2019 and 11/1/2019 and the resident was placed on observations every 15 minutes after each incident. The resident also had a medication change. The resident's care plan was updated on 11/30/2019 for inappropriate sexual behaviors involving Resident #2. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed had both short and long term memory problems and was moderately impaired for daily decision making skills. Medical record review of Resident #2's care plan dated 3/13/2019 revealed the resident had demonstrated previous inappropriate sexual behaviors on 2/18/2019 and 3/30/2019 and was placed on observations every 15 minutes after each incident. The resident's care plan was updated on 11/30/2019 for inappropriate sexual behaviors involving Resident #1. Review of a facility investigation dated 11/30/2019 revealed Resident #1 and Resident #2 were observed seated side by side in the hallway and Resident #1's genitalia was exposed and Resident #2 was touching Resident #1's genitalia. Telephone interview with Certified Nurse Assistant (CNA) #1 on 1/7/2020 at 4:00 PM revealed she witnessed the incident on 11/30/2019 between Resident #1 and Resident #2. CNA #1 separated the residents and notified the nurse of the incident and Resident #1 was relocated to a different floor. CNA #1 was aware both residents had a history of [REDACTED].#1 was not aware the residents could not be seated together. Telephone interview with Licensed Practical Nurse (LPN) #3 on 1/7/2020 at 4:30 PM confirmed she was aware both residents were to be watched for inappropriate sexual behaviors. Interview with CNA #5 on 1/8/2020 at 9:40 AM revealed Resident #2 was not cognitively aware of she was. In summary, Resident #1 was a cognitively intact resident and was known to have inappropriate sexual behaviors. Resident #2 had severe cognitive impairment and was also known to have inappropriate sexual behaviors. Both Resident #1 and Resident #2 were to be observed for inappropriate behaviors and were not to be seated close to each other. The facility failed to keep the residents separated and they were observed to be sitting next to each other in the hallway where Resident #1's pants were unzipped and Resident #2 was touching Resident #1 in a sexual manner.",2020-09-01
3608,TRINITY HEALTH AND REHABILITATION CENTER,445533,700 WILLIAMS FERRY RD,LENOIR CITY,TN,37771,2019-04-15,609,D,1,0,IWSW11,"**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 allegations of resident abuse to the Administrator timely 1 resident (#1) of 3 residents reviewed for abuse and neglect of 3 sampled residents. The findings included: Review of facility policy Abuse Prevention/Reporting Policy and Procedure dated (YEAR), revealed .All reports .will be reported immediately to the Administrator and Abuse Coordinator and or/D.O.N (Director of Nursing) . Medical record review revealed Resident #1 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 Resident #1 had short and long term memory problems and was dependent upon assistance of 2 or more persons for all activities of daily living. Review of a facility investigation dated 4/3/19 revealed the facility was informed of abuse allegations by Licensed Practical Nurse (LPN) #1, who had abruptly resigned without notice on 4/1/19. Further review revealed LPN #1 alleged the incident involved Resident #1 and Certified Nursing Assistant (CNA) #3 and occurred on 3/21/19 (14 days prior). Interview with CNA #5 on 4/11/19 at 2:45 PM, in the conference room, revealed on 3/21/19 the CNA was aware CNA #1 accused CNA #3 of .rough handling of (Resident #1) . Further interview confirmed the incident was not reported to the Administrator or the DON. Interview with CNA #2 on 4/11/19 at 3:15 PM, in the conference room, revealed CNA #2 received a text message from CNA #1 on 3/21/19 at 7:51 PM stating . (CNA #3) .took (Resident #1) by the neck and one arm and slung her on the bed . Continued interview confirmed CNA #2 did not report the allegation to the Administrator or the DON timely, but showed the text message to Registered Nurse (RN) #1 on 4/1/19. Interview with RN #1 on 4/11/19 at 4:44 PM, in the conference room, revealed RN #1 was aware of the allegation, but referred CNA #2 to the Staff Development Coordinator (SDC). Further interview confirmed RN #1 failed to report the allegation to the Administrator Interview with the DON on 4/11/14 at 5:38 PM in the conference room, revealed she was not of the abuse allegations until 4/3/19. Continued interview confirmed multiple staff failed to report an allegation of abuse allegations immediately to her or the Administrator. Interview with the SDC on 4/15/19 at 11:47 AM in the conference room, revealed the she was aware of .staff gossip . made by CNA #1 against CNA #3 as early as 3/26/19 but did not report the allegation to the DON or Administrator until 4/3/19 (14 days later). Interview with the Administrator on 4/15/19 at 3:30 PM, in the conference room, confirmed the facility failed to report an allegation of abuse timely.",2020-07-01
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
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
1762,LIFE CARE CENTER OF COLLEGEDALE,445294,"PO BOX 658, 9210 APISON PIKE",COLLEGEDALE,TN,37315,2017-10-18,225,D,1,0,71FX11,"**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 staff failed to report an allegation of abuse timely for 1 resident (#3) of 5 residents reviewed for abuse of 6 sampled residents. Review of facility policy, Reporting Alleged Abuse, dated 2/7/17 revealed .Facilities must 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 . Resident #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 Day Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 1 (severe cognitive impairment). Continued review revealed the resident required extensive assist with transfers, dressing, eating, and personal hygiene with 1 person assist. Further review revealed the resident was always incontinent of bowel and bladder. Review of a facility investigation dated 6/22/17 revealed Certified Nurse Assistant (CNA) #12 alleged she observed CNA #13 abuse Resident #3 while providing personal care on 6/20/17. Continued review revealed the facility was not notified of the alleged incident until 6/22/17 (2 days later). Interview with CNA #10 on 10/18/17 at 1:30 PM, in the conference room, revealed .told her (CNA #12) .she needed to fill out a witness statement and give it to the charge nurse . Telephone interview with CNA #12 on 10/23/17 at 10:30 AM revealed .I was new .had only been there a couple of weeks .wasn't sure what I needed to do .asked someone and they told me to fill out a paper and give to the supervisor or Director of Nursing .He was not there that day or the next .got in trouble because I didn't report it sooner . Interview with the Administrator and the Director of Nursing on 10/18/17 at 3:15 PM, in the conference room, confirmed the facility failed to report an allegation of abuse timely and failed to follow facility policy.",2020-09-01
2357,SIGNATURE HEALTHCARE OF MONTEAGLE REHAB & WELLNESS,445393,26 SECOND STREET,MONTEAGLE,TN,37356,2018-02-21,741,E,1,0,Q3XO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, observation, and interview, the facility failed to maintain sufficient staffing levels to assure resident safety and to maintain the highest practicable state of physical, mental, and psychosocial well-being for 6 residents (#2, #6, #7, #1, #10, and #5) of 16 secure unit residents reviewed on 1 unit (Secure Unit) of 5 units reviewed. The findings included: Review of facility policy Nursing Services, not dated, revealed .The facility will have sufficient nursing staff .to provide nursing and related services and to maintain the highest practicable physical, mental and psychosocial well-being of each resident .uses acuity based staffing (ABS) to determine staffing needs in each facility .staffing will be allocated and adjusted .considering the number, characteristics, and acuity of the facility's resident population . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data set ((MDS) dated [DATE] revealed Resident #2 was severely cognitively impaired, had hallucinations, delusions, and verbal and physical behaviors directed at self or others weekly. Continued review revealed Resident #2 ambulated with minimal assistance and required assistance of two persons for all Activities of Daily Living (ADLs). Medical record review revealed Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #6 with a Brief Interview of Mental Status Score (BIMS) of 0/15 (severe impairment) and the resident had a history of [REDACTED]. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #7 was severely cognitively impaired with a BIMS score of 1/15, had behaviors directed towards others daily, and symptoms of [MEDICAL CONDITION] which included hallucinations and delusions. Further review revealed the resident ambulated independently and required assistance of one or two persons for all ADLs. Review of a facility investigation dated 12/18/17 at 6:45 PM, revealed 3 residents (Resident #2, #6 and #7) were involved in a single altercation. Continued review revealed Resident #6 was in the hallway outside the common dining area of the secure unit and struck Resident #2 twice on the face. Continued review revealed Certified Nurse Aides (CNA) #10 and CNA #11 were nearby and separated the residents. Further review revealed CNA #10 escorted Resident #6 to his room and CNA #11 escorted Resident #2 to her room on the opposite side of the hallway. Continued review revealed Resident #6 was aggressive towards CNA #10 after he was escorted to his room, pushed past CNA #10, and exited his room back out into the hallway. Further review revealed CNA #10 attempted to redirect Resident #6, but he encountered Resident #7 outside the doorway of his room and he pushed Resident #7 from behind, which caused Resident #7 to fall to the floor. Continued review revealed Resident #6 remained agitated and aggressive and was redirected a second time by CNA #10 back into his room with difficulty. Further review revealed CNA #11 exited Resident #2's room and along with Licensed Practical Nurse (LPN) #3 assisted CNA #10 with Resident #6. Continued review revealed while CNA #10, CNA #11, and LPN #3 attempted to redirect Resident #2, the remainder of the secure unit rooms, the common areas, the other residents were unsupervised. Interview with CNA #8 and CNA #1 on 2/14/18 at 12:00 PM, on the secure unit hallway, revealed Resident #6 was prone to aggression and at times required 2 staff members to redirect and to provide ADLs care. Further interview revealed the secure unit nurse was also assigned to residents on the West Wing (located beyond the locked doors of the secure unit) and when the nurse was on the West Wing the CNAs were responsible for monitoring the entire unit. Continued interview revealed all residents on the secure unit required 2 persons for ADL assistance, which left the common areas and hallways unsupervised. Observation of the secure unit on 2/14/18 at 7:40 AM revealed staff were present in the secure unit dining room for meal tray pass. Continued observation revealed an alarm was affixed to the upper door frame on Resident #6's room and the door was closed. Further observation revealed the resident was in his room eating breakfast and when surveyor knocked on the door and asked for permission to enter the resident's room. Continued observation revealed as the surveyor opened the door to Resident' #6' room the alarm was activated. Further observation revealed a confused female resident entered Resident' #6's room, wandered about the room, returned to the doorway, and began to touch the wall and door frame for approximately 30 seconds. Continued observation revealed staff members did not respond to the door alarm and were unaware a female resident entered Resident #6's room, until signaled by the surveyor to approach the room. Interview with CNA #10 and CNA #11 on 2/21/18 at 9:20 AM, in the secure unit day area, revealed on 12/18/17 during the incident between Resident #2, #6, and #7 both CNAs were engaged in care of other residents in the secure unit common dining room. Continued interview revealed the CNAs responded to the altercation and separated Resident #6 and Resident #2 Further interview revealed CNA #10 took Resident #6 to his room and CNA #11 took Resident #2 to her room. Continued interview revealed CNA #11 calmed Resident #2 down, exited Resident #2's room, and proceeded to assist CNA #10 with Resident #6. Further interview Resident #6 was verbally and physically aggressive and was not responsive to simple commands or gentle redirection and distractions. Continued interview revealed when Resident #6 walked out into the hallway Resident #7 wandered by Resident #6's room and Resident #6 placed both hands on Resident #7's shoulders from behind and pushed her out of his way, which caused Resident #7 to fall to the floor. Further interview revealed staff had spoken to the unit manager on multiple occasions before and after the incident and expressed concerns the secure unit was understaffed and had requested a meeting with the Director of Nursing (DON) to discuss concerns related to the incident. Continued interview confirmed during the incident on 12/18/17 the other residents were unattended and unsupervised. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS revealed Resident #1 scored 9/15 (moderately cognitive impaired) on the BIMS. Further review revealed the resident required minimal assistance for transfer, ambulation, dressing, and hygiene/bathing. Review of a facility investigation dated 1/26/18 at 5:45 PM revealed 2 CNAs were in a resident's room performing ADL care when they heard a commotion. Further review revealed the CNAs exited the resident's room and walked up the hallway toward the room the sound was coming from and found Resident #1 swinging his bed remote and yelling Get out of my room to Resident #2. Continued review revealed Resident #1 stated he whacked Resident #2 on the shoulder to get her out of his room. Further review revealed neither resident was in their own room. Interview with LPN #1 on 2/12/18 at 11:15 AM, at the secure unit nurses station, revealed Resident #2 was confused and wanders up and down the hall often and requires redirection often. Telephone interview with CNA #1 on 2/12/18 at 12:45 PM, revealed she was in a resident's room at the end of the hall when she heard .fussing . Further interview revealed she then went into the room she observed Resident #1 attempting to get Resident #2 out of the room and Resident #1 stated he hit Resident #2 on the shoulder with the bed remote control. Continued interview revealed she attempted to watch wandering residents , but because some residents require 2 CNAs to provide ADL care there are times when there was no staff available to supervise residents on the secure unit. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #10 was severely cognitively impaired, ambulated independently, and required one or two person assistance for other ADLs. Review of facility investigation dated 1/29/18 at 8:15 AM revealed staff members on the secure unit heard a resident yell .help . and discovered Resident #10 sitting on the floor of the secure unit hallway. Continued review revealed Resident # 10 reported Resident #6 hit her and pushed her down. Further review revealed staff did not witness the incident but presumed the incident occurred because Resident #6 had a known history of aggressive behaviors towards others. Interview with LPN #1 on 2/20/18 at 7:48 PM revealed she was the nurse assigned to the secure unit on the morning of the occurrence and she was responsible for 16 residents on the secure unit and 8 residents on the West Wing (located outside the locked doors of the secure unit). Further interview revealed she did not witness the incident because she was oustide the secure unit and engaged in medication pass to the residents on the West Wing hallway. Continued interview confirmed the 2 CNAs were the only staff available on the secure unit. Interview with CNA #10 and CNA #11 on 2/21/18 at 9:20 AM, on the secure unit hallway, revealed the CNAs, at the time of the incident, were engaged in food tray pass and were involved with other incidents involving residents in the common day area on the secure unit. Continued interview confirmed the secure unit hallways were unmonitored when the incident between Resident #6 and #10 occurred and they did not have an opportunity to intervene. 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 Resident #5 was severely cognitive impaired and required supervision for transfer, ambulation, and eating. Review of a facility investigation dated 2/19/18 at 4:00 PM revealed two CNAs were in another resident's room when they heard a resident .holler . Continued review revealed the CNAs exited the room and saw Resident #1 in the hallway with Resident #5, who had her hands over her face. Further review revealed CNA #1 asked Resident #1 what happened and he replied he hit her (Resident #5) because she had been stalking him all day and he was tired of it so he hit her. Interview with CNA #1 on 2/20/18 at 11:35 AM, on the Secure unit hallway, revealed she was in another resident's room assisting another CNA perform ADL care when they heard Resident #5 scream. Continued interview revealed CNA #1 found Resident #5 leaned against the wall with her hands over her face and Resident #1 was sitting in his wheelchair. Further interview revealed CNA #1 asked Resident #1 what happened and Resident #1 stated Resident #5 aggravated him and he slapped her. Continued interview confirmed the 2 CNAs were the only staff present on the secure unit when the incident occured and they were unable to intervene. Interview with LPN #6 on 2/20/18 at 12:15 PM, at the West Wing nurses station, confirmed at the time of the altercation between Resident #1 and Resident #5 she was not on the secure unit. Observations of the secure unit on 2/14/18 from 11:00 AM to 12:38 PM, during the lunch time tray pass, revealed 16 residents present on the unit. Continued observation revealed 9 residents were in the common dining area at the far end (west end) of the L shaped secure unit and were supervised by 2 CNAS and 1 activity therapist. Continued observation revealed 5 confused residents were wandering unsupervised on the short hallway on the secure unit (running north south) in front of the nursing station. Further observation revealed LPN #6 was engaged in medication pass and redirection of 2 other confused residents. Continued observation revealed Resident #9 wandered to the east end of the unit, stopped in front of the nursing station, removed his penis from his pants and urinated on the floor directly in front of the nursing station, readjusted his clothing, turned and wandered toward the common dining area. Further observation revealed the staff was not aware of the incident until they were made aware by the surveyor. Interview with LPN #6 on 2/14/18 at 11:30 AM, on the secure unit hallway, revealed the majority of residents on the secure unit were severely cognitively impaired, prone to aggressive behaviors and other mental illnesses, and required close supervision. Further interview revealed all residents on the secure unit required 2 person assistance with ADLs and hygiene and during the time ADL care was provided the unit was left with one person to monitor all the rooms and common area simultaneously. Further interview revealed resident to resident altercations and resident to staff altercations on the secure unit were routine occurrences. Telephone interview with LPN #1 on 2/20/18 at 7:48 PM revealed the nurse assigned to the secure unit was also assigned to the residents on the West Wing. Continued interview revealed the staffing model was based upon total resident census and not on resident acuity. Further interview confirmed the residents on the secure unit were often left unsupervised because there was not enough staff to provide care. Interview with LPN #1 on 2/21/18 at 8:15 AM, at the secure unit nurses' station, revealed the unit was typically short one nurse on the 6:00 AM to 6:00 PM shift and the nurse was usually off the secure unit for 1 to 1 1/2 hours in the morning to administer medications to residents on the West Wing. Interview with the Director of Nursing (DON) on 2/21/18 at 9:40 AM, in the front office, revealed the DON confirmed the facility did not utilize acuity based staffing models for staffing the secure unit. Further interview confirmed the facility failed to maintain sufficient staffing on the secure unit and the facility failed to follow facility policy.",2020-09-01
1775,CONCORDIA NURSING AND REHABILITATION-NORTHHAVEN,445297,3300 BROADWAY NE,KNOXVILLE,TN,37917,2018-05-08,600,J,1,0,26B911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, observation, and interview, the facility failed to prevent abuse for 1 resident (#1) of 5 residents reviewed for abuse, which resulted in Resident #1 leaving the facility, being given alcohol, and being sexually assaulted. The facility's failure 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). F-600 was cited at a scope and severity of J and is Substandard Quality of Care. The Nursing Home Administrator was informed of the Immediate Jeopardy (IJ) on 5/7/18 at 11:00 AM, in his office. The IJ was effective from 2/25/18 through 2/27/18. The IJ was removed on 2/28/18. The facility implemented a corrective action plan and corrective actions were validated onsite by the surveyor on 5/7/18 and 5/8/18. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction for those tags. The findings included: Review of facility policy, Resident Elopement, dated 11/28/17 revealed .identify when a resident has left the premises or a safe area without authorization and/or any necessary supervision to do so . Review of facility policy, Abuse, dated 11/28/17 revealed .Verbal, sexual, physical and mental abuse .are strictly prohibited . Medical record review of Resident #1;s Pre-Admission Screening and Resident Review (PASRR) document dated 7/26/17 revealed .This Level 1 shows her (Resident #1) to have suspected [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder, alcohol and cocaine use disorder with most recent substance use in the past 15-30 days and dementia/neurocognitive disorder presenting with significant difficulty (with) communication, ambulating and/or completing routine motor tasks, recognizing familiar people or familiar objects, and has short/long term memory impairment. [MEDICAL CONDITION] medications have been prescribed. Currently or within the past 30 days, (resident) has had serious difficulty interacting with others, she has made substantial errors with tasks and she has experienced a life disruption due to mental health symptoms. (Resident) received mental health crisis services in the past 2-6 months and history of suicide attempt or gestures in the past 25 months - (to) 5 years and suicide attempt greater than 5 years ago . 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 11/8/17, revealed the resident was at risk for elopement due to impaired safety awareness and the intervention was the placement of a wander guard bracelet (device worn by residents which automatically locks any facility exterior doors and sounds an alarm when approached by residents) on the resident's ankle. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 15 (cognitively intact) on the Brief Interview Mental Status (BIMS). Continued review revealed the resident required supervision for bed mobility, transfers, and toilet use with 1 person assist, and required limited assist for bathing with 1 person assist. Review of a facility investigation dated 2/26/18 revealed, on 2/25/18 at approximately 9:00 PM, the facility staff were unable to locate Resident #1 and initiated the protocol for elopement of a resident. Continued review revealed the facility staff searched all rooms in the facility and the outside grounds and notified the Administrator and local police department of the missing resident. At approximately 10:15 PM, Resident #1 was returned to the facility by the alleged perpetrator, smelled of alcohol, and was unable to stand and exit the alleged perpetrator's vehicle. Further review revealed Licensed Practical Nurse (LPN) #2 and Certified Nurse Assistant (CNA) #4 assisted Resident #1 out of the vehicle, transferred her into a wheelchair, and took her to her room. Continued review revealed Resident #1 reported the alleged perpetrator took her out of the facility, got her drunk, and sexually assaulted her. LPN #2 notified the Nurse Practitioner (NP) and an order was obtained to send the resident to the hospital for evaluation and treatment. Medical record review of an acute care hospital nurse's triage note dated 2/25/18 at 11:14 PM, revealed .presenting complaint .EMS (emergency medical services) states called to (facility) for altered mental status .staff told EMS that another resident took pt's (patient's) wondering (wander) bracelet off of her and took her somewhere .pt. returned to facility intoxicated .asked what he had done to her .resident replied 'I (sexually assaulted)' .KPD (Knoxville Police Department) present at this time . Continued review of a hospital physician's note dated 2/26/18 at 5:01 AM revealed .patient is in nursing home due to prior TBI [MEDICAL CONDITIONS]([MEDICAL CONDITION]). She was taken out of the NH (nursing home) by another resident's family. She returned intoxicated and stated she had been sexually assaulted . Medical record review of a nurse's note dated 2/25/18 at 11:46 PM (documented after the resident was sent to the hospital) revealed .Resident observed with slurred speech, unable walk or stand without assist, C/O (complains of) lower ABD (Abdominal) pain. Call to NP .sent to ER (emergency room ) for evaluation . Medical record review of a hospital laboratory test result dated 2/26/18 revealed the resident's blood alcohol level was 0.19% (twice the legal limit). Medical record review of a psychiatric services progress note dated 2/26/18 and signed by Advanced Practice Nurse (APN) #2 revealed .History of Present illness: long term resident seen today for follow up at the request of staff. Last night, patient (Resident #1) was drinking with another resident and her male friend in facility. This patient (Resident #1) and the male friend cut off her wander guard, and exited facility and continued drinking. Patient has reported while she was out of the facility she was raped by male she was with .Staff report today, patient has been tearful and keeps to herself. She reports being 'sore' .recommend addition of [MEDICATION NAME] (antianxiety medication) 0.5 mg (milligrams) BID (twice daily) PRN (as needed) X (times) 7 days . Medical record review of a skin assessment dated [DATE] revealed .Site Lt (left) elbow, Description Bruise; Site Between Legs Description Red Bruises; Site Top of Lt hand Description Bruise; Site Rt (right) forearm Description Bruise . Observation and interview with Resident #1 on 5/1/18 at 2:30 PM, in her room, revealed .I knew him from that room over there where we go smoke .he was drinking and he was talking to me and we was going to get beer .don't like to talk about it (incident) . the psychiatrist is supposed to help me (coping with emotions from the assault) .I hope he (perpetrator) was put in jail .we went out the side door on the long hall (Northeast side of the building) .he forced himself on me . Observation on 5/1/18 revealed the facility had 4 entrance/exit doors with keypads that required a code to open or enter/exit: 1 main entrance doorway; 1 ambulance entrance/exit visible from nurse station #1; and 2 entrance/exit doors on the Northeast side of the building, which lead to the parking lot, with one of those doors visible from nurse station #2 and the other door not visible from any nurses station. Interview with the Maintenance Director on 5/2/18 at 4:15 PM, in his office, revealed .(Resident #1) wore a wander guard bracelet and on the day of the incident family members, friends, and all staff had the code to the doors .the same code was used on all of the doors .would change the door code monthly . Interview with the Social Services Director on 5/2/18 at 6:30 PM, in the conference room, revealed Resident #1 .is alert and oriented and can answer questions but her decision making and memory is not good .can try and educate her but she won't remember .met with her daily for 5 days (2/26/18 - 3/1/18) .still visit her weekly .the psychologist continues to visit her . Interview with Certified Nurse Assistant (CNA) #4 on 5/2/18 at 6:55 PM, in the conference room, revealed .it was after dinner .was making (resident) rounds .noticed (Resident #1) in (another resident's) room talking to the resident and her boyfriend .she does not normally go into the room .I went into the room and when I entered they all snickered .I went and told (LPN # 2) I thought something was going on and she told me to tell them both to leave the room .was always suspicious of him .he would say off the wall things .we looked everywhere .I got in my car and drove up and down (street) because I knew what his van looked like .just after I returned to the facility (LPN #2) asked me to come help her because (Resident #1) could not get out of the van .around 10:15 PM .Seemed like she (resident) was intoxicated or on something .she said 'He got me (expletive) up' .he (alleged perpetrator) was making excuses .her wander guard was found in the trash .was cut off . Interview with the Nurse Practitioner (NP) #1 on 5/3/18 at 10:45 AM, in the conference room, revealed .She (Resident #1) changes her story but consistently says he raped her .I think he brought in alcohol and enticed her .she is classic [MEDICAL CONDITION] .history of substance abuse .does not have the ability to make good decisions . Interview with LPN #3 on 5/3/18 at 11:00 AM, in the conference room, confirmed completion of a skin assessment on 2/26/18, which revealed Resident #1 had bruises to bilateral elbows, left wrist, right forearm, redness to both knees, and redness and bruising between her thighs. Continued interview revealed .she had knots on her head .she told me he pulled her hair . Interview with the Clinical Psychologist on 5/3/18 at 11:30 AM, in the activity room, revealed .the ability to make good decisions is not there .she (Resident #1) still having flashbacks .still has anger about the situation .has had an increase in the number of outbursts . Telephone interview with the Violent Crimes Investigator on 5/7/18 at 9:00 AM, revealed .The case is still open .will take another 2-3 months to get the results of the DNA (deoxyribonucleic acid) testing . Interview with Resident #1 on 5/7/18 at 9:40 AM, in her room, revealed .He (alleged perpetrator) cut it (wander guard) off in that room over (another resident's room) there and threw it in the garbage can . Interview with the Administrator on 5/7/18 at 11:00 AM, in his office, revealed .No one saw them leave .we had a camera malfunction .we think they went out the side door .they wouldn't have been seen going out that door .He had been given the door code. At that point in time visitors had the door code . Telephone interview with Resident #1's Physician (Medical Director) on 5/7/18 at 11:45 AM, revealed .She clearly has a cognitive impairment .needs supervision .this has been a learning experience .hard to imagine this would happen . Telephone interview with LPN #2 on 5/7/18 at 5:00 PM revealed .I was passing medications when (CNA #) came up and said he thought something was going on in the room (another resident's room). I told him (Resident #1) needed to go back to her room and he (alleged perpetrator) needed to leave .saw her come out and go down hallway toward her room .she looked mad .did not see him leave .thought I would talk with her in a few minutes .my main concern was to get her out of that room .did you ever see someone and just think I don't like them .nothing could put your finger on .maybe just how he looked .nothing he had done .the night before he gave (Resident #1) a soda and I told him he could not give residents food or drinks because they may have diet restrictions .at that time the (door) code was the current month and year. It was changed monthly; everybody just knew it . Continued interview revealed LPN #2 was not aware anyone had been drinking alcohol in the resident's room and LPN #2 did not go check on Resident #1. Interview with CNA #8 on 5/8/18 at 8:15 AM, on the 200 hallway, revealed since the incident .no one comes in and out the side doors unless a staff member lets someone in the handicapped accessible door .that is monitored by a camera at nurse station 1 .employees have to enter and exit through the front doors also .in-serviced to report any suspicious persons or activity to nurse or supervisor . Interview with LPN #4 on 5/8/18 at 8:45 AM, at nurse station #1, confirmed staff education since the event on 2/25/18 included to immediately investigate any concern of suspicious activity, and also to report the suspicious activity to the supervisor immediately. Interview with the Speech Language Pathologist on 5/8/18 at 9:00 AM, in the conference room, confirmed Resident #1 completed the Saint Louis University Mental Status Examination, not dated, with a score of 6 (indictor of dementia) on a scale to 30. Further interview revealed the resident completed the Montreal Cognitive Assessment on 2/27/18 with a score of 17 on a scale to 30 (score equal to or greater than 26 indicates normal cognition). Continued interview revealed .she (Resident #1) has deficits with higher level thinking skills .that has been consistent since she has been here .she says she wants to go home, leave, go to a motel .she does not comprehend that she would need money .feel like she is still at risk for elopement .she has mentioned to me in therapy that she still wants alcohol and drugs . The facility's corrective action plan included the following: On 2/25/18 the facility did the following: The facility checked the placement and functionality of wander guard bracelets (a device worn by residents that will automatically lock any facility exterior doors and sound an alarm when approached by residents) of all residents identified as being at risk for elopement. On 2/26/17 the facility did the following: [NAME] The Nursing Home Administrator, Director of Nursing Services, Director of Social Services, Director of Activities, Director of Nutrition, Business Office Manager, Maintenance Director, Director of Rehabilitation, Medical Director, Minimum Data Set Coordinator, Director of Admissions, and Licensed Practical Nurse (LPN) #3 conducted an ad hoc Quality Assurance Meeting to review the circumstances of the incident and implement an immediate action plan for the investigation of the incident. B. The Maintenance Director changed the codes to all the exterior entrance/exit doors. C. Conducted in-services with staff on abuse, reporting any unusual appearing activity and systemic changes that were implemented to enhance resident/staff safety. Staff was required to complete a post test. Systemic changes and in-services included: 1. A book placed at the entrance of the facility for visitors/vendors to sign-in and sign-out, all visitors/vendors are to sign when they arrive and when they exit the facility. 2. The door code is not to be given to any resident, visitor, or vendor under any circumstances; staff are to direct the visitor/vendor to the front door and the receptionist will assist the visitor/vendor. If a receptionist is not at the door the staff member will enter the code and let the visitor out the front door. The front door will be the only entrance and exit for the facility. All other exits will be used for emergencies only. If the code is given to any resident, visitor, or vendor disciplinary action will be taken. 3. If staff witness any activity in the facility that they feel is different or odd they report it to their supervisor immediately. The supervisor is responsible to investigate immediately and notify the Executive Director (ED) and/or Director of Nursing Services (DNS). D. Audited to ensure all residents at risk for elopement were assessed accurately. E. Head to toe skin assessment completed for all non-interviewable residents. F. Safe surveys (interviews with residents to determine their safety) were completed with all alert and oriented residents. [NAME] Posted a photo at both nurses station of the alleged perpetrator. H. Notification was given to the alleged perpetrator's girlfriend (also a resident) that he was not allowed to visit. I. Family notification by mail of a change in the process for entrance/exit to the facility was completed for 100% of the families. [NAME] The DNS or designee initiated a daily walk through on both shifts, on all hallways, and interviews with staff to ensure no unusual behaviors, reported allegations of abuse, or any unauthorized entry/exit of the doors on the Northeast side of the facility had occurred. This process is ongoing. K. The Administrator began an audit of all allegations of abuse or reportable incidents and this process is ongoing. L. The facility implemented an elopement drill twice monthly for 2 months, and then monthly, ongoing. On 2/27/18 the facility did the following: [NAME] Conducted an ad hoc Quality Assurance meeting to ensure all interventions of the immediate action plan were implemented. B. Continued staff in-services and post tests for 100% completion of all staff. The surveyor verified the facility's corrective action plan as follows: [NAME] Review of the Quality Assurance Meeting, Attendance, and Agenda sheets confirmed the facility conducted ad hoc Quality Assurance meetings on 2/26/18, 2/27/18, and began review monthly on 3/21/18 to ensure sustainability of the plan of correction. B. Comparison of the room roster dated 2/26/18 with the completed safe survey individual questionnaires and completed skin assessments revealed all residents were assessed for abuse between 2/26/18 - 2/27/18 with 100% completion on 2/27/18. The facility completed weekly safe survey individual questionnaires through 3/22/18 and weekly skin assessments are ongoing. C. Medical record review revealed the 4 residents at risk for elopement on 2/25/18 were re-evaluated using the Unsafe Wandering Risk Evaluation with 100% completion on 2/27/18. D. Nursing Home Administrator on 5/2/18 at 2:45 PM, in the conference room, confirmed letters were mailed to all responsible parties on 2/26/17 to inform of the new process of entering and exiting the facility. Continued interview revealed the Administrator began auditing all allegations of abuse or any reportable incident for timely reporting to the state agency and is ongoing. E. Observation of the wander guard tracking log, door alarms, and interview with the Maintenance Director on 5/2/18 at 4:10 PM, in the maintenance room, confirmed the wander guards are checked weekly for expiration date, function, and door alarm. Continued interview confirmed the keypad code for all entrance/exit doors was changed on 2/26/18 and the implementation of the use of 1 door for entry/exit of the facility. The facility staff must enter the door code to allow visitors/vendors exit from the facility. F. Medical record review of a progress note dated 2/26/18 and interview with the Social Service Director on 5/2/18 at 6:30 PM, in the conference room, confirmed the perpetrator's girlfriend was notified he was no longer allowed to visit. [NAME] Review of a facility document Room Roster (list of wandering residents) initiated 2/25/18, revealed the roster was used to document verification all residents identified as at risk for elopement were accounted for and to document verification of placement and function of the wander guards. Interview with LPN #2 on 5/2/18 at 7:00 PM, in the conference room, and review of the documentation, confirmed residents identified for risk of elopement had a functioning wander guard in place. H. Comparison of facility in-service records, sign in/out sheets, employee roster, and post tests for systemic changes and abuse dated 2/26/18 -2/27/18, and interview with the Director of Nursing Services (DNS) on 5/8/18 at 8:00 AM, in the conference room, confirmed staff education was 100% complete on 2/27/18. Continued review of the facility visitor sign in/out log and interview confirmed the facility initiated the process on 2/26/18 and is ongoing. Further interview with the DNS confirmed the process is monitored daily by DNS or designee which included: a walk through on all hallways, interviews with staff for any unusual behaviors, any allegation of abuse, and monitoring of visitor entrance and exit through the designated entrance door. Continued interview revealed the facility had conducted drills with facility staff for elopement on 2/26/18, 2/28/18, 3/6/18, 3/19/18, 4/4/18, and 5/3/18, and continues monthly. I. On 5/8/18 at 8:40 AM the surveyor attempted to exit through the doorway located on the Northeast side of the building setting off the alarm. The facility staff responded immediately and implemented the elopement protocol. [NAME] Multiple observations and interviews were conducted by the surveyor with residents, visitors, and employees on both shifts throughout the complaint survey conducted from 5/1/18 through 5/8/18, which confirmed full implementation of the systemic changes to enhance resident/staff safety and the reporting of any unusual appearing activity.",2020-09-01
753,"THE WATERS OF SHELBYVILLE, LLC",445171,835 UNION STREET,SHELBYVILLE,TN,37160,2017-12-06,689,G,1,1,BDXJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, observation, and interview, the facility failed to prevent an accident resulting in an arm fracture for 1 resident (#66), and failed to prevent elopement for 1 resident (#77) of 14 residents reviewed. The facility's failure resulted in HARM for Resident #66. The findings included: Review of facility policy, Accidents/Incidents, dated 1/1989 revealed, .any accidents/incidents involving Residents .are immediately reported to the charge nurse or immediate supervisor. All accidents/incidents involving Residents are evaluated by the charge nurse who, in consultation with the attending physician, determines the appropriate interventions . Review of facility policy, Gait Belt, dated 7/2007 revealed, .to prevent injury to the resident or staff while ambulating the resident and to provide an additional sense of security for the resident . Medical record review revealed Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #66 was cognitively impaired, rarely understood, required extensive assist of 2 people for transfers, and was mobile in a wheelchair per self. Continued review revealed [DIAGNOSES REDACTED]. Medical record review of Nurses Notes dated 10/27/17 at 8:30 PM revealed LPN #6 was called to the resident's room by the Certified Nurse Aide (CNA) #5 to look at a bruise and swelling of Resident #66's right arm and shoulder. Continued review revealed a Physician's Telephone Order was obtained by the Licensed Practical Nurse (LPN) #6 for an x-ray of the Resident's right arm and shoulder. LPN #6 applied ice to the area and notified Resident #66 responsible party. Medical record review of an x-ray report dated 10/28/17 at 3:40 PM revealed an acute [MEDICATION NAME] humeral metaphysis with slight medial displacement of the distal fracture fragment (fracture occurring at a ninety degree angle in relation to the long bone of the upper arm and near the shoulder joint). Continued review of the x-ray report dated 10/28/17 revealed the humerus and shoulder demonstrated generalized osteopenic (the bone density is more like a honeycomb than solid). Telephone interview with CNA #4 on 12/6/17 at 1:30 PM revealed, I found the bruise on his arm around 11:00 AM on 10/27/17 and told the nurse. Further interview revealed when asked how Resident #66 is transferred the CNA replied, now we use a lift but before we didn't. Further interview revealed when asked if the Nurse Aids used a gait belt to transfer Resident #66 before the injury she replied, No. We just supported his arms. Observation of Resident #66 on 12/4/17 at 1:30 PM in his room revealed the resident was wearing a right arm sling, lying in bed with yellow discoloration to visible aspect of right upper outer arm. Review of the facility Root Cause Analysis worksheet, dated 11/1/17, revealed the root cause of Resident #66's humerus fracture was due to .lack of education and training with system cause of the arm fracture listed as transferring . Interview with the Director of Nursing (DON) in the conference room on 12/6/17 at 4:38 PM revealed she stated, We do not have a transfer policy or written protocol, we just teach them how to use a gait belt and they come to us if they have any questions. Interview with the Assistant Director of Nursing (ADON) on 12/6/17 at 2:00 PM in the conference room, when asked if the fracture was avoidable she stated, Yes I feel the fracture could have been prevented if the staff had been better trained, for instance, if they had been using a gait belt instead of steadying the resident by his arms it could have taken some of the pressure off of his shoulder. Continued interview confirmed .the facility failed to provide adequate transfer training which resulted in the fracture for Resident #66 and actual Harm . Review of facility policy, Resident Elopement Policy, undated revealed .personnel who have residents under their care are responsible for knowing the location of those residents, and in the case of a missing resident ensuring appropriate action is taken. Medical record review revealed Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission MDS dated [DATE] revealed Resident #77 had a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment and required extensive assistance in transfers, eating, and hygiene and used a wheelchair for locomotion. Medical record review of an Elopement Risk Review dated 11/3/17 revealed the resident was not at risk for elopement. Medical record review of the Nurses Notes dated 11/7/17 at 11:19 PM revealed, .resident exited the garden room door and tipped his wheelchair off the sidewalk .noted by Dietary staff and LPN to be in the grass lying on his right side with the wheelchair tipped over in the grass as well. Small dime sized skin tear noted to back of left hand near his knuckles . Review of a facility investigation and witness statements revealed Resident #77 was last seen inside the facility on 11/7/17 at 6:50 PM after supper. Further review revealed, between 7:15 PM and 7:30 PM the LPN was unable to find the resident and began searching the resident rooms. At 7:45 PM staff began searching outside for the resident, and Resident #77 was found outside the facility lying on the ground at 8:15 PM, .with his wheelchair flipped over on its side . Further review of witness statements revealed, .We found him (Resident #66) outside, flipped over in his chair laying in the grass, wet, he was a little scraped up . Interview with the Maintenance Director on 12/4/17 at 3:45 PM in the garden room revealed, .I was called to the facility after hours and found the garden room exit door not to be functioning properly .I removed the electrical cover and noticed the wiring was corroded and there was moisture on the cover .I cleaned the corrosion and dried up the moisture .The area above the door was caulked and the door began to work properly .sign in sheets were made and the door was checked every fifteen minutes .then weekly .I ordered new mag locks and they were installed .'' Observation on 12/4/17 with the Maintanance Director present revealed all the exit doors functioned correctly. Further review revealed all wandergaurd alarms at exit doors functioned correctly. Interview with the Assistant Director of Nursing (ADON) on 12/6/17 at 2:15 PM in the conference room confirmed, that night the whole door malfunctioned.",2020-09-01
2105,SIGNATURE HEALTHCARE OF GREENEVILLE,445351,106 HOLT COURT,GREENEVILLE,TN,37743,2017-11-06,225,D,1,0,L1Q111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, observation, and interview, the facility failed to promptly report an injury of unknown injury to the appropriate facility for 1 resident (#9) of 9 residents reviewed for abuse. The findings included: Review of a facility policy, Abuse, Neglect, Exploitation, and Misappropriation of Property, last reviewed on 8/24/17 revealed .all alleged violations .which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property are investigated, and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies .Injury of Unknown Source: 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 . Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitive impaired and required total assistance from staff for transfers, dressing, and hygiene. Review of a facility investigation dated 10/31/17 a written statement from Registered Nurse (RN) #2. Continued review revealed Resident #9's son asked RN #2 about the bruise on 10/30/17 at approximately 5:00 PM and the nurse noted a slight area of shadowing with possible discoloration. Observation and interview with the resident's daughter on 10/31/17 at 10:15 AM, in the resident's room, revealed the resident had a yellow, brown, and green discolored area above the resident's right eye. Continued interview revealed the resident's son observed the discoloration on 10/30/17 and he asked the night shift nurse about happened, but he did not receive an acceptable answer. Further interview revealed the concern was then reported to the facility administrator by the daughter on 10/31/17. Interview with the Administrator on 11/6/17 at 10:20 AM, in the Administrator's office, confirmed the Administrator was not notified of the bruise until 10/31/17 at 10:15 AM (1 day after first observed). Interview with Certified Nursing Assistant (CNA) #2 on 11/6/17 at 11:15 AM, in the dining area, revealed she noticed the area above the resident's right eye on 10/31/17 around 6:30 AM when she was giving the resident a shower and .I assumed the bruise had been reported already so I didn't say anything more about it . Further interview confirmed she should have reported the bruise to her charge nurse or Administrator immediately but failed to do so. Telephone interview with RN #2 on 11/6/17 at 11:45 AM revealed the son asked RN #2 about the area above the resident's right eye on 10/30/17 at approximately 5:00 PM. Further interview confirmed she should have completed a written report and reported the incident immediately to the Administrator, but failed to do so.",2020-09-01
3269,WEST HILLS HEALTH AND REHAB,445501,6801 MIDDLEBROOK PIKE,KNOXVILLE,TN,37919,2018-11-29,600,D,1,0,WPMJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, observation, and interviews, the facility failed to ensure 1 resident (#3) was free from abuse of 5 residents reviewed for abuse. The findings included: Review of facility policy Abuse Prevention Policy & Procedure, last revised 1/23/17 revealed .The Resident has the right to be free from abuse, neglect, misappropriation of resident property .This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse .by any facility staff member, other residents, consultants .serving the resident . Medical record review revealed Resident #3 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 9/15 (moderately cognitive impaired) on the Brief Interview for Mental Status (BIMS) and required extensive assistance for bed mobility, transfer, and dressing. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's Admission Assessment MDS dated [DATE] revealed the resident scored 4/15 (severely cognitive impaired) on the BIMS and had physical, verbal, and other behavioral symptoms not directed toward others occurring 4-6 days but less than daily. Medical record review of a nursing progress notes dated 11/19/18 revealed Resident #2 was currently on 1 on 1 observation. Further review revealed Resident #2 was noted with increased agitation and confusion and was given [MEDICATION NAME] (anti-anxiety medication). Review of a facility investigation dated 11/20/18 at 8:23 PM revealed Certified Nursing Assistant (CNA) #1 reported to the nurse that she heard Resident #3 screaming and when she entered the room Resident #2 was seated in her wheelchair at the foot of Resident #3's bed and was hitting Resident #3 on the feet. Further review revealed CNA #1 immediately separated the residents and reported the incident to the nurse. Continued review revealed after the incident, Resident #2 continued to try to go into other residents' rooms and was threatening the nurse verbally. Further review revealed Resident #3 was interviewed on 11/21/18 and Resident #3 stated Resident #2 was pulling at her furniture and was shaking her leg. Interview with the Administrator on 11/29/18 at 11:30 AM revealed Resident #2 was on placed on one on one (1:1) observation after an incident on 11/18/18 and the facility had considered sending the resident for in-patient psychiatric care but the resident' son had planned on taking the resident home on 11/22/18 so the resident remained in the facility on 1:1 observation. Interview with CNA #1 on 11/29/18 at 2:05 PM, in the conference room, revealed CNA #1 was in a room across the hall when she heard Resident #3 screaming. Further interview revealed when she entered Resident #3's room she saw Resident #2 hitting Resident #3 on both lower legs with an open hand in a slapping motion. Continued interview revealed she did not remember seeing any other staff member in the room. Further interview revealed CNA #1 took Resident #2 to the nurses' desk and reported the incident to the nurse. Interview with CNA #2 on 11/29/18 at 2:40 PM, in the conference room, revealed on 11/20/18 the CNAs were taking turns watching Resident #2. Further interview revealed, at the time of the incident, CNA #2 was at one end of the hallway, close to the nurses' station while Resident #2 was rolling down the hallway in her wheelchair in the opposite direction from CNA #2. Continued interview revealed CNA #2 heard the elevator door open and she turned around for a second to make sure no one (resident) was getting on the elevator and when she turned back around she heard Resident #3 screaming .get out of here . Observation and interview with the Clinical Services Director on 11/29/18 at 3:15 PM, on the 2nd floor hallway, revealed there were 12 resident rooms between where CNA #2 was standing at the elevator and Resident #3's room. Interview with the Clinical Services Director confirmed residents who were on 1:1 observation must not be left unattended and the facility failed to maintain 1:1 observation of Resident #2. In summary, the facility failed to maintain 1:1 observation of Resident #2, resulting in Resident #2 entering Resident #3's room and hitting Resident #3 on the feet.",2020-09-01
2635,WOODBURY HEALTH AND REHABILITATION CENTER,445435,119 WEST HIGH STREET,WOODBURY,TN,37190,2019-06-10,600,D,1,0,468711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, observation, and interviews, the facility failed to prevent abuse for 1 resident (#1) of 3 residents reviewed for abuse. The findings include: Review of the facility policy, Abuse Prevention Policy and Procedure, last revised 2/26/18, revealed .This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physician and/or mental abuse .by any facility staff member, other residents, consultants, volunteers .Resident to Resident .It is the policy of this facility to take all steps reasonable and necessary to protect the residents from harm at all times, including protection from physical and verbal abuse from other 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 had short and long term memory loss and had disorganizing thinking with no behaviors identified. Medical record review revealed Resident #2 was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. Medical record review of a quarterly MDS dated [DATE] revealed Resident #2 scored a 3 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and had disorganized thinking with no behaviors identified. Medical record review of Resident #2's care plan dated 7/16/18 and updated on 2/17/19 revealed .1:1 (one to one) staffing due to resident to resident altercation . Review of a facility investigation dated 5/29/19, not timed, revealed Certified Nursing Assistant (CNA) #2 witnessed Resident #2 kick Resident #1 twice. Continued review of a witness statement from CNA #2 revealed .I was going to the dining room and as I approached the door, I looked over to my left and saw .(Resident #2) kicking .(Resident #1) .twice . Further review revealed Resident #2 was sent for a psychiatric evaluation and was discharged from the facility. Observation of Resident #1 on 6/10/19 at 10:00 AM, in the activity area, revealed the resident was seated with a staff member and no aggressive, fearful, or anxious behaviors were observed. Interview with the Director of Nursing (DON) on 6/10/19 at 10:55 AM revealed .after the altercation in (MONTH) (2/17/19) our goal was to keep the residents (Resident #1 and Resident #2) separated .medication changes were made .she (Resident #2) has not had any aggressive behaviors toward another resident until (the incident on 5/29/19) . Telephone interview with Licensed Practical Nurse (LPN) #1 on 6/10/19 at 11:00 revealed .I did the assessment on (Resident #1) and there were no new marks on her .earlier that morning the two (Resident #1 and Resident #2) were in the intersection at the same time .(Resident #2) had raised her hand at (Resident #1) but .did not make contact .have a history of a previous altercation .we do try to keep them separated . Interview with the Administrator on 6/10/19 at 12:40 PM, in the conference room, confirmed Resident #2 deliberately kicked Resident #1 in the shin two times and the facility failed to prevent abuse to Resident #1.",2020-09-01
2157,SIGNATURE HEALTHCARE OF FENTRESS COUNTY,445362,208 DUNCAN ST N,JAMESTOWN,TN,38556,2019-02-06,600,D,1,0,X1K211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, observation, and interviews, the facility failed to prevent abuse for 1 resident (#1) of 5 residents reviewed for abuse. The findings included: Review of the facility policy Abuse, Neglect and Misappropriation of Property, not dated, revealed .It is this organization's intention to prevent the occurrence of abuse .This policy applies to all residents without respect to the resident's cognitive condition, awareness, or ability to understand the event at issue .for the purpose of this policy .sexual abuse includes, but is not limited to, any physical contact with a resident's body that is not reasonably related to appropriate provision of care . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Further review revealed verbal behavioral symptoms directed towards others occurred 1 to 3 days during the assessment period. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of a Quarterly MDS dated [DATE] revealed a BIMS score of 11, indicating the resident had moderate cognitive impairment. Continued review revealed no physical or verbal behaviors occurred during the assessment period. Review of the facility investigation dated 1/24/19 revealed a Certified Nursing Assistant (CNA) observed Resident #2's with his hand on Resident #1's breast on the outside of her clothing. Further review revealed the CNA immediately removed Resident #2 from Resident #1's room and reported the incident. Continued review revealed the Director of Nursing (DON) questioned Resident #2 and asked him if he had permission from Resident #1 to touch her breast and he replied no. Further review revealed Resident #2 stated this was not the first time he had touched Resident #1 and claimed Resident #1 was receptive to his attention. Observation and interview with Resident #1 on 2/5/19 at 7:30 AM, in her room, revealed the resident was awake and alert and well groomed. Continued observation revealed the resident did not exhibit any fearful or anxious behaviors and was able to recall the incident. Interview with the resident revealed .he rolled to the edge of my bed and put his hand on my breast. It was on top of my gown. I thought we were friends but he took advantage of our friendship .was not okay with me . Continued interview revealed Resident #1 denied Resident #2 had touched her in the past. Interview with Resident #2 on 2/5/19 at 8:20 AM, in his room, revealed .I was in her room feeling of her breast and I got caught. She didn't tell me to stop .she acted like she was okay with it. I had been in her room twice before and done that and she told me to come back . Interview with CNA #1 on 2/5/19 at 9:50 AM, in the conference room, revealed .I went into her room .I saw him in her room which it's not uncommon for him to be in her room. They sit together and hold hands, but I saw his hand on her breast, I asked her if it was ok for him to touch her like that and she shook her head no. They weren't even looking at each other she was facing the television and his wheel chair was beside her bed and he was facing the wall but his arm was extended some and his hand was laying on her breast. He wasn't groping her, his hand was just on her breast, but it wasn't accidental. She wasn't protesting, or trying to move his hand she was just watching TV (television) until I asked her then she shook her head no . Interview with the DON on 2/6/19 at 2:00 PM, in the conference room, confirmed Resident #2's hand was on Resident #1's breast and the facility failed to prevent abuse of Resident #1.",2020-09-01
2318,GENERATIONS CENTER OF SPENCER,445388,87 GENERATIONS DRIVE,SPENCER,TN,38585,2020-02-04,600,D,1,0,CRSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, review of an incident report, observations, and interviews, the facility failed to prevent abuse of 1 resident (Resident #1) of 9 residents reviewed for abuse, resulting in Resident #1 being abused by staff. The findings included: Review of the facility's policy titled Abuse Prevention Policy & Procedure, last reviewed on 1/22/2020 showed .This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse .Physical Abuse: The infliction of physical pain or injury, includes but not limited to: slapping, pinching, hitting, kicking, or shoving . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1 scored a 5 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and the resident required assistance of one or more persons with activities of daily living (ADL's). Review of a facility investigation dated 1/25/2020 showed Certified Nursing Assistant (CNA) #3 told Licensed Practical Nurse (LPN) #1, LPN #2, and Hospitality Aide #1, that she had .'whooped on the bottom' of (Resident #1) to get her to go to bed .'tapped her on the bottom like tapping your leg to the beat of the music' so she would go to bed . Review of a facility Incident/Accident report dated 1/25/2020 showed .Name .(Resident #1) .Employee had made the statement in front of other staff that she had 'whipped' residents bottom when she put her to bed .conversation with me (Director of Nursing) on the phone employee stated 'I tapped, patted her bottom' . Observation in Resident #1's room on 2/3/2020 at 1:55 PM showed the resident lying in bed. No fearful or anxious behaviors were observed. The resident made no attempt to communicate with the surveyor. During an interview on 2/3/2020 at 6:40 AM, CNA #3 stated .I had (Resident #3) with me .she had been yelling and trying to push herself out of her wheelchair. I asked her if she wanted her bottom whooped .(LPN#1) heard me and said 'what you whoop residents' .I told her 'I had whooped (Resident #1) when I was trying to get her in to bed' .I would never hurt any of my residents .I had no intent of abuse, I just was trying to get her in the bed . During an interview on 2/3/2020 at 7:20 AM, Hospitality Aide #1 stated .I was coming down the hall to the nurses station .I overheard .(CNA#3) talking to .(LPN #1) .(CNA #3) just blurted out she had smacked one of the residents .she said (Resident #1) .(LPN #1) asked her what did you say and she said 'oh I lightly smacked one of the residents' .(LPN #1) said 'you can't do that, that is abuse and I have to report it' . During an interview on 2/3/2020 at 7:30 AM, the Administrator stated .(CNA #3) had admitted to smacking (Resident #3) on the bottom .I received a phone call from (LPN #1) she said .(CNA #3) is here and she has something to tell you .(CNA #3) reported she had said .she had whooped (Resident #1) .(CNA #3) did admit she patted (Resident #1) on the bottom like you tap your leg to the music, but when she described it at the team area she stated she whooped (Resident #1) .when asked why she did that she said it was to get her to go to bed .on the follow up interview (CNA #3) said it was to try to get (Resident #1) to participate in the act of getting her to go to bed . During an interview on 2/3/2020 at 10:00 AM, LPN #1 stated .I was sitting at the team area .(CNA #3) was talking about how she 'has to whoop (Resident #1) to get her to go to bed' .I said do you know what you are saying, do you know what you are talking about, she said yes she knew what she was saying she said 'I have to whoop (Resident #1) to get her to go to bed' . During an interview on 2/3/2020 at 2:15 PM, the Director of Nursing (DON) stated .When I talked to (CNA #3) I asked her why .was she trying to punish her (Resident #1) hurt her or what .she said no and she thought if she (Resident #1) was going to act like a child .she treated her like one she would go to bed. I asked her if she thought it was appropriate to treat anyone this way and she said I guess not, but she said she wasn't being mean or trying to hurt her . During an interview on 2/4/2020 at 11:30 AM, the Administrator stated .(CNA #3) was overheard saying she had 'whooped (Resident #1) on the bottom' . The Administrator confirmed the facility failed to prevent abuse to Resident #1.",2020-09-01
1693,WILLOW RIDGE CENTER,445284,215 RICHARDSON WAY,MAYNARDVILLE,TN,37807,2018-11-20,610,D,1,0,PGOW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigations, and interviews, the facility failed to complete a thorough investigation of abuse for 4 residents (#1, #2, #3, and #4) of 9 residents reviewed for abuse. The findings included: Review of the facility policy Abuse Prohibition, last revised on 7/1/18, revealed .will prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents .the facility will implement an abuse prohibition program through the following .Investigation of incidents and allegations . 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 for Mental Status (BIMS) score of 12 (moderate cognitive impairment). Continued review revealed the resident required extensive assist for bed mobility, transfers, and activities of daily living (ADLs) with 1-2 person assist. 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 a BIMS score of 14 (cognitively intact). Continued review revealed the resident required extensive assistance with bed mobility, transfers, and ADLs with 1-2 person assist. Review of a facility investigation dated 11/8/18 revealed a resident to resident altercation between Resident #1 and Resident #2. Continued review revealed Resident #1 and Resident #2 were assessed for injuries with none noted, but no other residents were assessed or interviewed for possible abuse. 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 a BIMS score of 14 (cognitively intact). Continued review revealed the resident required extensive assist for bed mobility, dressing, toileting, and personal hygiene with 1-2 person assist. Review of a facility investigation dated 10/21/18 revealed Resident #3 alleged a nurse grabbed her by the wrist and threatened to withhold her pain medication. Continued review revealed the resident was assessed for injury with none noted, but no other residents were assessed or interviewed for possible abuse. Continued review revealed co-workers of the accused nurse were not interviewed. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE] revealed a BIMS score of 7 (severe cognitive impairment). Continued review revealed the resident required extensive assistance for bed mobility and ADLs with 1-2 person assist. Review of a facility investigation dated 9/27/18 revealed Resident #4 alleged someone had beaten her up. Continue review revealed the resident was assessed for injury with none noted, but no other residents were assessed or interviewed for possible abuse. Interview with the Center Executive Director on 11/20/18 at 3:30 PM, in her office, confirmed the facility failed to do a complete and thorough investigation during investigations of abuse involving Resident #1, #2, #3, and #4.",2020-09-01
2529,AHC VANAYER,445423,460 HANNINGS LANE,MARTIN,TN,38237,2018-08-09,607,D,1,0,8HJ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility reported incident, and interview the facility failed to implement a written policy related to suspension of an accused staff member (Certified Nurses Aide (CNA) #1) during an allegation of verbal abuse for 1 (Resident #1) of 3 sampled residents. The findings included: 1. The facility's Abuse, Neglect, Exploitation Policy dated 2/2018 documented, .resident has the right to be free from abuse .Verbal Abuse .use of oral .gestured language .disparaging and derogatory terms to residents .j. Removing the alleged perpetrator from the schedule .e. Suspend the accused employee pending completion of the investigation . 2. 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 for Mental Status of 15 which indicated Resident #1 had no impairment for decision making. 3. Review of the facility's investigation dated 7/22/18 revealed on 7/21/18 between the hours of 10:00 PM and 12:00 AM Resident #1 reported to Registered Nurse (RN) #1, CNA #1 had said to him .what do you [***] ing want .I don't have time for your [***] ing ass . The investigation also concluded that RN #1 did not remove CNA #1 from patient care. Interview with the Administrator on 8/2/18 at 2:55 PM, in the conference room, the administrator stated .became aware of this incident after she (CNA #1) contacted me by phone that morning 7/22/18 around 6:30 AM she (CNA #1) asked if she would lose her job . A telephone interview with CNA #2 on 8/2/18 at 4:15 PM, CNA #2 was asked to explain the incident involving Resident #1 CNA #2 stated, .I heard (CNA #1) say to (Resident #1) .What the [***] do you want (with her hands up) .not in the mood for this .don't act [***] ing crazy . A telephone interview with RN #1 on 8/2/18 at 7:30 PM, RN #1 was asked if CNA #1 was removed from resident care. RN #1 stated, .no . Interview with the Director of Nursing (DON) and Administrator on 8/2/18 at 5:00 PM, in the conference room, the Administrator and DON confirmed that CNA #1 should've been removed from patient care immediately.",2020-09-01
2236,NORTHSIDE HEALTH CARE NURSING AND REHABILITATION C,445373,202 EAST MTCS ROAD,MURFREESBORO,TN,37130,2017-11-30,600,D,1,1,Z9P511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of an Investigation Summary, and interview, the facility failed to prevent resident-to-resident abusive behaviors between 2 residents (#11 and #37) of 13 residents reviewed. The findings included: Review of facility policy, Abuse, Neglect, Exploitation, effective 1/27/2016 revealed .each resident has the right to be free from abuse . Medical record review revealed Resident #11 was admitted [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Continured medical record review revealed a quarterly Minimum Data Set ((MDS) dated [DATE] revealed severe cognitive impairment with no moods or behaviors exhibited. Medical record review revealed Resident #37 was admitted [DATE] with [DIAGNOSES REDACTED]. Continued medical record review revealed a quarterly MDS dated [DATE] revealed moderate cognitive impairment with poor decision making. Review of an Investigation Summary dated 11/6/17 at 10:00 AM revealed Resident #37 was in his wheelchair propelling in the 300 hall toward the dining room while Resident #11 was in her wheelchair propelling in the 300 hall away from the dining room and directly in the path of Resident #37. Resident #37 made an obscene gesture toward Resident #11 to move from his path and when Resident #11 did not move, Resident #37 slapped her left arm. Continued review revealed Licenced Practical Nurse (LPN) #3 observed the event and separated Resident #11 and #37; Certified Nurse Aide (CNA) #2 was slapped and received an obscene gesture by Resident #37 when attempting to take him toward his room. Continued review revealed Resident #37 was transferred to an emergency department for medical evaluation, clearance, and possible placement in a psychiatric facility. Continued review revealed Resident #11 sustained a slight discoloration to the left mid-forearm. Medical record review of a Nurse's Note dated 11/2/17 at 6:20 AM revealed Resident #37, was spitting and making obscene gestures toward staff when he learned he might be getting a roommate. Continued review of a Nurse's Note dated 11/3/17 at 12:10 PM revealed Resident #37 refused his medications and care relating to a possible new roommate. Continued review of the Nurse's Notes dated 11/6/17 at 3:21 PM and 3:46 PM respectively revealed a physical altercation with another resident had occurred and CNA #2, was hit on the arm by resident (#37). Interview with CNA #2 on 11/30/17 at 10:40 AM in the 300 hall revealed Resident #37 hit and made an obscene gesture toward Resident #11 on the left arm for not getting out of his way. Continued interview revealed CNA #2 helped take Resident #37 back to his room and he made an obscene gesture toward CNA #2 and .hit my arm Interview with LPN #1 on 11/30/17 at 10:45 AM in the 300 hall revealed Resident #37 was upset about the possibility of getting a roommate and acted-out by hitting at others. Interview with the Social Services Director on 11/30/17 at 1:35 PM in her office revealed Resident #37 was upset at the possibility of getting a roommate and this probably triggered him to act out. Interview with the Director of Nursing (DON) on 11/30/17 at 1:45 PM in her office confirmed Resident #37 was triggered by the possibility of getting a roommate and slapped Resident #11. Continued interview confirmed the facility failed to prevent abusive behaviors of Resident #37 towards Resident #11.",2020-09-01
1750,BEECH TREE HEALTH AND REHABILITATION,445292,"240 HOSPITAL LANE, PO BOX 300",JELLICO,TN,37762,2018-05-15,677,D,1,0,3BRZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility document, and interviews, the facility failed to provide incontinence care, in a timely manner for one resident (#1) of 5 residents reviewed for incontinence. The findings included: Review of the facility policy Routine Resident Checks revised 7/13 revealed .Staff shall make routine resident checks to help maintain resident safety and well-being .Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met .identify whether the resident has any concerns .needs toileting assistance, etc . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Continued review revealed the resident was frequently incontinent of bladder, and always incontinent of bowel. Review of a care plan dated 2/7/17 revealed .I am incontinent of bowel and bladder .My goal is that I will be kept clean and dry .I need checked for incontinence Q2 (every two) hours and as needed. Review of a facility document Bowel and Bladder Screener dated 3/22/18 revealed .not a candidate for sch (scheduled) toileting related to physical condition .she will be checked for incontinence Q2 hours and as needed . Interview with certified Nursing Assistant (CNA) #2, on 5/15/18 at 2:12 PM, in the conference room revealed I was picking up supper trays, and (Resident #1) told me that she needed to be cleaned up .I told her I would be back just as soon as I finished picking up meal trays; it took me a little while because I had to answer a few call lights. I told her to put on her call light so I didn't forget to come back. It is my assumption it is cross-contamination and we can't change or toilet a resident during meal time. Interview with the Director of Nursing on 5/15/18 at 6:10 PM, in the conference room confirmed her expectations of CNA # 2, would have been for the resident to be cleaned and dried immediately, and the CNA had failed to provide incontinence care timely for Resident #1.",2020-09-01
3259,WEST HILLS HEALTH AND REHAB,445501,6801 MIDDLEBROOK PIKE,KNOXVILLE,TN,37919,2019-03-20,656,G,1,1,VPMF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility documentation, and interview the facility failed to follow the plan of care for bed mobility for 1 resident (#9) of 5 residents reviewed for falls of 24 sampled residents. The facility's failure to follow the plan of care for Resident #9 resulted in actual harm. The findings include: Review of the facility policy Falls Management, undated, revealed, .The facility strives to reduce the risk for falls and injuries by promoting the implementation of the Risk Reduction: Falls and Injuries Program. Residents are assessed for the fall risk factors. The interdisciplinary team works with the residents and family to identify and implement appropriate interventions to reduce the risk of falls or injuries . Continued review of the facility's fall policy revealed, .Procedure .3. Discuss goals and interventions with resident/family for inclusion in the interdisciplinary plan of care. 4. Implement the Plan of Care- Fall Risk Reduction based on individual resident needs. 5 Complete the individual resident care plan. 6. Communicate interventions during shift report and clinical rounds to the care teams as appropriate . Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #9 scored a 2 on the Brief Interview for Mental Status (BIMS) indicating the resident was severely cognitively impaired. Continued review revealed Resident #9 required the extensive assistance of 2 staff for bed mobility, and the total dependence of 2 staff for transfers, toileting and hygiene. Medical record review of the comprehensive care plan dated 12/11/18 revealed, .Risk for falls will be minimized/managed and resident will suffer no serious injury related to falls . Continued review revealed, .2 person assist for bed mobility . Medical record review of an undated Certified Nurse Assistant (CNA) ADL (Activities of Daily Living) Care Guide revealed, .two person (staff) for ADLs, bed mobility, and transfers . Medical record review of a Fall Scene Investigation form dated 3/2/19 revealed, .Rolled out of bed while being assisted by one CNA . Medical record review of local hospital History and Physical Reports dated 3/2/19 revealed, .Chest x-ray reveals .rib fractures on the left 2 through 7 .Pneumothorax (collapsed lung) . Further review revealed Resident #9 had a chest tube placed due to the collapsed lung. Review of a Personnel Action Form dated 3/6/19 revealed, .(CNA #1) was providing patient care, alone, on a person who required the assist (assistance) of 2 (staff). The patient (Resident #9) fell from the bed and sustained injury. Associate did not adhere to the ADL care guide . Interview with CNA #1 on 3/19/19 at 2:20 PM, by phone, confirmed, .changed her (Resident #9) by myself, I always changed her with 1 CNA . Interview with the Director of Nursing (DON) and the Administrator on 3/19/19 at 4:05 PM, in the DON's office, confirmed Resident #9 was care planned for requiring the assistance of 2 staff members for bed mobility. Further interview with the DON and Administrator confirmed CNA #1 had provided care to Resident #9 alone, and had failed to follow the resident's care plan resulting in Resident #9's fall from the bed and sustaining fractured ribs and a collapsed lung.",2020-09-01
716,LIFE CARE CENTER OF CROSSVILLE,445167,80 JUSTICE ST,CROSSVILLE,TN,38555,2018-07-11,658,D,1,1,QYTP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility documentation, and interview, the facility failed to follow professional standards of practice for 1 resident (#49) of 30 residents reviewed for medication administration. The findings include: Review of the facility policy Administration of Medication, undated, revealed .Standard .All medications are administered safely and appropriately .Responsibility of the nursing professional: be aware of the classification, action, correct dosage, and side effects of a medication before administration .Read each order entirely . Medical record review revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 12, indicating moderate cognitive impairment. Further review revealed Resident #49 required extensive 2 person physical assistance for all activities of daily living except eating, which required supervision and set up and personal hygiene which only required extensive assistance by 1 staff member. Further review revealed the resident experienced behaviors not directed towards others 4-6 days per week and rejected care 1-3 days a week. Continued review revealed the resident received an antipsychotic, antianxiety, and antidepressant medication for 7 of 7 days. Medical record review of a Physician's Recapitulation Order dated 10/23/17 revealed .Quetiapine (antipsychotic medication) 150 MG (milligrams) PO (by mouth) daily at bedtime [MEDICAL CONDITION] Disorder . Review of facility documentation dated 11/7/17 revealed .Resident had an order for [REDACTED]. (approximately) 2:30 PM prior to MD (physician) being called to obtain a new order to separate the dose . Telephone interview with Registered Nurse (RN) #1 on 7/10/18 at 10:16 AM confirmed .(on 11/4/17) took it upon myself to give (Resident #49) a part of her bedtime dose of (antipsychotic medication) .I gave her 50 (mg) of that (150 MG dose) around 4pm .it was too early .doctor was later contacted . Interview with the Director of Nursing (DON) on 7/11/18 at 4:10 PM, in the DON's office, confirmed the facility failed to follow professional standards of practice for medication administration for Resident #49.",2020-09-01
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
482,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-09-13,684,D,1,0,9GQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility documentation, and interviews, the facility failed to provide 1 antipsychotic medication and 1 antianxiety medication as ordered for 1 resident (#9) of 3 residents reviewed. The findings include: Review of the facility policy, Medication Administration Guidelines, dated 5/16 revealed .Medications are administered in accordance with written orders of the prescriber .Medications are administered within 60 minutes of scheduled time . Medical record review revealed Resident #9 was admitted to the facility on [DATE], and discharged on [DATE], with the [DIAGNOSES REDACTED]. Review of the Physician Order Sheet dated 9/7/18, revealed .[MEDICATION NAME] .5 mg Tablet by mouth three times a day .Ziprasidone HCL 80 mg twice daily . Review of the Medication Administration Record [REDACTED].Ziprasidone HCL 80 mg (milligram) give one cap (capsule) by mouth twice a day with food .16:00 (4:00 PM) and AM . with no documentation the medication was administered at 4:00 PM on 9/7/18. Continued review revealed .[MEDICATION NAME] .5 mg Tablet Give one tab (tablet) by mouth three times a day 6:00 (AM), 14:00 (2:00 PM), 20:00 (8:00 PM) with no documentation the medication was administered at 2:00 PM or 8:00 PM on 9/7/18. Interview with Licensed Practical Nurse (LPN) #6 on 9/12/18 at 12:00 PM, in the conference room, confirmed she had not given Resident #9 his 8:00 PM, dose of .5 mg of [MEDICATION NAME] (antianxiety medication). I figured his medication would be here soon and I would give it then. I didn't think a .5 mg of [MEDICATION NAME] would make much difference. I did not attempt to obtain the medication from the E-box (emergency box) or contact the pharmacy. Interview with LPN #3 on 9/12/18 at 12:40 PM, in the conference room, confirmed Resident #9's [MEDICATION NAME] and Ziprasidone HCL (antipsychotic medication) had not been delivered to the facility by the pharmacy at the time they were scheduled to be administered. Continued interview confirmed she did not administer Resident #9 a scheduled 2:00 PM dose of .5 mg [MEDICATION NAME] or his 4:00 PM scheduled dose of 80 mg Ziprasidone HCL. Continued interview confirmed LPN #3 did not attempt to obtain the 2:00 PM, dose of .5 mg [MEDICATION NAME] from the E-box. Interview with the Director of Nursing on 9/12/18 at 4:10 PM, in the conference room, confirmed Resident #9 did not receive his 4:00 PM scheduled dose of Ziprasidone 80 mg, and did not receive his 2:00 PM and 8:00 PM dose of .5 mg [MEDICATION NAME]. Continued interview revealed it was her expectation if a medication was unavailable for a resident the Physician was to be notified for a new order. Continued interview confirmed they had access to a local pharmacy, and [MEDICATION NAME] was available in the E-box, but had not been utilized. Further interview confirmed the facility failed to provide Resident #9 his medications as ordered.",2020-09-01
368,BEVERLY PARK PLACE HEALTH AND REHAB,445131,5321 BEVERLY PARK CIRCLE,KNOXVILLE,TN,37918,2018-04-30,569,D,1,0,0TGD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility documentation, and interviews, the facility failed to refund the balance of a Patient Trust Fund, within the required time frame, for one discharged Resident (#2) of 6 residents reviewed for Patient Trust Funds. The findings included: Review of the facility policy Resident AR (Accounts Receivable) Refund Policy not dated revealed . will review and credit balances for appropriate refund, and issue refund within 30 days based on the following: .There are no funds due to the facility by a third party payer, i.e. an insurance secondary to Medicare .Any refund will be payable to the resident, or responsible party when applicable . Medical record review revealed Resident #2 was admitted to the facility on [DATE], and discharged on [DATE] with the [DIAGNOSES REDACTED]. Review of a facility document Trial Balance dated 4/25/18 revealed Resident #2 had a balance of #213.13 in his Patient Trust Fund. Interview with Resident #2's daughter, on 4/25/18 at 11:45 AM, via telephone revealed Resident #2 had discharged from the facility on 1/8/18, and neither she nor Resident #2 had received a refund check, or any notification from the facility in reference to closing his Patient Trust Account. Interview with the Business Office Assistant, on 4/25/18 at 2:00PM, in the conference room confirmed Resident #2 discharged from the facility on 1/8/18. The facility did not send a Resident Fund Management Service statement to the resident within 30 days, disclosing the balance of his Patient Trust Account. Interview with the Business Office Manager, on 4/25/18 at 2:40 PM, in the conference room confirmed Resident #2 had met the criteria for his Patient Trust Fund to be refund as of 2/12/18. Further interview confirmed the facility failed to follow their AR Refund Policy, and had not issued a refund check for Resident #2's Patient Trust Account within the required time frame.",2020-09-01
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
1098,RENAISSANCE TERRACE,445223,257 PATTON LANE,HARRIMAN,TN,37748,2018-09-25,697,D,1,0,V9FH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility documentation, observations and interviews, the facility failed to provide 3 scheduled doses of [MEDICATION NAME] HCL 20 mg tablet (medication to control pain) as ordered for 1 Resident (#2) of 3 residents reviewed. The findings include: Review of a facility policy, Medication Administration-General Guidelines, dated 11/08 revealed .Medications are administered in accordance with written orders of the attending physician .Medications are administered with 60 minutes of scheduled time . Medical record review revealed Resident #2 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Review of a Care Plan dated 6/21/18, for Resident #2, revealed .I have chronic pain r/t (related to) Fracture multiple .Administer [MEDICATION NAME] as per orders . Review of a Physicians order dated 4/11/18, revealed .[MEDICATION NAME] HCL tablet 20 mg (milligram) Give 1 tablet every 4 hours for pain related to Radiculopathy [MEDICATION NAME] Region . Review of a Medication Administration Record [REDACTED].[MEDICATION NAME] HCL 20 Tablet 20 mg give one by mouth every 4 hours for pain . Continued review revealed on 9/23/18 Resident #2 was not administered his 12:00 AM dose, or his 4:00 AM dose. Continued review revealed the 8:00 AM, dose was signed off by Licensed Practical Nurse #1 as given. Further review revealed on 9/24/18, Resident #2 had rated his pain at a level of 2 at 12:00 AM, 4:00 AM, and at 8:00 AM. Observation/interview with Resident #2 on 9/24/18 at 10:20 AM, in his room, revealed the resident in his room lying in bed, awake and alert. Continued obsrvation revealed Resident #2 was not grimacing, moaning, or restless. Interview at this time revealed until last night he hadn't had any problems getting his medications. I haven't had my pain medication since 8:00 PM, last night, the nurse said they didn't have it. When asked if he had reported he was in pain he responded It wouldn't do any good they don't have it. Interview with Resident #2 on 9/25/18 at 3:10 PM, in his room, revealed prior to him receiving his 12:00 PM, dose of [MEDICATION NAME] HCL 20 mg on 9/24/18, his pain level had reached 8 1/2 -to 9. Interview with the Administrator, on 9/25/18 at 1:40 PM, in the conference room, revealed the facility had been conducting an investigation related to a probable medication diversion. Continued interview confirmed an order for [REDACTED]. As a result of the missing medication the resident was 1 day short of pain medication that resulted in him missing 3 doses of his scheduled pain medication. Interview with Licensed Practical Nurse #1 on 9/25/17 at 3:30 PM, in the conference room, confirmed on 9/24/18 at 8:00 AM, resident #2 did not receive his 20 mg [MEDICATION NAME] tablet as ordered. Continued interview confirmed she had mistakenly initialed the medication as given, not as missed. Interview with the Registered Nurse supervisor on 9/25/18 at 3:50 PM, in the conference room confirmed Resident #2, did not receive his scheduled [MEDICATION NAME] HCL 20 mg on 9/24/18 at 12:00 AM, 4:00 AM, and at 8:00 AM and the facility had failed to control Resident #2's pain, and had failed to follow their Medication Administration Policy.",2020-09-01
405,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2017-11-13,323,E,1,1,UJ6N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility falls investigations, and interview, the facility failed to complete a thorough investigation and implement interventions to prevent further falls for 3 residents (#85, #43, #104), and failed to provide adequate supervision to prevent falls for one resident (#93) of 8 residents reviewed for accidents of 29 residents reviewed. The findings included: Review of the facility policy Falls Management Guideline, last review date 8/10/16, revealed .to minimize the risk of falls .appropriate interventions are implemented .the Interdisciplinary Team reviews .and makes additional recommendations . Review of the facility policy Post Fall Analysis Summary & (and) Guidelines for Completion, last reviewed 11/23/15, revealed .after every known resident fall .identify the reason and/or risk factor for the fall .to prepare a plan of care to reduce the potential for future fall . Medical record review revealed Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Fall Risk assessment dated [DATE] revealed a falls score of 17, indicating the resident was a high risk for falls. Medical record review of the 14 day Minimum Data Sed ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 3, indicating severe cognitive impairment; behaviors including physical, verbal, and rejection of care; and required extensive assist with 2 staff for transfer, hygiene, and toileting. Medical record review of the Progress Notes dated 10/10/17 at 9:41 PM revealed, .resident found sitting in the floor next to the bed. Small skin tear noted to right forearm. no other injury noted . Medical record review of the Progress Notes dated 10/10/17 at 9:49 PM revealed, .while passing hs (nighttime) medications found resident sitting in the floor next to the sink .no injury noted . Medical record review and review of facility falls investigations revealed the facility failed to complete an investigation to determine the cause and to implement interventions to prevent further falls for the falls on 10/10/17. Medical record review of the Progress Notes dated 10/15/17 at 7:47 AM, revealed, .Observed resident lying in floor prone position .skin tear noted on left wrist .Recommendations: Bolster mattress put on bed for intervention . Medical record review and review of facility falls investigations revealed the facility failed to complete an investigation to determine the cause and to implement interventions to prevent further falls for the fall on 10/15/17. Interview with the Director of Nursing (DON) on 11/8/17 at 11:55 AM, in the DON's office, confirmed the facility failed to complete and investigation to for the two falls on 10/10/17 and the fall on 10/15/17. Medical record review revealed Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. Review of the significant change MDS dated [DATE] revealed the resident was incontinent of urine, required extensive assist of 2 persons for bed mobility, transfers, toilet use; and extensive assist of 1 person for locomotion on the unit, dressing, and eating. Medical record review the resident's current care plan revealed, .At risk for falls . with the resident's first fall on the care plan dated 9/15/16 and interventions to be utilized to prevent further falls. Review of a falls investigation dated 8/5/17 at 3:15 PM revealed, .Resident observed leaning to the side of her W/C. two nurses assisted to upright position. Resident then observed to quickly lean forward throwing herself out of W/C onto her hands and knees .Immediate action Taken .Tilt drop seat to W/C . Further review revealed the resident had no injuries. Medical record review of the resident's care plan revealed the new intervention for the Tilt drop seat to W/C was not implemented. Review of a falls investigation dated 8/22/17 at 3:15 AM revealed, .Resident observed to be scooting on buttocks in floor in hallway near her room. No obvious injuries noted New intervention: Scheduled toileting Q 2 hours (every 2 hours) day and night (a nursing action that should be done on every incontinent resident) . Review of a falls investigation dated 8/22/17 at 3:49 PM revealed, .Resident was observed lying on left side in floor in the lobby area. W/C cushion had slid down in chair .No injury noted .New Intervention: Anti-skid material in W/C cushion . Medical record review of the resident's care plan revealed the new intervention for the Anti-skid material in W/C was not implemented. Review of a falls investigation dated 8/30/17 at 10:51 PM revealed, .Resident was observed crawling on floor in her room .no injury was noted .New Intervention: Psyc NP (Psychiatric Nurse Practitioner) to review meds (medications) again . Medical record review revealed there was no medication changes and no other interventions to prevent falls was put in place. Interview with the Regional Nurse Consultant and Registered Nurse (RN) #1 on 11/8/17 at 2:42 PM, in the small conference room, confirmed the facility had failed to put new interventions in place for the falls on 8/5/17, 8/22/17, and 8/30/17. Medical record review revealed Resident #104 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 3, indicating the resident was severely cognitively impaired. Continued review revealed the resident required extensive assistance with 2 person physical assist for bed mobility and transfers and extensive assistance with 1 person physical assist for all other ADLs. Medical record review of a Progress Note dated 6/1/17 at 11:15 AM, revealed .pt. (patient) found in floor by bed. Upon assessment found large knot to back of head .denies pain with movement of either upper or lower extremities . Medical record review and review of facility falls investigations revealed no investigation was completed to determine the cause of the fall and to implement interventions to prevent further falls. Interview with the Director of Nursing, Administrator, and Regional Consultant Nurse on 11/09/17 at 1:22 PM, in the DON's office, confirmed the facility failed to investigate Resident #104's fall on 6/1/17. Medical record review revealed Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the resident was discharged on [DATE]. Medical record review of Resident #93's care plan initiated 11/23/16 revealed, .at risk for falls .requires ADL (activities of daily living) assist for transfers and mobility . Further review revealed care plan documentation the resident had a fall on 12/15/16. Further review revealed the care plan was revised 5/18/17 with .physical functioning deficit .related to .mobility impairment .extensive assistance of 2 . Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 14, indicating Resident #93 was cognitively intact. Further review revealed the resident required extensive assistance of two person physical assist for bed mobility, dressing, toilet use, and personal hygiene. Continued review revealed the resident was totally dependent with two person physical assist for transfers. Further review revealed Resident #93 was unable to stabilize himself without staff assistance when moving on and off the toilet and was impaired on one side in his lower extremity. Medical record review of a Progress Note dated 6/29/17 at 7:00 PM revealed .discovered laying on the bath room floor in face down position .awake and oriented .answer questions appropriately .laying on stomach . Medical record review of a Fall report dated 6/29/17 revealed .location .bathroom .nursing description .observed laying on bathroom floor .alert and oriented .attempting to stand from toilet to clean self after having a BM (bowel movement) .legs weakened .fell from toilet . Interview with Certified Nursing Assistant (CNA) #1 by telephone on 11/8/17 at 8:01 AM, confirmed she assisted Resident #93 to the restroom the evening of 6/29/17 with assistance from CNA #2. Further interview revealed CNA #1 left the room to obtain supplies and at that time CNA #2 was still in the room. Continued interview revealed upon returning to the room CNA #2 was no longer in the room and Resident #93 was laying in the bathroom floor. Interview with Registered Nurse (RN) #1 on 11/8/17 at 8:35 AM, in the nursing office, confirmed it was the facility's practice if a resident required staff assistance to the restroom, a staff member will stay with them to ensure the resident's safety. Continued interview confirmed it was the facility's practice to never leave a resident alone in the restroom. Interview with the DON on 11/9/17 at 7:55 AM, in the DON's office, confirmed it was her expectation if a resident required assistance to the restroom, staff would stay with the resident to ensure their safety. Interview with the DON on 11/13/17 at 8:15 AM, in the DON's office, confirmed the facility failed to provide supervision for Resident #93 while in the restroom.",2020-09-01
3882,LAURELBROOK SANITARIUM,4.4e+201,114 CAMPUS DRIVE,DAYTON,TN,37321,2018-04-11,600,G,1,0,FLCH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility incidents and investigations, review of personnel files, observation, and interview, the facility failed to ensure residents were received services and were free from neglect for one resident (#3) of ten residents reviewed. The facility's failure to ensure a resident was not neglected resulted in a fracture (Harm) for Resident #3. The findings included: Review of an undated, Reporting Abuse to Facility Management Policy and Procedure indicated, 'Neglect' is defined as (a) failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of an undated, Accident and Incident, including fall Safety Policy and Procedure revealed, Do not move the resident .until the Licensed Nurse has done an evaluation .The Licensed Nurse is to do a total evaluation on mental, physical (including ROM-Range of Motion), any injuries, deformity of change from Resident's baseline .The Charge/Licensed nurse is to give direction & (and) assist with moving the resident. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 had a BIMS (Brief Interview for Mental Status) score of 15 out of 15, which indicated no cognitive impairment. Section G: Functional Status indicated Resident #3 required extensive assistance of 1 person for transfers and toileting, was unsteady when moving on and off toilet and with surface-to-surface transfers, and was only able to stabilize with staff assistance. Section G also indicated Resident #3 had impaired range of motion (ROM) to 1 side of her upper and lower extremities. Review of Section H: Bladder and Bowel, indicated Resident #3 had occasional incontinence of urine. Review of Resident #3's care plan indicated the staff developed the following problems: a. Initiated on 10/18/17: The resident has (bladder) incontinence. The interventions included: Uses disposable briefs and pads. b. Initiated on 10/19/17: The resident is at risk for falls and falls with injury related to bladder incontinence, confusion, gait/balance problems, history of falls, and unaware of safety needs. The interventions included: Be sure call light is within reach and encourage to use it as needed. The resident needs prompt response to all requests for assistance. c. Initiated on 10/26/17: The resident has an ADL (activities of daily living) self-care performance deficit related to impaired balance and limited mobility. The interventions for Toilet Use included: (Resident #3) requires staff assistance with toileting daily. Monitor/document to the charge nurse any changes, reasons for self-care deficit, declines in function. Review of a facility reported incident dated 1/11/18, revealed, (Resident #3) reported that nurse helped (Resident #3) on the bed pan and when she finished she pressed her call light. Her CNA (Certified Nurse Aide) came in to answer her call light and told (Resident #3) that she would have to stay on her bedpan until she came back from her break .Upon investigation, it was determined .The nurse (Licensed Practical Nurse (LPN) #2) reported she was going on break to the other charge nurse (LPN #3) but did not report that (Resident #3) was on the bed pan .CT (computed tomography scan) of lumbar spine impression .Suspected mild acute inferior endplate compression fracture at L2 (lumbar spine level 2). Medical record review of a Progress Note completed by LPN #2, dated 1/11/18, revealed, Nurse (LPN #2) interviewed (the) resident concerning (her) fall .She (Resident #3) reported (her) pain level to be (a) 5 compared to her usual 3. Scheduled pain medications were given. (Nurse Practitioner) was notified. Nurse (LPN #2) called family with summary of events. Medical record review of an Initial Evaluation completed by the physician, dated 1/11/18, revealed, Pain in right hip, stiffness of right hip, muscle weakness. (Resident #3) presents today for musculoskeletal evaluation of R (right) hip pain .The mechanism of injury: States she fell out of bed .She was put on a bed pan and the CNA told her she was going to eat and the pt. (patient) would have to wait for help until she got back. The pt. reports she fell out of bed and reinjured her hip and back .The patient reports loss of function, severe, difficulty standing. Assessment: Patient presents with signs and symptoms that are consistent with R hip pain. Medical record review of an Imaging Services Report, dated 1/12/18, revealed, Suspected mild acute inferior endplate compression fracture at L2. Further review revealed [DIAGNOSES REDACTED]. Review of a facility Interview Form (Resident) (a document used to interview Resident #3 and obtain her account of what happened) dated 1/11/18, revealed Resident #3 reported, (LPN #2) put me on the bedpan-said she would tell someone. I put on the call light. (CNA #6) said 'I'd have to lay on it-I'm going on break.' I fell over .I fell off the bedpan- my legs just fell over. I hit the floor with my knee. My legs fell off the bed. Review of a facility Interview Form (Staff/Family) (a document used by LPN #2 for her account of what happened) dated 1/11/18, revealed, I put resident on bedpan at 620 PM. (I) instructed her to put on call light when she was finished. Further review of the document revealed LPN #2 did not report to the charge nurse or any other staff that Resident #3 was left on the bed pan while LPN #2 went on break. Review of a facility Typed Statement from the Assistant Director of Nursing (ADON) to CNA #6, dated 1/12/18, revealed, (Resident #3) stated that when you answered her call light you informed her that she would have to stay on her bed pan until you came back from break which was a 30 min (minute) break. During her wait for you to return (Resident #3) fell out of bed. Review of a facility Staff Interview document, dated 1/22/18, in which the ADON interviewed LPN #2, revealed, Around 6:20pm nurse helped resident onto the bedpan .instructed resident to push call light when she was finished because she (nurse) was going on break .Nurse went on break but did not report .that resident was on bedpan .While on break CNA reported that resident was on the floor. Review of a Disciplinary Action CNA's & Nurses document, dated 1/22/18, regarding LPN #2, revealed, When (Resident #3) fell , it was reported that you had the CNA's go ahead and help resident up out of the floor without being assessed. Review of a facility Interview Form (Staff/Family), dated 2/8/18, (in which Resident #7- who was the roommate to Resident #3 at the time of the incident gave her statement of what occurred) revealed (Resident #3) turned on her call light. (LPN #2) came in to answer it and put (Resident #3) on the bedpan. (LPN #2) said, 'I can't take you off the bedpan because I am going on break .(and) told (Resident #3) that she would tell a CNA to take her off the bedpan. A few minutes later (CNA #6) came in (the) room .(and) asked (Resident #3) what she wanted. (Resident #3) stated to be taken off the bedpan. (CNA #6) stated I'm going on break. I don't have time to take you off the bed pan .If I don't take my break now, I won't get one. (Resident #3) wiggled herself down to the end of the bed by holding onto the side rail and sat herself in the floor and put bed pan on the floor. Medical record review of a Physician Nursing Home Visit, dated 2/14/18, revealed, Had a 'fall' off bedpan and to floor from bed that was low position. There was a compression fx (fracture) noted. Observation on 4/9/18 at 4:10 PM, in the resident's room, revealed Resident #3 was asleep in a low bed with a fall mat on the floor on the right side of the bed. The call light was in place and within reach. Interview with the Director of Nursing (DON) on 4/9/18 at 4:20 PM, in the conference room, revealed, (LPN #2) put (Resident #3) on the bed pan then she went on her break. (LPN #2) did not tell the charge nurse (LPN #3) or any other staff that the resident was on the bed pan. The DON stated, My expectation is that (LPN #2) should have told someone like the CNA covering the floor, or the charge nurse that (Resident #3) was on the bedpan when she was going on break but that didn't happen. She (LPN #2) only told the charge nurse she was going on break but made no mention of the resident being on the bed pan. The DON stated, When I did my investigation and spoke to (Resident #3) she told me that (LPN #2) 'put me on the bedpan and told me to put call light on because she was going on break. Later on (CNA #6) came to my door and I told her I needed to get off the bed pan and she told me I would have to stay on the bedpan until she (the CNA) comes back from break.' The DON stated, the incident occurred on 1/11/18 and an X-ray was done on 1/12/18, which showed a suspected mild acute inferior endplate compression fracture at L2 and this was something new that the resident sustained [REDACTED].>Interview with LPN #2 on 4/9/18 at 5:05 PM, in the conference room, revealed, I told the resident (referring to Resident #3) since you need to go so bad, I will put you on the bedpan. Then I said (to the resident) I will be going on break and you need to turn your call light on and wait for someone to come get you off the bedpan. I went to the charge nurse and said I was going on break. When LPN #2 was asked if she told the charge nurse that she left Resident #3 on the bed pan when going on her break, LPN #2 stated, No, I don't really recall. LPN #2 then stated A while later 2 CNAs (CNA #6 and CNA #7) came to me while I was still on break and said she (Resident #3) was on the floor. My thought was, the charge nurse knew I was on my break. Why didn't they (CNA #6 and CNA #7) go tell the other nurse? I told them (CNA #6 and CNA #7) to get vitals and tell the other nurse (the charge nurse) if she is ok. The CNAs said, 'We couldn't pick her up from the floor and we had to go get another CNA to help us put her back to bed.' I was thinking in my mind that the charge nurse knew I was on my break so why didn't she go and check on the resident? Later, I went and talked with her (Resident #3). I know she gets [MEDICATION NAME] for pain so I gave her one. She told me she was feeling sore in her hip area and I recall calling the doctor. Interview with CNA #7 on 4/9/18 at 5:40 PM, in the conference room, revealed, I came back from break and I saw her (Resident #3) call light on. Both me and the other CNA (CNA #6) walked in the room. The resident was on the floor leaning sideways. She (the resident) did not say what happened. I don't know how she got on the bedpan. I went and told the nurse (LPN #2) who was on her break, that the resident was on the floor. I was not her CNA at the time. (CNA #6) was. (LPN #2) said, 'I'm on my break right now.' She said to check her vitals and look her over and then put her to bed. I went and got another CNA (CNA #5) and me, (CNA #6) and (CNA #5) got her off the floor. One person under each arm and lifted her back to bed. She was complaining of pain to her hip. Afterwards, I went back to the breakroom and told (LPN #2) her vitals were good and we put her back to bed and that she was complaining of pain then I went back to my side of the hall. Interview with Resident #3 on 4/10/18 at 8:15 AM, in her room, revealed, The nurse (LPN #2) put me on the bedpan. She told me she was going on break and to put my call light on and she would be back. The right side of my bed was against the wall at the time. I had my call light on. (CNA #6) came in my room and asked me what I needed and I told her I needed to get off the bedpan. She told me, 'I'm going on break' and said I would have to wait on the bedpan until she got back from her break. Then she left my room right away. So, I was trying to turn myself over to get off the bedpan and my legs went to the floor and the bedpan spilled on me. About thirty minutes went by and another CNA (CNA #7) came in my room and saw me on the floor. I told her what happened and she had to go get 2 more CNAs to help lift me up to my bed. It really shocked me when she (CNA #6) said I would have to wait for her to get back from her break before she could help me off the bedpan. It made me sad. Interview with the Administrator on 4/10/18 at 8:45 AM, in the conference room, revealed, When we first did our investigation the CNA (CNA #6) denied it, then later admitted that she told the resident she would have to wait on the bed pan until she got off break and that was just not acceptable. Interview with Resident #7 (who witnessed her roommate, Resident #3, needing assistance to get off the bed pan) on 4/10/18 at 11:45 AM, revealed, The nurse (LPN #2) put her (Resident #3) on the bedpan and told her she was going on break. The nurse (LPN #2) said she would tell a CNA to come in to help her off the bedpan, but that didn't happen. About thirty minutes later my roommate had the call light on and a CNA (CNA #6) came in our room to see what she (Resident #3) wanted. My roommate told the CNA she needed some help getting off the bedpan and she (CNA #6) told my roommate 'I can't help you because I'm on my break and if I don't take one right now, I won't get a break' so my roommate got upset. The next thing I knew, she (Resident #3) moved herself off the bed by moving her hips and she was on the floor. A while later a CNA (CNA #7) walked in our room and said, 'What did you do'? She left and got 2 more CNAs and they picked her up off the floor. They went to get the nurse but the nurse never came in to check on her. I thought it was very unprofessional for the CNA (CNA #6) to leave her on the bedpan and I thought it was also wrong of the nurse (LPN #2) to put her on the bedpan and not come back. I think she should have known as a nurse, to not leave her on the bedpan then go to break. Telephone interview with LPN #3 (who was the charge nurse when the incident occurred) on 4/10/18 at 2:15 PM, revealed, I was assigned to the other hall. I didn't really know anything. (LPN #2) who was her nurse at the time, mentioned to me after the fact that (Resident #3) fell . (LPN #2) never asked for my help. She told me she was going on break and I didn't know anything happened while she was on break. There was no mention of her (Resident #3) being left on the bedpan and the CNAs did not say anything or come to get me after she fell . Review of personnel files revealed the facility terminated CNA #6, and LPN #2 received a Disciplinary Action on 1/22/18 for failing to assess Resident #3 before the staff transferred her back to bed. Interview with the DON on 4/11/18 at 9:05 AM, in the conference room, revealed, My expectation for the CNA would have been for her to get the resident off the bed pan when she was requesting assistance. The CNA could have said I can take my break later or let the charge nurse know, so I would have considered this as neglect. That is something you just don't do. The DON further stated, The staff should not have moved a resident without the nurse first doing a head-to-toe assessment. That is just basic common sense and they should not have moved her. Interview with the Administrator on 4/11/18 at 9:45 AM, in the conference room, revealed, Anytime there is an incident, the nurse is to be involved. With (Resident #3), I would consider what happened (to be) neglect for going on a break and leaving a resident on a bed pan. The Administrator further stated that CNA #6 was terminated because she at first did not tell the truth, and his expectation would have been that the resident not be moved without first being looked at by a nurse. My expectation would be that the nurse (LPN #2) should have told the other nurse (LPN #3) or other staff that the resident was on the bed pan when going on her break, and when the resident was found, the nurse should have assessed her before they put her back to bed.",2020-02-01
1743,BEECH TREE HEALTH AND REHABILITATION,445292,"240 HOSPITAL LANE, PO BOX 300",JELLICO,TN,37762,2018-03-07,607,D,1,0,1FZ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility incidents, interview, and observation, the facility failed to develop and implement written policies and procedures to identify when, how, and by whom determinations of capacity to consent to a sexual contact would be made, and where it would be documented, and failed to conduct an evaluation to make the determination of whether sexual activity was consensual for 2 (Resident #6 and Resident #10) of 11 sampled residents. The findings included: Review of the facility policy Abuse, Neglect, Exploitation Misappropriation of Resident Property (undated), revealed, It is the facility's policy to investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of [REDACTED]. Under Definitions, the policy indicated, Sexual Abuse - Non-consensual sexual contact of any type with a resident. There was no additional information in the policy addressing sexual contact and a determination of capacity for residents to consent to sexual contact. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility Incident with a date of occurrence of [DATE], at 8:15 PM, revealed, (On) [DATE], (Resident #10) and (Resident #6) were noted to be sitting in the alcove on 200 Unit on public sofa out of line of sight from nurse station. (Resident #10) had her blouse raised to her neck. Residents were not touching. Residents were separated, redirected, placed on 1-minute checks for 24 hours and continued to only be permitted to visit in common areas for increased supervision. (On) [DATE], (Resident #6) and (Resident #10) were noted to be sitting in the alcove on 200 Unit on public sofa out direct line of sight from nurse's station. (Resident #6) had his pant unzipped and his hand in his pants. (Resident #10) was leaning against (Resident #6) but she did not have her hands in his pants. Residents were immediately separated and the sofa was removed from the common area and replaced with two single person chairs. Both residents were placed on 15-minute checks. Continue to allow residents to only visit in common (high traffic, public) areas for increased supervision, staff encourage resident to visit in Day Room as much as possible, which is direct line of sight from Nurses Station .(Resident #6) was on 15-minute checks due to exit seeking behaviors, at 8 p.m. Resident was in the day room according to staff. At 8:15 p.m. resident was not in in the day room, nor in his room, staff found (Resident #6) in (Resident #10) bed undressed engaging in sexual activity. Both residents are confused. (Resident #6) has a BIMS (Brief Interview for Mental Status) of 5 (severe cognitive impairment). (Resident #10) has a BIMS of 7 (severe cognitive impairment). Both residents requested staff to leave them alone, but staff separated the residents. Physical assessment was completed with no injuries noted. (Resident #10) was moved to the locked unit to prevent any further interaction between the residents. Psych services met with both residents .Social services interviewed both residents, neither acknowledge clear recollection of events. (Resident #6) has [DIAGNOSES REDACTED]. (Resident #10) has [DIAGNOSES REDACTED]. Review of a handwritten, undated statement from Registered Nurse (RN) #1 revealed she was the nurse on duty at the time of the incident on [DATE]. RN #1 indicated she spoke with Resident #10 following the incident. Resident #10 verified she and Resident #6 were having sex and that they both wanted to have sex and be together. Review of handwritten statements by Nurse Aide (NA) #1 and NA #2 dated [DATE] revealed they had seen Resident #10 and Resident #6 together all day, every day. Resident #10 was documented as looking for Resident #6 when she was not around and calling her Cat. Medical record review of the Psychiatric Progress Note, dated [DATE], revealed the psychologist saw Resident #6 for Chief Complaint/Nature of Presenting Problem: Sexual disinhibition. The note indicated Resident #6 was asked about having recent sexual intercourse and denied it, saying he was not that interested in it anymore. The note did not specifically address the resident's capacity to consent to sexual intercourse. Medical record review of the Psychiatric Progress Note dated [DATE], revealed the psychologist saw Resident #10 for Chief Complaint/Nature of Presenting Problem: Sexual disinhibition. The note indicated Resident #10 was asked about having recent sexual intercourse which she denied. Resident #10 was noted to receive intramuscular [MEDICATION NAME] on [DATE] due to agitation and wanting to get out of the locked unit to see a male resident. Interview with Resident #6 on [DATE] at 2:00 PM, at the entrance to his room, revealed he liked it in the facility and stated, he had lived there all his life and loved the people. Resident #6 reported he still worked and was a coal miner. He stated he had not seen his wife recently, but thought she was still actively employed (his wife was deceased ). Resident #6 reported he could visit with anyone he wanted to. When asked about female friends, he stated he did not have any female friends. Observations of Resident #6 during the survey from [DATE] - [DATE] revealed he wandered around the facility independently. Interview with Resident #10 on [DATE] at 2:30 PM, in the activity day room on the secured unit, revealed, when Resident #10 was asked about living in the facility, she stated, It's ok. When asked if she had previously lived in a different room on a different hall, she reported, I don't live here. When asked if she could come and go as she wanted, she stated, I guess. When asked if she could spend time with whoever she wanted in the facility, she indicated she could. Interview with the Social Worker (SW) on [DATE] at 10:52 AM, in her office confirmed the series of events on [DATE] with Resident #6 and Resident #10 being found in Resident #10's room, engaged in sexual intercourse, and they both asked staff to leave them alone and continued to have sex after the staff entered the room. The SW stated the residents were separated by staff and Resident #10 was moved to the secured unit where she continued to reside as a measure of safety. The SW stated the residents were not able to consent to have sexual relations due to their levels of cognition. When asked if there was a policy, procedure or process and designated individuals responsible for evaluating residents who wanted to have sexual relations, but may not have been capable of consent due to impaired cognition, the SW stated she was not aware of a policy, procedure or process. The SW stated, The doctor does this or the psych (psychiatric) doctor or the regular doctor. If competent, we provide privacy. The SW stated the psychologist may have completed an evaluation and it might be in psych notes, but she was not sure. Interview with NA #1 on [DATE] at 12:42 PM, in the conference room, revealed Licensed Practical Nurse (LPN) #1 was doing 15-minute checks and found Resident #6 and Resident #10 in Resident #10's room, engaged in sexual intercourse on [DATE]. NA #1 stated LPN #1 tried to stop them, but was unable to and she (NA #1) was called back to get help to separate the residents. NA #1 stated when she arrived in the room to help, Resident #6 was putting his clothes on and Resident #10 was covered up. NA #1 stated, prior to this incident, the residents spent a great deal of time together sitting on the couch. NA #1 said Resident #6 called Resident #10 Cat, which was the pet name of his deceased wife. NA #1 stated both residents were confused, but Resident #6 was more confused than Resident #10. NA #1 stated the residents were separated after this incident, with Resident #10 being moved to the secured unit the night of the incident. Interview with the Administrator and Director of Nursing (DON) on [DATE] at 3:38 PM, in the social worker's office revealed, when asked about an evaluation of Resident #10 and Resident #6 for their ability to consent to sexual activity, they provided a Psychiatric Progress Note dated [DATE] for Resident #6 that read, Judgment/Insight: Poor judgment and decision-making ability. The note did not say anything related to the ability to make decisions related to sexual activity. When asked about Resident #10 being evaluated for the ability to consent to sexual activity, he stated there was no evaluation for Resident #10. The Administrator stated neither Resident #6 nor Resident #10 had the cognitive ability needed to consent to sexual activity and Resident #10's family member was in favor of moving Resident #10 to the secure unit to keep her away from Resident #6. Further interview confirmed there was no specific policy, procedure, or process to determine whether residents could consent to sexual relations. The Administrator confirmed this was not addressed in any of the facility's policies.",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
1566,MABRY HEALTH CARE,445272,1340 N GRUNDY QUARLES HWY P O BOX 7,GAINESBORO,TN,38562,2020-01-15,600,D,1,0,SGJ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility investigation witness statements, and interviews the facility failed to prevent abuse for 1 resident (#1) of 3 residents reviewed for abuse. The findings include: Review of the facility policy Resident Abuse, revised 11/14/2018 revealed .The right to be free from verbal, sexual, physical and mental abuse . Medical record review showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set assessment dated (MDS) 11/15/2019 showed Resident #1 had severe cognitive impairment, had no physical, verbal, or behavioral symptoms directed toward others, and required assistance of one or more persons with activities of daily living (ADL's). Medical record review showed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. MDS assessment dated [DATE] showed Resident #2 had severe cognitive impairment, was rarely/never understood and had continuous disorganized thinking. Resident #2 required supervision with walking in his room and in the corridor and required assistance of one or more persons with all other ADL's. Review of Resident #2's current Comprehensive Care Plan revealed .resident may have fluctuation in mood and behavior problems r/t (related to) becomes agitated . Medical record review showed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. MDS assessment dated [DATE] revealed Resident #3 had moderate cognitive impairment. Review of the facility investigation revealed a witness statement by Physical Therapy Assistant #1 dated 11/4/2019, .I heard the sound of someone hitting the floor nearby. Walked up on (Resident #1) laying on the floor on his L (left) side, kicking at (Resident #2) who was standing over him . A witness statement by the Director of Nursing (DON) revealed Resident #3 stated Resident #2 was in the hall and went up to Resident #1 and hit him. Review of an Incident Note by the DON on 11/4/19 revealed .When asked resident (Resident#1) what happened he stated, I got into a fight with that man (Resident #2) and I fell trying to hit him (Resident #2). Another resident (Resident #3) states that resident (Resident #1) .hit this resident (Resident #2) and then this resident (Resident #2) attempted to retaliate and fell .resident has half dollar size abrasion to left elbow area .Resident (Resident #2) assisted back to wheelchair and removed from the immediate area of the other resident (Resident #1) for safety: MD of other resident (Resident #1) notified for further orders . Review of a Behavior Note by Licensed Practical Nurse (LPN) #1 dated 11/4/2019 revealed .notified by CNA (Certified Nurse Aide #1) that resident (Resident #2) started yelling at another resident (Resident #1) becoming physically aggressive .witnessed by another resident (Resident #3) which reported this resident (Resident #2) had hit and pushed a man (Resident #1) in his w/c (wheel chair) . Interview with CNA #1 on 1/15/2020 at 10:25 AM, revealed on 11/4/2019 she heard someone yell for help by the nurse's station. She observed Resident #1 on the floor. Resident #1 seemed upset and told her to make sure that man (Resident #2) stayed away from him. Interview with the DON on 1/15/2020 at 10:33 AM, revealed Resident # 2 had been more agitated on 11/4/2019. Resident #1 had been observed lying on the floor on 11/4/2019 with Resident #2 standing near Resident #1. In summary, Resident #2 was on 1:1 behavior monitoring prior to incident on 11/4/19 related to agitation. The incident was observed by Resident #3 as per interview by the Assistant Director of Nursing. Resident #1 was found on the floor after the incident by facility staff and was moved from the immediate area for safety concerns.",2020-09-01
3717,SIGNATURE HEALTHCARE OF FENTRESS COUNTY,445362,208 DUNCAN ST N,JAMESTOWN,TN,38556,2017-03-28,155,J,1,0,Q88111,"**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 administer Cardiopulmonary Resuscitation (CPR) in accordance with the resident's advanced directives for 1 resident (Resident #6) of 6 resident deaths sampled, of 13 residents reviewed for advanced directives. The facility's failure to honor Resident #6's Advance Directives status resulted in Resident #6 not receiving CPR on [DATE] and dying, placing Resident #6 in Immediate Jeopardy (a situation where the providers noncompliance with one or more requirements of participation, has caused, or is likely to cause, serious injury, harm, impairment or death). The Administrator, Director of Nursing (DON), and Corporate Nurse were informed of the Immediate Jeopardy on [DATE] at 3:25 PM, in the conference room. The IJ was effective [DATE] - [DATE]. The facility's corrective action plan which removed the IJ was received and corrective actions were validated onsite by the surveyor on [DATE] - [DATE]. The IJ was cited as past noncompliance for F-155, the facility is not required to submit a plan of correction. The findings included: Review of the facility policy, Cardiopulmonary Resuscitation, (CPR), undated, revealed .Upon identifying a resident with a change of condition which presents as an unresponsive condition .check the medical record for advance directive status .if resident record indicates CPR is to be instituted, then initiate Basic Life Support (maintenance of airway, breathing, circulation) if a pulse and/or respirations are undetectable .if a resident is found unresponsive and without respirations, a licensed staff member who is certified in CPR .shall promptly initiate CPR for residents .who have requested CPR in their advance directives . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Admission Consent Forms and the Tennessee Physicians Orders for Scope of Treatment (POST or advanced directives form) executed on [DATE], revealed Resident #6, a [AGE] year old resident, was to receive CPR, Intubation (insertion of a breathing tube), advanced airway interventions, mechanical ventilation as indicated, transfer to a hospital or intensive care unit if indicated, and full treatment in an intensive care unit if indicated, in the event of a respiratory or [MEDICAL CONDITION]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE], revealed Resident #6 had a Brief Interview of Mental Status (BIMS) score of 15 (cognitively intact), was independent in decision making, dependent upon supplemental oxygen to breathe, and the resident required moderate assistance of one person for activities of daily living (ADLs). Medical record review of a Nursing Progress Notes Report dated [DATE] at 6:00 AM, revealed Resident #6 was found seated on her bedside by Licensed Practical Nurse (LPN) #1, and the resident reported to the LPN she had problems breathing. Continued review revealed LPN #1 administered ordered breathing treatments ([MEDICATION NAME], a medication to open airways in the lungs) and oral medications ([MEDICATION NAME], narcotic for pain relief) to the resident. Review of the facility investigation dated [DATE] revealed after LPN #1 administered medications to Resident #6, she informed her supervisor, Registered Nurse (RN) #1 of the resident's status. Continued review revealed at 6:37 AM, Resident #6 activated the call light and RN #1 and LPN #1 responded to the resident's call. Medical record review of the Nursing Progress Notes Report dated [DATE], revealed RN #1 and LPN #1 found Resident #6 again seated on the side of the bed, and the resident informed them she remained short of breath and requested to be transferred to the hospital for intubation. Continued review of the Nursing Progress Note Report revealed the resident's vital signs were heart rate at 88 beats per minute (within normal limits, WNL) Oxygen (O2) Saturation (a measure of blood oxygen levels) 95% (WNL) and Respiratory Rate 36 breaths per minute (abnormally elevated). Further review revealed Resident #6 asked for assistance back into bed and RN #1 placed the resident in her bed, with head of the bed elevated 90 degrees. Continued review revealed no documentation either nurse attempted to arrange transport for Resident #6 to the hospital as requested. Continued review of the Nursing Progress Notes Report revealed . elder did not look right .pulled .the .elder .chart and looked up to see the next of kin .and attempted to call the ex-husband work number x4 (4 times) .next call was made to .son in law .went to voice mail . Continued review revealed at around 7:00 AM (23 minutes after the resident exhibited respiratory distress and requested to be transported to the hospital), RN #1 re-entered the resident's room and discovered Resident #6 slumped over, without a pulse or respirations, and gray in color. Continued review of the Nursing Progress Notes Report revealed .I (RN #1) entered the room and there were no breath sounds .elder gray in color .no palpable pulse was felt .Despite elder being full code .I did not perform CPR on elder . Continued review of the Nursing Progress Notes revealed RN #1 declared Resident #6 deceased at 7:06 AM (6 minutes after she was discovered in cardiac and respiratory arrest) and no attempts to resuscitate the resident were documented. Review of RN #1's investigative interview summary (the findings of the investigative interview conducted by the facility's attorney) dated [DATE], revealed .Entered resident's room to give drink .assisted resident with same .replaced resident O2 mask back on face .(LPN #1) giving meds .Resident SATS (blood oxygen saturation) were 95% good .Later 2 CNAs (Certifiied Nurse Aide) approached, saying resident would like to go to hospital .I assessed resident .resident stated she wanted to be intubated .I found not needed and that resident was very tired .covered resident with blanket .put at 90 degrees . relayed I would notify her family and doctor .skin color dusky color .cool to touch .room was very cool .with .(LPN #1) .started looking up family contact info (information) .called ex-husband and son in law both went to VM (voice mail) with no ability to leave message .tried calling son in law again .no connect .then walked back to resident room to get more family names from resident .found resident slumped over with her head down to the end of bed .this was approximately 30 minutes after I had left resident .yelled for stethoscope .two other nurses nearby .one went to call resident's daughter .assessed resident .no pulse or respirations .skin dusky, eyes 1/2 open, lips and nails blue tinge .Nurse (LPN #1) said resident is full code .I responded resident has clearly passed, nothing to do .Spoke with Doctor, told him resident expired and I would not initiate code, would pronounce her at 7:06 AM .Doctor adamant about doing compressions, I refused, relayed he could speak to administration about it .I then told my administrator and DON (Director of Nursing) what happened, wanted them to know from me . Interview with CNA #1 on [DATE] at 6:55 PM, in the conference room, revealed she was present on the unit when Resident #6 was declared deceased by RN #1, and confirmed no CPR was attempted on the resident. Further interview revealed CNA #1 overheard RN #1 advise the resident's physician .I will not do chest compressions on a dead person . Interview with Physician #3 on [DATE] at 10:57 AM, by telephone, revealed the physician reported he was called sometime between 7:00 and 7:15 AM on [DATE], and was informed by RN #1 Resident #6 had expired and no CPR was attempted. Continued interview revealed the Physician questioned RN #1 if CPR was in progress or had been attempted on Resident #6, prior to her being declared deceased . Continued interview revealed Physician #3 informed RN #1 the resident was a full code and CPR was to have been attempted. Physician #3 reported RN #1 questioned him initially and asked him you want me do compressions on a dead person? Continued interview revealed Physician #3 stated RN #1 failed to honor the resident's wishes and he did not order CPR to begin after his conversation with RN #1, as he was given the impression by the nurse Resident #6 had been pulseless for an extended period of time when the telephone call to him was made. Interview with LPN #1 on [DATE] at 11:36 AM, in the conference room, revealed on [DATE] at 7:00 AM, when Resident #6 was discovered in cardiac and respiratory arrest, LPN #1 entered the resident's room behind RN #1, and LPN #1 informed RN #1 the resident was a full code and the resident's desire was to have CPR. Continued interview revealed RN #1 stated to the LPN .we're not doing nothing to this poor woman, she's gone, she has been through enough . Continued interview revealed LPN #1 reported Respiratory Therapist (RT) #4, LPN #3 and LPN #15 had also been prohibited from performing CPR on Resident #6 by RN #1. LPN #1 reported RN #1 stood between the staff and the resident's body, with her arms outstretched laterally, as if to block them from approaching Resident #6, as she told the staff no CPR would be performed. Interview with LPN #3 on [DATE] at 12:47 PM, in the conference room, confirmed RN #1 refused to perform CPR on Resident #6. Interview with the DON on [DATE] at 2:45 PM, in the conference room, revealed the facility investigation concluded RN #1 was fully aware of Resident #6's Advance Directives status at the time she elected not to perform CPR on Resident #6. The DON confirmed the nurse failed to perform CPR in accordance with the resident's advance directives and failed to follow facility policy. Interview with Respiratory Therapist (RT) #4 on [DATE] at 1:40 PM, in the conference room, revealed on [DATE] around 7:00 AM, she entered Resident #6's room and observed her slumped sideways in the bed with her head tilted backwards, mouth open, not breathing, and ashen in color. Continued interview revealed RT #4 informed RN #1 the resident was a full code. Continued interview revealed RN #1 stated to her, .absolutely not, we are not doing a code, she has been down too long . Further interview revealed RN #1 repeatedly prohibited attempts by other staff members to perform CPR. Telephone Interview with LPN #15 on [DATE] at 2:24 PM, revealed she was present on the unit as an oncoming day shift nurse on [DATE] and witnessed the incident. Continued interview revealed when Resident #6 was discovered without a pulse or respirations at 7:00 AM, she responded to the room to assist in resuscitation efforts and she informed RN #1 the resident was a full code. Continued interview revealed RN #1 refused to permit CPR to be performed and ordered her from the resident's room. Further interview revealed RN #1 told LPN #15 to go to the nursing station and call Physician #3 and advise him the resident was deceased . Further interview revealed LPN #15 called Physician #3 sometime after 7:06 AM, and as she spoke to the Physician, RN #1 took the phone from her hands and took over the phone call at that point. Further interview revealed as LPN #15 and LPN #3 moved the crash cart toward the resident's room, RN #1 waved her hands, pointed at the two LPNs and mouthed NO. The facility's corrective action plan included the following: On [DATE] the facility did the following: [NAME] Held an ad hoc Quality Assurance (QA) meeting during the daily stand up meeting and reviewed the incident. Incident was reported to the State Agency. Follow up QA meeting was scheduled for [DATE]. Responsible party was the Administrator. B. The regional nurse consultant reviewed with the DON and the Administrator the education to be provided to all staff on [DATE] to include Abuse, Resident Rights, Advance Directives, Where to Locate the Advance Directives in the Medical Record, Cardiopulmonary Resuscitation (CPR), Following Physician Orders, Change in Condition and Following Care Plans. Responsible party was the Director of Nursing (DON). C. Once the Administrator and DON were educated, they were assigned to educate the Nursing Administration team Assistant Director of Nursing (DON), Unit Managers, Minimum Data Set (MDS) Nurses, and Staff Development Coordinator), who in turn were assigned to educate all the staff on Abuse, Neglect, Resident Rights, Advance Directives, Where to Locate Advance Directives in the Medical Record, CPR, Following Physician Orders, Change in Condition, and Following Care Plans. Responsible party was the DON). D. Began written competency testing of all staff educated on Abuse, Neglect, Resident Rights, Advance Directives, Where to Locate Advance Directives, CPR, Following Physician Orders, Change in Condition and following Care Plans. Responsible party was the Director of Nursing (DON). E. All staff educated, were required to submit written post-tests with scores of 100% before being permitted to work. All staff who failed to score 100% on the post-tests were immediately re-educated and re-tested until all staff scored 100% on the post tests. Responsible party was the Director of Nursing (DON). F. Initiated the first Mock Code Drill conducted by the DON, ADON, Unit Manager (UM) and the Staff Development Coordinator (SDC) to ensure staff understanding and compliance with the facility code blue policy (policy related to emergency resuscitation) and procedures. No irregularities noted. Mock codes were then planned to be completed for every shift (7 A-7P, 7P-7A) for 72 hours through [DATE], then twice weekly on rotating shifts for 4 weeks starting on [DATE] through [DATE] (scheduled to occur on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and on [DATE] on both shifts) to ensure staff understanding and compliance with the facility code blue policy. The first two Mock Codes were conducted by members of the Nursing Administration Team under observation of the DON, then Mock codes were conducted by nursing staff members under observation of members of the Nursing Administration team. Findings were to be reported to the QA committee weekly for 4 weeks to determine compliance and any further need of continued education or revision of the plan. Responsible party was the Director of Nursing (DON). [NAME] Began ongoing monitoring of staff compliance with abuse, advanced directives, resident rights, CPR, location of advanced directives and Do Not Resuscitate (DNR) forms in the medical record, following physician orders, change in condition reporting and following Care Plans. Responsible party was the Administrator. On [DATE] the facility did the following: [NAME] Resident #6's chart and care plan were reviewed by the Regional Nurse Consultant and Director of Clinical Operations. Registered Nurse (RN) #1 was to have been terminated concluding the investigation but resigned prior to termination. Licensed Practical Nurses (LPN) LPN #1 LPN #3, LPN #15 and Respiratory Therapist (RT) #4 received disciplinary action related to not following facility policy. Responsible party was the DON. B. Began audits of the medical records for all residents in the facility, by the Regional Nurse Consultant and Director of Clinical Operations, to ensure advance directives were in the medical record, were addressed on the care plan, and had current Physician orders related to each resident's code status. Responsible party was the DON. C. All residents were assessed for any possible resident rights violations. Those residents with Brief Interview of Mental Status (BIMS scores, a measure of cognitive function), greater or equal to 8 (cognitively intact) were interviewed by the DON, ADON, UM, Social Services Director (SSD), Social Services Assistant (SSA) for quality of life or resident rights violations. No issues were identified. Responsible party was the DON. D. All residents with BIMS scores less or equal to 7 (cognitively impaired) had skin assessments completed on [DATE] for any concerns by ADONs and UMs for any possible abuse or neglect issues. All residents with a BIMS greater or equal to 8 were interviewed for possible abuse or neglect violations. No issues were identified. Responsible party was the DON. E. Held a Resident Council Meeting (a group of residents who reside in the facility and meet regularly, discuss resident concerns, and discuss resident concerns with Administration) and the SSD and Activities Director reviewed the Resident Rights Statement and Policies for Prohibition of Abuse, Neglect and Misappropriation of Property and provided a copy to each resident. Responsible party was the DON. F. All deaths in the facility for the past 30 days were reviewed by the Regional Nurse to ensure advanced directives were honored with no irregularities noted. The DON reviewed all resident deaths in the facility for the prior 12 months with no irregularities noted. Results were discussed in the QA meeting. Responsible party was the Administrator. [NAME] Held first formal QA meeting to address the incident. DON, ADON, UM, Nursing Supervisors or Medical Records staff were to review all new admissions/readmits and residents with DNR related changes, 24 hour shift reports, and incidents accidents daily for 2 weeks, then Monday through Friday ongoing, starting during morning clinical meeting, to ensure sustained compliance with physician notification, physician orders, interim care plan, advance directives, and resident rights. Corporate administrative oversight of the QA meeting was completed by the Regional Vice President or member of the regional staff weekly for 4 weeks beginning [DATE], then monthly for one quarter. The facility allegation of compliance (A[NAME]) was reviewed by the committee. Responsible party was the Administrator. H. Continued staff education and post testing on Abuse and Neglect, Advanced Directives, Where to find Advanced Directives in the chart, CPR, Resident Rights, following Physician orders, Notification of Change in Condition, and Following Care plans. Responsible party was the DON. I. Grievance logs were reviewed by the Director of Clinical Operation with no irregularities noted. [NAME] Continued Mock Code drills as outlined. Responsbile party was the DON. K. Corrective actions were reviewed by the Administrator, DON, Medical Director and Regional Consultants. Responsible party was the Administrator. On [DATE] the facility did the following: [NAME] The DON, ADON, UM, Administrator and Department Heads continued advance directive/abuse post-tests with 10 random Nursing staff members daily on rotating shifts for 2 weeks through [DATE]. Then 5 random nursing staff members on rotating shifts daily for 2 weeks through [DATE], then 5 random Nursing staff members weekly for 3 weeks through [DATE], with all staff required to score 100% on the post tests. Staff members who failed to achieve 100% scores on the tests were immediately re-educated and required to re-test until 100% scores were achieved. Responsible party was the DON. B. Continued education of all staff members on the facility Abuse and Neglect Policy, Resident Rights, CPR, Advance Directives and Where to find them in the medical record, Notification of Change in Condition, Physician Orders, and Care plans. Responsible party was the DON. C. Continued Mock Code drills on every shift through [DATE] as outlined. Responsible party was the DON. On [DATE] the facility did the following: [NAME] Completed review of all residents medical records by the Director of Clinical Operations and the Regional Nurse to ensure advance directives were in the medical records, addressed on the care plans, and had a current Physician Order regarding code status. No irregularities noted. Responsible party was the Director of Clinical Operations. B. Completed a 100% audit of licensed clinical staff CPR certifications by the Regional Vice President and Regional Nurse Consultant. C. Completed 100% audit of all licensed staff to verify valid Tennessee professional licensure completed by the Regional Vice President. No irregularities were noted. D. Completed 100% audit to ensure staff were not listed on the abuse registry by the Regional Vice President with no irregularities noted. E. Mailed certified letters to all employees who had not completed mandatory training and education and advised completion of training was required prior to any return to work at the facility. The letters included all employees on vacation or paid leave, part time or prn (as needed status). Responsible party was the DON. F. The Administrator began reviews of completed audits for new admissions, readmissions and residents with DNR to ensure sustained compliance with all advanced directives. [NAME] DON, ADON, UM or Weekend Manager on duty began interviews with 5 residents with BIMS scores equal or greater than 8 and 5 family members of residents with BIMS scores less than 8 daily for 2 weeks ([DATE] to [DATE]) for any possible resident rights violations; then 3 residents and 3 family members daily for 2 weeks ([DATE] to [DATE]), then 2 residents and 2 family members daily for 4 weeks ([DATE] to [DATE]), then 1 resident and 1 family member daily for 4 weeks ([DATE] to [DATE]). Results of the interviews and assessments forwarded to the QA committee. Responsible party was the DON. H. All deaths in the facility were reviewed by the DON, ADON, UM or Administrator to ensure code status was implemented correctly as per the resident's wishes and documented on the advance directives daily for 2 weeks through [DATE]; then weekly for 4 weeks from [DATE] to [DATE], then continuing as part of the daily stand up meetings attended by the Administrator, DON, ADONs, UM, MDS Coordinator, Treatment Nurses, Chaplain, SDC, Quality of Life Department Head, SSD, Dietary Manager and Formulary Nurse (the nurse in charge of the central supply office) to ensure sustained compliance. Responsible party was the DON. I. Began Administrative oversight of the facility by a member of Senior Regional Team twice weekly for 2 weeks, beginning [DATE] to [DATE]; then weekly for 4 weeks beginning [DATE] through [DATE], then monthly for one quarter. Responsible party was the Director of Clinical Operations. [NAME] Continued Mock Code drills as outlined above. Responsible party was the DON. K. The DON and SDC began tracking all licensed staff members for CPR certification monthly for 3 months; then every 6 months to ensure all licensed nurses maintained CPR certifications. Findings documented and forwarded to the QA committee monthly to determine any need for education or revision of the process. Responsible party was the DON. L. Established plans for daily contact between the facility and nurses from the regional team or corporate office for 2 weeks, then 2 times weekly for 4 weeks. Nurses from the regional team or home office reviewed compliance with the Plan of Correction and Policy and Procedures, compliance of any code blue to occur, and review of compliance with all new/readmissions. Responsible party was the DON. On [DATE] the facility did the following: [NAME] Completed the twice daily mock code drills as outlined above with no irregularities noted. Initiated the plan for transition to twice weekly Mock Code drills to occur on rotating shifts for another 4 weeks. Responsible party was the DON. B. Continued staff education and competency testing on Abuse and Neglect, Resident Rights, Advance Directives and Where to find them in the Chart, CPR, Notification of Change in Condition, Physician Orders, and Care Plans. Responsible party was the DON. C. Held a follow up QA meeting to review findings from initial audits, scheduled weekly QA meetings for 4 weeks, then monthly, for recommendations and further follow up regarding the Corrective Action Plan. At that time, based upon evaluation, the QA committee would determine at what frequency any ongoing audits would be continued. Responsible party was the Administrator. On [DATE] the facility did the following: [NAME] Completed education and competency testing of all staff, with the exception of those on Family Medical Leave (FMLA) or PRN status who had not worked, with 100% scores attained on all post-tests for facility Abuse and Neglect Policy, Resident Rights, CPR and Advance Directives, Where to Locate Advance Directives in the Medical Records, Physician Orders, Notification of Change in Condition, and Care Plans. Employees on FMLA or PRN status were not permitted to work until all education and competency testing completed. Responsible party was the DON. B. Continued all random audits, staff and resident interviews, and competency testing as outlined above. Responsible party was the DON. C. Continued daily stand up meeting reviews as outlined above, which included reports to Administration on the progress of the facility corrective action plans and changes in resident condition. Responsible party was the DON.",2020-03-01
2355,SIGNATURE HEALTHCARE OF MONTEAGLE REHAB & WELLNESS,445393,26 SECOND STREET,MONTEAGLE,TN,37356,2018-02-21,600,E,1,0,Q3XO11,"**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 ensure 4 secure unit residents (#2, #10, #5, and #7) were free from abuse of 10 secure unit residents sampled. The findings included: Review of facility policy Abuse, Neglect, Exploitation, and Misappropriation of Property, last reviewed 8/24/17, revealed .It is .policy to prevent the occurrence of abuse, neglect .Abuse Is the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting harm, pain or mental anguish .For purposes of this policy, 'willful' means non-accidental, or not reasonably related to the appropriate provision of ordered care and services . Medical record review revealed Resident #2 was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 was severely cognitive impaired, had symptoms of [MEDICAL CONDITION], physical and verbal behaviors directed at self and others 1 to 3 times weekly, and required moderate assistance for Activities of Daily Living (ADLs). Review of Resident #2's Care Plan dated 7/13/17 revealed .assess wandering behavior .redirect from inappropriate areas .engage in diversional activity .invite and encourage activity programs consistent with resident's interests .monitor behavioral episodes .attempt to determine underlying cause . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] revealed Resident #1 scored 9/15 (moderately cognitive impaired) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident with verbal and physical behaviors and required minimal assistance for ADLs. Review of Resident #1's interim Care Plan dated 1/26/18 revealed .physically abusive .intervene as needed to protect the rights (and) safety of others .remove from situation . Review of a facility investigation dated 1/26/18 at 5:45 PM revealed two Certified Nursing Assistants (CNAs) were in a resident's room performing ADL care when they heard a commotion. Continued review revealed the CNAs exited the room and entered the room where the sound was coming from and found Resident #1 swinging his bed remote control and yelling .Get out of my room . to Resident #2. Further review revealed Resident #1 said he .whacked .(Resident #2) in the shoulder . Continued review revealed the room where the incident occurred was neither resident's room. Telephone interview with CNA #1 on 2/12/18 at 12:45 PM revealed she was in a resident's room at the end of the hall when she heard .fussing . Continued interview revealed Resident #1 was trying to get Resident #2 out of the room and .whacked .(Resident #2) on the shoulder with the bed remote control . Interview with the Director of Nursing (DON) on 2/20/18 at 3:30 PM, in the front office, confirmed the facility failed to protect Resident #2 from abuse. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #10 was severely cognitively impaired, ambulated independently, and required one or two person assistance for ADLs. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #6 with a BIMS of 0/15 (severe impairment) and a history of wandering, [MEDICAL CONDITION], and behaviors directed towards self, was able to ambulate independently, and required moderate to extensive assistance of one or two persons for ADLs. Review of Resident #6's Care Plan dated 8/4/17 revealed .aggression impulsive behaviors .invite and encourage activity programs consistent with the resident's interests .monitor behavior episodes (and) attempt to determine underlying cause .intervene as needed to protect the rights and safety of others . Review of facility investigation dated 1/29/18 at 8:15 AM revealed staff members on the secure unit heard a resident yell .help . and discovered Resident #10 sitting on the floor of the secure unit hallway. Continued review revealed Resident # 10 reported Resident #6 hit her and pushed her down. Further review revealed staff did not witness the incident but presumed the incident occurred because Resident #6 had a known history of aggressive behaviors towards others. Interview with CNA #10 and CNA #11 on 2/21/18 at 9:20 AM, on the secure unit hallway, revealed the CNAs, at the time of the incident, were engaged in food tray pass in the common day area on the secure unit. Continued interview confirmed the secure unit hallways were unmonitored with the incident between Resident #6 and #10 occurred and they did not have an opportunity to intervene. Interview with the DON on 2/20/18 at 3:30 PM, in the front office, revealed the facility presumed Resident #6 struck Resident #10 based upon Resident #6's history of similar behaviors and aggressive acts towards other residents. Continued interview revealed at the time of the incident the secure unit nurse was off the secure unit tending to residents on the West Wing. Further interview confirmed the facility failed to protect Resident #10 from abuse. 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 Resident #5 was severely cognitively impaired and required supervision for transfer, ambulation, and eating. Review of a facility investigation dated 2/19/18 at 4:00 PM revealed two CNAs were in a resident's room when they heard a resident .holler . Continued review revealed the CNAs exited the room and saw Resident #1 in the hallway with Resident #5, who had her hands over her face. Further review revealed CNA #1 asked Resident #1 what happened and he replied he hit her (Resident #5) because she had been stalking him all day and he was tired of it so he hit her. Interview with CNA #1 on 2/20/18 at 11:35 AM, on the secure unit hallway, revealed she was in a resident's room assisting another CNA perform ADL care when they heard Resident #5 scream. Continued interview revealed CNA #1 found Resident #5 leaned against the wall with her hands over her face and Resident #1 was sitting in his wheelchair. Further interview revealed CNA #1 asked Resident #1 what happened and Resident #1 stated Resident #5 aggravated him and so he slapped her. Interview with the Director of Nursing (DON) on 2/20/18 at 3:30 PM, in the front office, confirmed the facility failed to protect Resident #5 from abuse. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #7 was severely cognitively impaired with a BIMS score of 1/15, had behaviors directed towards others daily, and symptoms of [MEDICAL CONDITION] which included hallucinations and delusions. Further review revealed the resident ambulated independently and required assistance of one or two persons for all ADLs. Review of a facility investigation dated 12/18/17 at 6:45 PM, revealed 3 residents (Resident #2, #6 and #7) were involved in a single altercation. Continued review revealed Resident #6 was in the hallway outside the common dining area of the secure unit and struck Resident #2 twice on the face. Continued review revealed CNA #10 and CNA #11 were nearby and separated the residents. Further review revealed CNA #10 escorted Resident #6 to his room and CNA #11 escorted Resident #2 to her room on the opposite side of the hallway. Continued review revealed Resident #6 was aggressive towards CNA #10 after he was escorted to his room, pushed past CNA #10, and exited his room back out into the hallway. Further review revealed CNA #10 attempted to redirect Resident #6, but he encountered Resident #7 outside the doorway of his room and he pushed Resident #7 from behind, which caused Resident #7 to fall to the floor. Continued review revealed Resident #6 remained agitated and aggressive and was redirected a second time by CNA #10 back into his room with difficulty. Interview with CNA #10 and CNA #11 on 2/21/18 at 9:20 AM, in the secure unit day area, revealed on 12/18/17 during the incident between Resident #2, #6, and #7 both CNAs were engaged in care of other residents in the secure unit common dining room. Continued interview revealed the CNAs responded to the altercation and separated Resident #6 and Resident #2 Further interview revealed CNA #10 took Resident #6 to his room and CNA #11 took Resident #2 to her room. Continued interview revealed both residents were known to have a history of aggression towards staff and others and had been involved in prior altercations. Further interview revealed CNA #11 calmed Resident #2 down, exited Resident #2's room, and proceeded to assist CNA #10 with Resident #6. Continued interview revealed Resident #6 push past CNA #10 and CNA #11 yelled at CNA #10 to .watch out . as she observed Resident #6 approach CNA #10 from the rear and feared Resident #6 would strike CNA #10 on the back or back of the head. Further interview revealed Resident #6 was verbally and physically aggressive and was not responsive to simple commands or gentle redirection and distractions. Continued interview confirmed Resident #6 struck Resident #2 on the face and proceeded to pushed Resident #7, which caused Resident #7 to fall on the floor.",2020-09-01
1399,"SUMMIT VIEW OF FARRAGUT, LLC",445258,12823 KINGSTON PIKE,KNOXVILLE,TN,37923,2017-09-05,225,D,1,0,9YDY11,"**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 ensure staff followed facility policy for reporting abuse allegations for 1 resident (Resident #1) of 12 residents reviewed for abuse, on 1 of 3 units in the facility. The findings included: Review of the facility policy, Preventing Resident Abuse, revised (MONTH) 2013, revealed .any individual observing an incident of resident abuse, or suspecting an incident of abuse must immediately report such incident to .Administrator, Director of Nursing Services .charge nurse .the Administrator or Director of Nursing Services must be immediately notified of suspected abuse .if such incidents occur after hours .must be called at home or paged and informed of such incident . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued medical record review revealed Resident #1 was fluent in Swahili and spoke no English. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was severely cognitively impaired, had periods of intermittent confusion, altered thought processes, and intermittent behaviors directed towards others. The resident required moderate assistance of one person for all activities of daily living (ADLs). Review of the facility investigation and witness statements dated 4/27/17 (Thursday) revealed Registered Nurse (RN) #2 reported allegations of abuse to the on call coordinator on 4/27/17 around 9:00 AM. RN #2 alleged on Tuesday 4/25/17, around 7:00 PM, as she attempted to give oral medication to Resident #1, Certified Nurse Aide (CNA) #20 had verbally and physically abused the resident. Continued review of the investigation revealed RN #2 stated the resident was confused and agitated. RN #2 attempted to administer medication to the resident and he refused and clenched his mouth shut. RN #2 attempted to redirect Resident #1 and CNA #20, who was present in the room, injected herself into the situation, yelled at the resident in English, .take your medicine . and squeezed the resident's jaw with her right hand, which forced the resident's mouth open, as RN #2 placed medications crushed in applesauce on a spoon near his lips. RN #2 reported she redirected CNA #20 away from the resident. RN #2 alleged, as she attempted to administer a second spoonful of medication to Resident #1, CNA #20 again forced the confused resident's mouth open as she yelled at him to take his medication in English. RN #2 ordered CNA #20 from the room, and completed administration of medication to Resident #1 without further incident. Continued review of the investigation revealed RN #2 did not immediately report the allegations to the facility Administrator, Director of Nursing (DON), or Charge Nurse and RN #2 completed her shift on 4/26/17 at 7:00 AM. RN #2 reported the allegations to the on call coordinator on 4/27/17 at 9:00 AM, (36 hours after the alleged incident had occurred). Interview with the Administrator on 8/22/17 at 4:45 PM, in the conference room, confirmed RN #2 failed to report allegations of abuse to the facility Administration immediately when they were observed, as required by the Preventing Abuse, and Reporting Abuse to Facility Management Policies. The Administrator confirmed the facility was not informed of the allegations until 36 hours after the alleged incident had occurred.",2020-09-01
4648,"WEXFORD HOUSE, THE",445207,2421 JOHN B DENNIS HIGHWAY,KINGSPORT,TN,37660,2016-08-30,225,D,1,0,S1DY11,"**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 immediately report an allegation of abuse for two residents (#1, #2) of six residents reviewed. The findings included: Review of facility policy, Abuse Reporting and Investigation (revised ,[DATE]) revealed, .To ensure prompt enforcement of employee disciplinary procedures in the case of alleged or suspected abuse, to appropriately respond to alleged violations and to comply with applicable state and federal laws and regulations. The following will apply to both alleged and suspected abuse .4. All reports of alleged or suspected abuse must be reported to the Administrator immediately . Medical record review of the Admission Record revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was moderately impaired with a Brief Interview for Mental Status (BIMS) score of ten, with fifteen being the highest attainable score for intact cognition. Medical record review of a Discharge Plan revealed Resident #1 was discharged on [DATE] to an Assisted Living Facility upon completion of skilled therapy and nursing services. Review of a facility investigation dated [DATE] revealed on [DATE] on night shift, Certified Nursing Assistants (CNAs) #1 and #2 alleged CNA #4 told Resident #1, who was attempting to get up from the bed, he may as well just lay there (on the bed) because you aren't going to be able to make it (to the bathroom) anyway. Continued review revealed CNA #1 alleged CNA #4 was not rough with her hands with the Resident, but was hateful. Further review revealed CNA #4 called Resident #1 expletives (swear words) to CNA #2. Continued review revealed the investigation of the allegation was not initiated until [DATE]. Telephone interview with CNA #1 on [DATE] at 3:35 PM, revealed CNA #1 stated, When she (CNA #4) cussed about (Resident #1) we were in the hallway and nobody was around .she said it to me, not to (Resident #1) .he didn't hear her .She (CNA #4) was not physically rough .just hateful with her tone of voice . Continued interview revealed CNA #1 felt CNA #4's hateful tone was abuse. Further interview revealed CNA #1 had been trained on abuse and allegations of abuse were required to be reported immediately. Continued interview with CNA #1 confirmed she did not report the allegation of abuse to the Director of Nursing (DON) or Administrator until [DATE]. Medical record review of Resident #2's Admission Record revealed Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed Resident #2's cognition was severely impaired with a BIMS score of four. Medical record review of a Nurse's Note dated [DATE] at 9:22 AM, revealed Resident #2 expired while under the services of hospice for end-stage Dementia. Review of a facility investigation dated [DATE] revealed on [DATE] and [DATE], on night shift, CNAs #1 and #3 alleged CNA #4 used a hateful tone, was rough, and had a bad attitude with Resident #2. CNA #3 alleged, on [DATE], CNA #4 told Resident #2 to Get her (expletive) back in bed. Further review revealed the investigation of the allegation was not initiated until [DATE]. Telephone interview with CNA #1 on [DATE] at 3:35 PM, revealed CNA #1 stated, I was the only one in (Resident #2's) room when (CNA #4) told (Resident #2) to get her (expletive) back in bed. Continued interview confirmed CNA #1 did not report the allegation of abuse to the DON or Administrator until [DATE]. Telephone interview with CNA #3 on [DATE] at 4:06 PM, revealed CNA #3 felt CNA #4 was hateful and rough with her tone of voice, had a bad attitude, and felt this was verbal abuse. Continued interview revealed CNA #3 was not present when CNA #4 allegedly told Resident #2 to get her (expletive) back in bed, but heard about it from CNA #1. Further interview with CNA #3 revealed CNA #3 had been trained on abuse and allegations of abuse were required to be reported immediately. Continued interview confirmed CNA #3 did not report the allegation of abuse to the DON or Administrator until [DATE]. Telephone interview with the DON and Administrator on [DATE] at 3:58 PM, confirmed the ,[DATE] and [DATE] allegations of abuse were not reported to the DON and Administrator until [DATE]. Further interview with the DON and Administrator confirmed the facility staff failed to follow their policy and report the allegations of abuse immediately.",2019-08-01
3718,SIGNATURE HEALTHCARE OF FENTRESS COUNTY,445362,208 DUNCAN ST N,JAMESTOWN,TN,38556,2017-03-28,157,J,1,0,Q88111,"**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 notify the physician of a change in condition for 1 resident (Resident #6) of 6 resident deaths sampled, of 13 residents reviewed for Notification of Change in Condition. The facility's failure to notify the Physician of a change in respiratory status for Resident #6 resulted in failure to implement appropriate interventions to prevent Resident #6's death on [DATE], placing Resident #6 in Immediate Jeopardy (a situation where the providers noncompliance with one or more requirements of participation, has caused, or is likely to cause, serious injury, harm, impairment or death). The Administrator, Director of Nursing (DON), and Corporate Nurse were informed of the Immediate Jeopardy on [DATE] at 3:25 PM, in the conference room. The IJ was effective [DATE] - [DATE]. The facility's corrective action plan which removed the IJ was received and corrective actions validated onsite by the surveyor on [DATE] - [DATE]. The IJ was cited as past noncompliance for F-157 and the facility is not required to submit a plan of correction. The findings included: Review of the Facility Policy, Change of Condition (undated) revealed .The facility will assess and document changes in the resident's condition .to relay assessment information to physician .to document actions to include but not limited to .significant change in the resident's physical, mental or psychosocial status . Medical record review of hospital Admission Summary and Discharge Summaries revealed Resident #6 was briefly admitted to the hospital from [DATE] to [DATE], with [DIAGNOSES REDACTED]. Resident #6 was stabilized and transferred to the nursing home on [DATE]. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Admission Consent Forms and the Tennessee Physicians Orders for Scope of Treatment (POST or advanced directives form) executed on [DATE], revealed Resident #6, a [AGE] year old resident, was to receive CPR (cardiopulmonary resuscitation), Intubation (insertion of a breathing tube), advanced airway interventions, mechanical ventilation as indicated, transfer to a hospital or intensive care unit if indicated, and full treatment in an intensive care unit if indicated, in the event of respiratory or [MEDICAL CONDITION]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #6 had a Brief Interview of Mental Status (BIMS) score of 15 (indicating she was cognitively intact), was independent in decision making, dependent upon supplemental oxygen to breathe, and the resident required moderate assistance of one person for activities of daily living (ADLs). Review of the Daily Skilled Nursing Note dated [DATE] at 1:30 AM, revealed .Cardiovascular .Cardiovascular concerns yes .radial/apical (pulse) irregular .Respiratory Concerns .yes .Labored Breathing .Orthopnea (shortness of breath with movement) shallow respirations .SOB (short of breath) .on exertion .at rest .lying flat .Lung Sounds .Rales (a type of abnormal lung sound often associated with lung disease, fluid in the lungs or swelling in the lungs) .Wheezing .(a type of abnormal lung sound often associated with [MEDICAL CONDITION], decreased lung volume, inflammation or mucous in the airways of the lungs) . Review of the Nursing Progress Notes Report revealed on the morning of [DATE], during the conclusion of the [DATE] 7:00 PM to 7:00 AM shift, at approximately 6:00 AM, Resident #6 exhibited an onset of symptoms of increased anxiety and increased shortness of breath, and summoned her primary nurse that evening, Licensed Practical Nurse (LPN) #1, to her room. Continued review revealed LPN #1 entered the room and found the resident seated on the side of her bed complaining of severe shortness of breath. Continued review revealed LPN #1 assessed the resident's blood oxygen saturation levels (O2 SAT) which were at 95% (within normal limits) at the time, administered a scheduled breathing treatment ([MEDICATION NAME], a medication to improve breathing) and oral [MEDICATION NAME] (narcotic, for pain) from 6:00 AM to 6:15 AM, and informed her supervisor, Registered Nurse (RN) #1, of the resident's status. Continued medical record review revealed no documentation in the medical record LPN #1 reported the changes in Resident #6's respiratory condition to the Physician. Continued review of the Nursing Progress Notes Report revealed, around 6:30 AM, Resident #6 activated the call light and RN #1 and LPN #1 returned to the resident's room. Continued review revealed LPN #1 and RN #1 found Resident #6 again seated on the side of the bed, and the resident informed them she remained short of breath and wished to be transferred to the hospital to be intubated. Continued review revealed the resident's vital signs were heart rate at 88 beats per minute (within normal limits, WNL) O2 Saturation as 95% (WNL) and Respiratory Rate was 36 breaths per minute (elevated). Further review revealed RN #1 adjusted the resident's position and elevated the head of the bed 90 degrees. The resident was not transported to the hospital. Continued review revealed RN #1 documented .her color did not look right .the LPN and I pulled the chart and looked up to see the next of kin .and attempted to call .next call was made to .went to voice mail . Medical record review revealed no documentation either LPN #1 or RN #1 had attempted to call the resident's attending Physician to inform him of the deterioration in the resident's condition at 6:00 AM or at 6:30 AM. Continued review revealed on [DATE] at 7:00 AM, RN #1 entered the resident's room and found Resident #6 slumped over in the bed, gray in color, without respirations or a heart rate, and after assessing for heart and lung sounds and performing a check for a pulse, RN #1 determined Resident #6 was deceased . No CPR was initiated and RN #1 pronounced Resident #6 dead at 7:06 AM. Continued medical record review revealed RN #1 contacted the attending Physician for Resident #6 shortly after 7:06 AM and advised the Physician she had pronounced Resident #6 dead. Review of RN #1's investigative interview summary (the findings of the investigative interview conducted by the facility's attorney) dated [DATE], revealed .Entered resident's room to give drink .assisted resident with same .replaced resident O2 (oxygen) mask back on face .(LPN #1 giving meds) .Resident SATS (blood oxygen saturation) were 95% good .Later 2 CNAs (Certified Nurse Aide) approached, saying resident would like to go to hospital .I assessed resident .resident stated she wanted to be intubated .I found not needed and that resident was very tired .covered resident with blanket .put at 90 degrees in middle of the bed .relayed I would notify her family and doctor .skin color dusky color .cool to touch .room was very cool .with .(LPN #1) .started looking up family contact info (information) .then walked back to resident room to get more family names from resident .found resident slumped over with her head down to the end of bed .this was approximately 30 minutes after I had left resident .yelled for stethoscope .two other nurses nearby .one went to call resident's daughter .assessed resident .no pulse or respirations .skin dusky, eyes 1/2 open, lips and nails blue tinge .Nurse (LPN #1) said resident is full code .I responded resident has clearly passed, nothing to do .Spoke with Doctor, told him resident expired and I would not initiate code, would pronounce her at 7:06 AM . Telephone interview with Physician #3 (Resident #6's Physician) on [DATE] at 10:57 AM, revealed the Physician reported he was called sometime between 7:00 and 7:15 AM on [DATE] and was informed by RN #1, Resident #6 had expired. Continued interview revealed at no time during the overnight shift was he contacted by the facility and informed of the deterioration in the resident's respiratory condition prior to her [MEDICAL CONDITION]. The Physician stated had he known he would have given an order to transfer Resident #6 to the hospital immediately. Interview with LPN #1 on [DATE] at 11:36 AM, in the conference room, revealed on [DATE] at 6:30 AM, after discussions with RN #1, LPN #1 attempted to contact family members to notify them of the change in the resident's condition, but LPN #1 had not called the Physician. LPN #1 confirmed to her knowledge RN #1 had not attempted to contact the Physician to report changes in Resident #6's condition. Interview with the DON on [DATE] at 2:45 PM, in the conference room, confirmed RN #1 had failed to follow the facility policy and notify the physician of significant changes in Resident #6's respiratory status. The facility's corrective action plan included the following: On [DATE] the facility did the following: [NAME] Held an ad hoc Quality Assurance (QA) meeting during the daily stand up meeting and reviewed the incident. Incident was reported to the State Agency. Follow up QA meeting was scheduled for [DATE]. Responsible party was the Administrator. B. The regional nurse consultant reviewed with the DON and the Administrator the education to be provided to all staff on [DATE] to include Abuse, Resident Rights, Advance Directives, Where to Locate the Advance Directives in the Medical Record, Cardiopulmonary Resuscitation (CPR), Following Physician Orders, Change in Condition and Following Care Plans. Responsible party was the Director of Nursing (DON). C. Once the Administrator and DON were educated, they were assigned to educate the Nursing Administration team Assistant Director of Nursing (DON), Unit Managers, Minimum Data Set (MDS) Nurses, and Staff Development Coordinator), who in turn were assigned to educate all the staff on Abuse, Neglect, Resident Rights, Advance Directives, Where to Locate Advance Directives in the Medical Record, CPR, Following Physician Orders, Change in Condition, and Following Care Plans. Responsible party was the DON). D. Began written competency testing of all staff educated on Abuse, Neglect, Resident Rights, Advance Directives, Where to Locate Advance Directives, CPR, Following Physician Orders, Change in Condition and following Care Plans. Responsible party was the Director of Nursing (DON). E. All staff educated, were required to submit written post-tests with scores of 100% before being permitted to work. All staff who failed to score 100% on the post-tests were immediately re-educated and re-tested until all staff scored 100% on the post tests. Responsible party was the Director of Nursing (DON). F. Initiated the first Mock Code Drill conducted by the DON, ADON, Unit Manager (UM) and the Staff Development Coordinator (SDC) to ensure staff understanding and compliance with the facility code blue policy (policy related to emergency resuscitation) and procedures. No irregularities noted. Mock codes were then planned to be completed for every shift (7 A-7P, 7P-7A) for 72 hours through [DATE], then twice weekly on rotating shifts for 4 weeks starting on [DATE] through [DATE] (scheduled to occur on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and on [DATE] on both shifts) to ensure staff understanding and compliance with the facility code blue policy. The first two Mock Codes were conducted by members of the Nursing Administration Team under observation of the DON, then Mock codes were conducted by nursing staff members under observation of members of the Nursing Administration team. Findings were to be reported to the QA committee weekly for 4 weeks to determine compliance and any further need of continued education or revision of the plan. Responsible party was the Director of Nursing (DON). [NAME] Began ongoing monitoring of staff compliance with abuse, advanced directives, resident rights, CPR, location of advanced directives and Do Not Resuscitate (DNR) forms in the medical record, following physician orders, change in condition reporting and following Care Plans. Responsible party was the Administrator. On [DATE] the facility did the following: [NAME] Resident #6's chart and care plan were reviewed by the Regional Nurse Consultant and Director of Clinical Operations. Registered Nurse (RN) #1 was to have been terminated concluding the investigation but resigned prior to termination. Licensed Practical Nurses (LPN) LPN #1 LPN #3, LPN #15 and Respiratory Therapist (RT) #4 received disciplinary action related to not following facility policy. Responsible party was the DON. B. Began audits of the medical records for all residents in the facility, by the Regional Nurse Consultant and Director of Clinical Operations, to ensure advance directives were in the medical record, were addressed on the care plan, and had current Physician orders related to each resident's code status. Responsible party was the DON. C. All residents were assessed for any possible resident rights violations. Those residents with Brief Interview of Mental Status (BIMS scores, a measure of cognitive function), greater or equal to 8 (cognitively intact) were interviewed by the DON, ADON, UM, Social Services Director (SSD), Social Services Assistant (SSA) for quality of life or resident rights violations. No issues were identified. Responsible party was the DON. D. All residents with BIMS scores less or equal to 7 (cognitively impaired) had skin assessments completed on [DATE] for any concerns by ADONs and UMs for any possible abuse or neglect issues. All residents with a BIMS greater or equal to 8 were interviewed for possible abuse or neglect violations. No issues were identified. Responsible party was the DON. E. Held a Resident Council Meeting (a group of residents who reside in the facility and meet regularly, discuss resident concerns, and discuss resident concerns with Administration) and the SSD and Activities Director reviewed the Resident Rights Statement and Policies for Prohibition of Abuse, Neglect and Misappropriation of Property and provided a copy to each resident. Responsible party was the DON. F. All deaths in the facility for the past 30 days were reviewed by the Regional Nurse to ensure advanced directives were honored with no irregularities noted. The DON reviewed all resident deaths in the facility for the prior 12 months with no irregularities noted. Results were discussed in the QA meeting. Responsible party was the Administrator. [NAME] Held first formal QA meeting to address the incident. DON, ADON, UM, Nursing Supervisors or Medical Records staff were to review all new admissions/readmits and residents with DNR related changes, 24 hour shift reports, and incidents accidents daily for 2 weeks, then Monday through Friday ongoing, starting during morning clinical meeting, to ensure sustained compliance with physician notification, physician orders, interim care plan, advance directives, and resident rights. Corporate administrative oversight of the QA meeting was completed by the Regional Vice President or member of the regional staff weekly for 4 weeks beginning [DATE], then monthly for one quarter. The facility allegation of compliance (A[NAME]) was reviewed by the committee. Responsible party was the Administrator. H. Continued staff education and post testing on Abuse and Neglect, Advanced Directives, Where to find Advanced Directives in the chart, CPR, Resident Rights, following Physician orders, Notification of Change in Condition, and Following Care plans. Responsible party was the DON. I. Grievance logs were reviewed by the Director of Clinical Operation with no irregularities noted. [NAME] Continued Mock Code drills as outlined. Responsbile party was the DON. K. Corrective actions were reviewed by the Administrator, DON, Medical Director and Regional Consultants. Responsible party was the Administrator. On [DATE] the facility did the following: [NAME] The DON, ADON, UM, Administrator and Department Heads continued advance directive/abuse post-tests with 10 random Nursing staff members daily on rotating shifts for 2 weeks through [DATE]. Then 5 random nursing staff members on rotating shifts daily for 2 weeks through [DATE], then 5 random Nursing staff members weekly for 3 weeks through [DATE], with all staff required to score 100% on the post tests. Staff members who failed to achieve 100% scores on the tests were immediately re-educated and required to re-test until 100% scores were achieved. Responsible party was the DON. B. Continued education of all staff members on the facility Abuse and Neglect Policy, Resident Rights, CPR, Advance Directives and Where to find them in the medical record, Notification of Change in Condition, Physician Orders, and Care plans. Responsible party was the DON. C. Continued Mock Code drills on every shift through [DATE] as outlined. Responsible party was the DON. On [DATE] the facility did the following: [NAME] Completed review of all residents medical records by the Director of Clinical Operations and the Regional Nurse to ensure advance directives were in the medical records, addressed on the care plans, and had a current Physician Order regarding code status. No irregularities noted. Responsible party was the Director of Clinical Operations. B. Completed a 100% audit of licensed clinical staff CPR certifications by the Regional Vice President and Regional Nurse Consultant. C. Completed 100% audit of all licensed staff to verify valid Tennessee professional licensure completed by the Regional Vice President. No irregularities were noted. D. Completed 100% audit to ensure staff were not listed on the abuse registry by the Regional Vice President with no irregularities noted. E. Mailed certified letters to all employees who had not completed mandatory training and education and advised completion of training was required prior to any return to work at the facility. The letters included all employees on vacation or paid leave, part time or prn (as needed status). Responsible party was the DON. F. The Administrator began reviews of completed audits for new admissions, readmissions and residents with DNR to ensure sustained compliance with all advanced directives. [NAME] DON, ADON, UM or Weekend Manager on duty began interviews with 5 residents with BIMS scores equal or greater than 8 and 5 family members of residents with BIMS scores less than 8 daily for 2 weeks ([DATE] to [DATE]) for any possible resident rights violations; then 3 residents and 3 family members daily for 2 weeks ([DATE] to [DATE]), then 2 residents and 2 family members daily for 4 weeks ([DATE] to [DATE]), then 1 resident and 1 family member daily for 4 weeks ([DATE] to [DATE]). Results of the interviews and assessments forwarded to the QA committee. Responsible party was the DON. H. All deaths in the facility were reviewed by the DON, ADON, UM or Administrator to ensure code status was implemented correctly as per the resident's wishes and documented on the advance directives daily for 2 weeks through [DATE]; then weekly for 4 weeks from [DATE] to [DATE], then continuing as part of the daily stand up meetings attended by the Administrator, DON, ADONs, UM, MDS Coordinator, Treatment Nurses, Chaplain, SDC, Quality of Life Department Head, SSD, Dietary Manager and Formulary Nurse (the nurse in charge of the central supply office) to ensure sustained compliance. Responsible party was the DON. I. Began Administrative oversight of the facility by a member of Senior Regional Team twice weekly for 2 weeks, beginning [DATE] to [DATE]; then weekly for 4 weeks beginning [DATE] through [DATE], then monthly for one quarter. Responsible party was the Director of Clinical Operations. [NAME] Continued Mock Code drills as outlined above. Responsible party was the DON. K. The DON and SDC began tracking all licensed staff members for CPR certification monthly for 3 months; then every 6 months to ensure all licensed nurses maintained CPR certifications. Findings documented and forwarded to the QA committee monthly to determine any need for education or revision of the process. Responsible party was the DON. L. Established plans for daily contact between the facility and nurses from the regional team or corporate office for 2 weeks, then 2 times weekly for 4 weeks. Nurses from the regional team or home office reviewed compliance with the Plan of Correction and Policy and Procedures, compliance of any code blue to occur, and review of compliance with all new/readmissions. Responsible party was the DON. On [DATE] the facility did the following: [NAME] Completed the twice daily mock code drills as outlined above with no irregularities noted. Initiated the plan for transition to twice weekly Mock Code drills to occur on rotating shifts for another 4 weeks. Responsible party was the DON. B. Continued staff education and competency testing on Abuse and Neglect, Resident Rights, Advance Directives and Where to find them in the Chart, CPR, Notification of Change in Condition, Physician Orders, and Care Plans. Responsible party was the DON. C. Held a follow up QA meeting to review findings from initial audits, scheduled weekly QA meetings for 4 weeks, then monthly, for recommendations and further follow up regarding the Corrective Action Plan. At that time, based upon evaluation, the QA committee would determine at what frequency any ongoing audits would be continued. Responsible party was the Administrator. On [DATE] the facility did the following: [NAME] Completed education and competency testing of all staff, with the exception of those on Family Medical Leave (FMLA) or PRN status who had not worked, with 100% scores attained on all post-tests for facility Abuse and Neglect Policy, Resident Rights, CPR and Advance Directives, Where to Locate Advance Directives in the Medical Records, Physician Orders, Notification of Change in Condition, and Care Plans. Employees on FMLA or PRN status were not permitted to work until all education and competency testing completed. Responsible party was the DON. B. Continued all random audits, staff and resident interviews, and competency testing as outlined above. Responsible party was the DON. C. Continued daily stand up meeting reviews as outlined above, which included reports to Administration on the progress of the facility corrective action plans and changes in resident condition. Responsible party was the DON.",2020-03-01
4814,BEECH TREE MANOR,445292,"240 HOSPITAL LANE, PO BOX 300",JELLICO,TN,37762,2016-07-07,157,D,1,0,TDWC11,"**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 notify the physician of an altercation for two (#5 and #6) of five residents reviewed for behaviors affecting others. The findings included: Review facility policy, Notification of Resident/Patient Change in Condition, revealed, Our Facility's clinicians will notify the resident, his/her attending physician .if there is a crucial/significant change in the resident's condition .1. Notify the resident's attending physician .at the earliest possible time, during waking hours, if there is a change in condition . Medical record review revealed Resident #5 was admitted to the facility on (MONTH) 16, 2013, with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated (MONTH) 29, (YEAR), revealed Resident #5 had the ability to understand others, scored a 12 on the Brief Interview for Mental Status (BIMS) and verbal behavioral symptoms directed toward others occurring less than daily. Continued review revealed the resident required limited assistance for bed mobility, transfers, walk in room, dressing and toilet use; extensive assistance for personal hygiene; was totally dependent on staff for bathing; and the resident used the wheelchair as a mobility device. Medical record review of the Care Plan revised (MONTH) 5, (YEAR), revealed, I have a [DIAGNOSES REDACTED]. Care plan interventions included: I like my door to remain closed, I need a stop sign wander strip placed over my door to decrease other resident from wandering in my room, provide me with frequent reminders to ask for assistance if a resident wanders in my room and I need them removed; and to provide resident with cues and redirection. Resident #6 was admitted to the facility on (MONTH) 11, 2013, with [DIAGNOSES REDACTED]. Medical record review revealed the MDS dated (MONTH) 25 and (MONTH) 19, (YEAR), revealed Rresident #6 had short and long term memory problems, moderately impaired cognitive skills and behaviors of inattention and disorganized thinking indicating [MEDICAL CONDITION]. Review revealed the resident walked in room independently, required supervision to walk in the corridor and locomotion on the unit, and used a wheelchair as a mobility device. Review revealed wandering was not exhibited for the resident. Medical record review of the Care Plan (undated) revealed, I have impaired cognitive function and I usually understand others related to my Alzheimer's Dementia. I wander at times. Continued review of the Care Plan revealed (undated) interventions including encourage me to attend activities, and I am easily redirected and enjoy being around other people. Medical record review of a Resident to Resident Altercation Report dated (MONTH) 18, (YEAR) revealed Resident #6 wandered into Resident #5's room and resident #5 and started twisting the arm of Resident #6. Continued review revealed the immediate intervention included the residents were separated and placed on every 15 minute checks. Continued review revealed there was no physical injury present on assessment for Resident #5 or Resident #6. Continued review of the investigation revealed the Physician of Resident #5 and Resident #6 was not notified with explanation written as No injury to resident for each resident. Interview with the Director of Nursing (DON) in the conference room on (MONTH) 23, (YEAR), at 12:15 p.m., confirmed the physician notification was not completed for Resident #5 and Resident #6. Interview with the DON by telephone on (MONTH) 6, (YEAR), at 10:30 a.m., confirmed the altercation is a significant change in condition requiring physician notification.",2019-07-01
3929,LIFE CARE CENTER OF RED BANK,445240,1020 RUNYAN DR,CHATTANOOGA,TN,37405,2017-01-05,333,D,1,0,7K3L11,"**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 prevent significant medication errors for 2 residents (#1 and #2) of 6 residents reviewed for medication administration. The findings included: Review of the facility policy, Administration of Medication, not dated, revealed .be aware of the classification, action, correct dosage and side effects .before administration .A Physician Order that includes dosage, route, frequency, duration and other required considerations is required for administration of medication .if there is a discrepancy between the MAR (medication administration record) and label check physician orders before administering medication . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's recapulation order dated 7/22/16 revealed .[MEDICATION NAME] (long acting insulin) 100 unit/ml (per milliliter) .Subq (subcutaneously) twice daily . Medical record review of a Medication Administration Record [REDACTED].[MEDICATION NAME] 100 unit/ml subcutaneous .twice daily . Continued medical record review revealed Licensed Practical Nurse (LPN) #1 administered [MEDICATION NAME] 100 units on 7/22/16 at 9:00 PM. Review of a facility investigation dated 7/22/16 revealed LPN #1 (admitting nurse) failed to include the correct dosage of [MEDICATION NAME] onto the physician's admission orders [REDACTED]. Continued review revealed LPN #2 detected the error during routine checks of physician orders and immediately corrected the dose discrepancy on the electronic physician orders form, but failed to correct the dose discrepancy on the handwritten MAR indicated [REDACTED]. Further review revealed the correct dosage as ordered by the physician was 5 units twice daily. Interview with the Unit Manager on 1/4/17 at 4:00 PM, in the Administrator's Office, revealed the transcription error on Resident #1's MAR indicated [REDACTED]. Continued interview confirmed the facility failed to accurately transcribe the physician admission orders [REDACTED]. Further interview confirmed the facility failed to follow facility policy and failed to prevent a significant medication error for Resident #1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's order dated 8/22/ at 1:30 PM revealed .[MEDICATION NAME] (blood thinner) 6 mg (milligrams) .daily . Medical record review of a MAR indicated [REDACTED]. Review of a facility investigation dated 8/22/16 revealed Resident #2 received 8mg [MEDICATION NAME] on 8/22/16. Continued review revealed the medication error was detected on 8/23/16 during the daily medication audit. Interview with the Director of Nursing (DON) on 1/5/17 at 11:45 AM, in the Administrator's office, confirmed Resident #2 received the wrong dosage of [MEDICATION NAME]. Continued interview confirmed the facility failed to follow facility policy and failed to prevent a significant medication error for Resident #2.",2020-01-01
3947,MT JULIET HEALTH CARE CENTER,445439,2650 NORTH MT JULIET ROAD,MOUNT JULIET,TN,37122,2017-01-25,225,D,1,0,AP4211,"**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 promptly report an allegation of abuse for 2 residents to the appropriate facility staff and failed to initiate and complete a timely investigation for allegations of abuse for 2 residents (#2 and #3), and failed to report timely an allegation of abuse to the appropriate state agency for 1 resident (#3) of 5 residents reviewed for abuse of 8 sampled residents. The findings included: Review of the facility's Abuse Policy dated 1/14 revealed .To operate the facility where all patients are free from verbal, sexual, physical and mental abuse .Incidents of reasonable suspicion of abuse of a patient by an employee, another resident, or any other person shall be recorded .Accused employees, who comply with the interrogation proceedings, and who deny accusations of abuse .shall be under immediate suspension .Report all alleged violations and all substantiated incidents to the State agency .ANY report of actual or suspected abuse MUST be acted upon immediately .Per the Abuse Policy, any employee who is accused of abuse is immediately suspended, pending the results of the investigation .When an allegation or a suspicion of abuse/neglect/exploitation is made, the employee should immediately notify the Administrator or his/her designee . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the initial Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 09/15 (Moderately cognitive impaired) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident exhibited physical and verbal behaviors during the assessment period. Continued review revealed the resident required limited assistance for transfer, ambulation, dressing, and hygiene/bathing. Review of a facility investigation revealed a signed witness statement dated 12/20/16 by Licensed Practical Nurse (LPN) #5 revealed. Continued review revealed .12/18/16 @ (at) approximately 1630 (4:30 PM) witnessed (LPN #5) interact with a resident rudely . (LPN #5) stated 'I don't know why you always sit in the hallway crying and acting this way come on I'll get your medicine' .Resident proceeded to sit and cry. Nurse came over and snatched the arm of wheelchair while whispering in resident's ear meanly while pushing wheelchair fast. Reported to on call nurse @ approximately 1635 (4:35PM) .12/19/16 witnessed the same nurse (LPN #5) with the same resident .Resident was again agitated. Nurse stated to resident the only thing good about you is the part that ran down your mother's leg . A written statement signed by the accused nurse and dated 12/20/16 revealed I have never at any time verbally or physically abused any residents. Review of Personnel Action form dated 12/22/16 completed by Interim DON and signed by the accused employee revealed .On 12/20/16 several staff members reported to Nursing management that they witnessed employee being verbally abusive and rude to two residents on 12/7/16, 12/18/16 and 12/19/16 .immediately investigated and reported .On 12/20/16 employee was called in to the facility to speak with Interim DON regarding these allegations .was suspended pending investigation . Interview with LPN #5 on 1/24/17 at 9:20 AM, in the Conference Room, revealed LPN #5 was the nurse who wrote the witness statement for the incident on 12/18 and 12/19/16. LPN #5 stated on 12/18/16 she witnessed the accused nurse yank the wheelchair of Resident #2's wheelchair and push the resident down the hallway. LPN #5 stated the accused nurse whispered something in the ear of Resident #2 but was unable to hear anything said. LPN #5 stated she felt the push down the hallway was an aggressive push. Further interview with LPN #5 revealed on 12/19/16 she heard the accused nurse state to Resident #2 the only good thing about you is what ran down your mother's leg. LPN #5 stated she thought she had called the nurse on call after the 1st incident (12/18/16). Interview with the Interim Director of Nursing (DON) on 1/24/17 at 9:55 AM, in the Conference Room, confirmed the witnesses did not report the incidents of 12/18/16 or 12/19/16 until 12/20/16. Interview with LPN #4 on 1/24/17 at 4:05 PM, in the Conference Room, revealed LPN #4 was the nurse on call 12/18/16 and she couldn't actually say she received a phone call on 12/18/16 regarding an alleged incident but thought she remembered a face to face notification from LPN #5 on 12/19/16. Further interview with LPN #4 revealed when she and LPN #5 talked about the allegation on 12/19/16 the 2 nurses thought the accused nurse may have just had a bad day. Continued interview revealed after the second incident on 12/19/16 the 2 nurses (LPN #4 and #5) said it was just mean. Interview with the Interim DON on 1/25/17 at 8:45 AM, in the DON office, confirmed LPN #4 and LPN #5 failed to report the allegation of verbal abuse for the incident on 12/18/16 and 12/19/16 until 12/20/16. Continued interview with the Interim DON confirmed the investigation and completion of the alleged incidents including suspension of the accused nurse did not occur until 12/20/16 when she (Interim DON) was notified. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the initial Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 03/15 (severely cognitive impaired) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance for transfer, dressing, and hygiene/bathing. Review of a facility investigation dated 12/20/16 revealed during an investigation of alleged verbal involving Resident #2, it was discovered there was an alleged incident involving Resident #3 and LPN #5, which occurred on 12/7/16. Continued review of witness statement #1 completed by LPN #8 revealed .Was at the nurses' station when (Resident #3) was brought because she was upset after watching a movie in the dining room regarding[NAME]Harbor .the resident kept repeating .'The German's are coming . over and over' .sat down with the resident to attempt to calm her down .(LPN #5) .turns and says .'The Germans are coming' . basically antagonizing the resident and of course she got upset again . Further review of a witness statement #2 completed by Certified Nursing Assistant (CNA) #2 revealed . (LPN #5) put his hands on (Resident #3) .the resident was slightly confused and agitated .(the resident) was playing in the nurses' station drawer when (LPN #5) turned around and snatched the resident's hand away and yelled .'You don't touch that' . and said .'the Germans are coming .' Interview with the Interim DON on 1/24/17 at 9:45 AM, in the Conference Room, confirmed she was not aware of the allegation of verbal abuse for the alleged incident involving Resident #3 on 12/7/16 until she initiated an investigation on 12/20/16 related to another allegation involving LPN #5 and Resident #2. Continued interview confirmed the facility failed to promptly report an allegation of abuse involving Resident #2 and #3 to the appropriate facility staff, failed to promptly initiate an investigation of abuse for Resident #2 and #3, and failed to report timely an allegation of abuse to the appropriate state agency for Resident (#3).",2020-01-01
3721,SIGNATURE HEALTHCARE OF FENTRESS COUNTY,445362,208 DUNCAN ST N,JAMESTOWN,TN,38556,2017-03-28,309,J,1,0,Q88111,"**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 provide Cardiopulmonary Resuscitation (CPR) to 1 resident (Resident #6) of 6 resident deaths reviewed, of 13 sampled residents. The facility's failure to provide CPR in accordance with the resident's Advanced Directives, Physician Orders, and the Care Plan on [DATE] at 7:00 AM, resulted in the death of Resident #6 on [DATE] at 7:06 AM, placing Resident #6 in Immediate Jeopardy (a situation where the providers noncompliance with one or more requirements of participation, has caused, or is likely to cause, serious injury, harm, impairment or death). F-309 at scope and severity J constitutes Substandard Quality of Care. The Administrator, Director of Nursing (DON), and Corporate Nurse were informed of the Immediate Jeopardy on [DATE] at 3:25 PM, in the conference room. The IJ was effective [DATE] - [DATE]. The facility's corrective action plan which removed the IJ was received and corrective actions validated onsite by the surveyor on [DATE] - [DATE]. The IJ was cited as past noncompliance for F-309 and the facility iss not required to submit a plan of correction. The findings included: Review of the facility policy, Cardiopulmonary Resuscitation, (CPR, undated) revealed .Upon identifying a resident with a change of condition which presents as an unresponsive condition .check the medical record for advance directive status .if resident record indicates CPR is to be instituted, then initiate Basic Life Support if a pulse and/or respirations are undetectable .if a resident is found unresponsive and without respirations, a licensed staff member who is certified in CPR .shall promptly initiate CPR for residents .who have requested CPR in their advance directives .who do not have a valid Do Not Resuscitate DNR order . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Admission Consent Forms and the Tennessee Physicians Orders for Scope of Treatment (POST, or advanced directives form), executed on [DATE], revealed Resident #6, a [AGE] year old resident, was to receive CPR, Intubation (insertion of a breathing tube), advanced airway interventions, mechanical ventilation as indicated, transfer to a hospital or intensive care unit if indicated, and full treatment in an intensive care unit if indicated, in the event of a respiratory or [MEDICAL CONDITION]. Medical record review of the Physician Orders dated [DATE], at 4:21 PM, revealed .Advanced Directive .FULL CODE . Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #6 had a Brief Interview of Mental Status (BIMS) score of 15 (indicating she was cognitively intact), was independent in decision making, dependent upon supplemental oxygen to breathe, and the resident required moderate assistance of one person for activities of daily living (ADLs). Review of the Daily Skilled Nursing Note dated [DATE] at 1:30 AM, revealed .Cardiovascular .Cardiovascular concerns yes .radial/apical (pulse) irregular .Respiratory Concerns .yes .Labored Breathing .Orthopnea (shortness of breath with movement) shallow respirations .SOB (short of breath) .on exertion .at rest .lying flat .Lung Sounds .Rales (a type of abnormal lung sound often associated with lung disease, fluid in the lungs or swelling in the lungs) .Wheezing .(a type of abnormal lung sound often associated with [MEDICAL CONDITION], decreased lung volume, inflammation or mucous in the airways of the lungs) . Review of the Nursing Progress Notes Report revealed on the morning of [DATE], during the conclusion of the [DATE] 7:00 PM to 7:00 AM shift, at approximately 6:00 AM, Resident #6 exhibited an onset of symptoms of increased anxiety and increased shortness of breath, and summoned her primary nurse that evening, Licensed Practical Nurse (LPN) #1, to her room. Continued review revealed LPN #1 entered the room and found the resident seated on the side of her bed complaining of severe shortness of breath. Continued review revealed LPN #1 assessed the resident's blood oxygen saturation levels (O2 SAT) which were at 95% (within normal limits) at the time, administered a scheduled breathing treatment ([MEDICATION NAME], a medication to improve breathing) and oral [MEDICATION NAME] (narcotic, for pain) from 6:00 AM to 6:15 AM, and informed her supervisor, Registered Nurse (RN) #1, of the resident's status. Continued review of the Nursing Progress Notes Report revealed, around 6:30 AM, Resident #6 activated the call light and RN #1 and LPN #1 returned to the resident's room. Continued review revealed LPN #1 and RN #1 found Resident #6 again seated on the side of the bed, and the resident informed them she remained short of breath and wished to be transferred to the hospital to be intubated. Continued review revealed the resident's vital signs were heart rate at 88 beats per minute (within normal limits, WNL) O2 Saturation as 95% (WNL) and Respiratory Rate was 36 breaths per minute (elevated). Further review revealed RN #1 adjusted the resident's position and elevated the head of the bed 90 degrees. The resident was not transported to the hospital. Continued review revealed RN #1 documented .her color did not look right . and the nurses attempted to contact family members. Medical record review of the Nursing Progress Notes Report dated [DATE] at 7:00 AM, revealed Resident #6 was found by Registered Nurse (RN) #1 slumped over in bed, gray in color, without a pulse or respirations (cardiac and respiratory arrest). Continued review revealed RN #1 did not attempt to perform CPR on Resident #6 in accordance with the Residents' Advance Directives, Physicians Orders, and Care Plan, and instead pronounced the resident deceased at 7:06 AM. Continued review revealed .Despite elder being full code I (RN #1) did not perform CPR on elder who was clearly passed and stated that to Dr (doctor) .DON and ADON (assistant director of nursing) .notified . Medical record review revealed no documentation or evidence evidence to indicate the resident had been monitored from 6:37 AM until 7:00 AM (23 minutes after she complained of increased shortness of breath and requested to be hospitalized ) while the nurses attempted to contact family members. Review of the Record of Death, signed by the Physician, dated [DATE], revealed .immediate cause of death .Respiratory Arrest .pronounced by .( (RN #1). Review of the facility investigation and witness statements revealed on [DATE] at 7:00 AM, when Resident #6 was found in cardiac and respiratory arrest, RN #1 was informed by Licensed Practical Nurse (LPN) #1, LPN #15 and Respiratory Therapist (RT) #4, Resident #6 had advance directives and Physician Orders which specified the resident was a full code and CPR was to be performed. Continued review of the facility investigation revealed RN #1 ignored the directives of the employees, prohibited them from performing CPR on Resident #6, stood between them and the resident's bed with her arms out stretched to prevent them from approaching Resident #6, and informed them no CPR would be performed. RN #1 pronounced Resident #6 deceased at 7:06 AM on [DATE]. Review of RN #1's investigative interview summary (the findings of the investigative interview conducted by the facility's attorney) dated [DATE], revealed .Entered resident's room to give drink .assisted resident with same .replaced resident O2 (oxygen) mask back on face .(LPN #1 giving meds) .Resident SATS (blood oxygen saturations) were 95% good .Later 2 CNAs (Certified Nurse Aide) approached, saying resident would like to go to hospital .I assessed resident .resident stated she wanted to be intubated .I found not needed and that resident was very tired .covered resident with blanket .put at 90 degrees in middle of the bed .relayed I would notify her family and doctor .skin color dusky color .cool to touch .room was very cool .with .(LPN #1) .started looking up family contact info (information) .then walked back to resident room to get more family names from resident .found resident slumped over with her head down to the end of bed .this was approximately 30 minutes after I had left resident .yelled for stethoscope .two other nurses nearby .one went to call resident's daughter .assessed resident .no pulse or respirations .skin dusky, eyes 1/2 open, lips and nails blue tinge .Nurse (LPN #1) said resident is full code .I responded resident has clearly passed, nothing to do .Spoke with Doctor, told him resident expired and I would not initiate code, would pronounce her at 7:06 AM . Telephone interview with Physician #3 (the attending Physician for Resident #6) on [DATE] at 10:57 AM, revealed when he was contacted by RN #1 on [DATE] between 7:00 and 7:15 am, he questioned RN #1 if CPR had been initiated or was in progress at the time of the telephone call, and was informed by RN #1 CPR had not been initiated. Continued interview revealed he advised RN #1 the resident was full code status and CPR was to have been attempted and RN #1 asked, you want me do CPR on a dead person? Continued interview revealed RN #1 informed him she had pronounced the resident deceased at 7:06 AM and he was led to believe the resident had been pulseless for an extended period. Continued interview revealed he believed .CPR should have been attempted on Resident #6 prior to declaration of death by RN #1 . Further interview revealed RN #1 stated to him on [DATE], .you can take my license all the way to the state if you want, I'm not doing CPR on a dead person . Interview with LPN #1 on [DATE] at 11:36 AM, in the conference room, revealed she observed Resident #6 in [MEDICAL CONDITION] with RN #1 present, and the resident's appearance was .slumped over on the side of the bed, upright with no breathing and no pulse . and she assisted RN #1 to position the resident in the bed for assessment. Continued interview revealed as she assisted RN #1 to reposition the resident, she told RN #1 .she (Resident #6) is a full code . Continued interview revealed as RN #1 assessed Resident #6, LPN #15 and Respiratory Therapist (RT) #4 entered the room, and LPN #15 and RT #4 asked RN #1 if CPR was to begin. Both staff members advised RN #1 of the resident's advanced directives. Further interview revealed .(LPN #3 and LPN #15) came in the room, asked 'Are we gonna (going to) code her?' and (RN #1) said 'No we aren't gonna do anything' .no one else questioned it .(RN #1) was guarding the body, standing between us and everyone else and the body, arms outstretched, and said to everybody, 'No, we aren't going to do a thing.' Continued interview revealed no CPR was performed on Resident #6 and RN #1 declared the resident deceased . Interview with the Director of Nursing (DON) on [DATE] at 2:45 PM, in the conference room, confirmed Resident #6 had valid Advance Directives to Perform CPR in the event of cardiac or respiratory arrest, had valid Physician orders in place for full code status, and confirmed RN #1 had willfully failed to provide CPR in accordance with the Physician Orders, Care Plan and the Resident's Advance Directives. Interview with the Assistant Director of Nursing (ADON) on [DATE] at 3:45 PM, in the conference room, revealed on [DATE] around 7:30 AM, RN #1 informed the DON that she had not performed CPR on Resident #6 in spite of valid Physician Orders and Care Plan directives to do so. Continued interview revealed RN #1 alleged the resident was clearly deceased when found, and stated to her and the DON, I take full responsibility for this. Continued interview revealed the facility investigation of the incident determined RN #1 failed to provide CPR to Resident #6, who had valid Advance Directives and Physician Orders for full code status. Interview with Respiratory Therapist (RT) #4 on [DATE] at 1:40 PM, revealed on [DATE] around 7:00 AM, she had entered Resident #6's room and observed her to be slumped sideways in the bed with her head tilted backwards, mouth open, not breathing, and ashen in color. Continued interview revealed she informed RN #1 the resident was a full code. Continued interview revealed when she informed RN #1 Resident #6 was a full code and CPR was to begin at once, the RN stated to her, .absolutely not, we are not doing a code, she has been down too long . Interview with the Administrator on [DATE] at 12:41 PM, in the conference room, revealed on [DATE] around 7:45 AM, RN #1 had informed him she did not perform CPR on Resident #6 in accordance with the Care Plan and Physician Orders. Continued interview revealed RN #1 stated to him I take full responsibility for this situation. Further interview revealed when he questioned RN #1 about the Physician's reaction to her refusal to perform CPR, she replied, .not much, but I told him I'm not performing CPR and you can take my license to the state . Continued interview confirmed RN #1 willfully failed to provide CPR to Resident #6 in accordance with the Physician Orders, Advance Directives and Care Plan. Telephone interview with LPN #15 on [DATE] at 2:24 PM, revealed she was present on the unit as an oncoming day shift nurse on [DATE] and witnessed the incident. Continued interview revealed when Resident #6 was discovered without a pulse or respirations at 7:00 AM, she responded to the room to assist in resuscitation efforts and she also informed RN #1 the resident was a full code. Continued interview revealed .I told (RN #1) the resident was a full code, we needed to code, and (RN #1) said, 'No we are not going to code her' .I advised (RN #1) facility policy was to code the resident, and (RN #1) refused even after I advised of facility policy . Continued interview revealed RN #1 told LPN #15 to leave from the resident's room and call Physician #3, report to him the resident was deceased . Further interview revealed LPN #15 reported when she contacted the Physician and advised him of the situation, he asked to speak directly to RN #1. Further interview revealed she heard RN #1 say to the Physician, I refuse to do CPR on a dead person. Continued interview revealed .I was getting crash cart with (LPN #3), (RN #1) held up her hand, waved 'No' to me .after that we stopped, we were taught to never disobey a RN but taught to do codes, felt stuck . The facility's corrective action plan included the following: Telephone interview with LPN #15 on [DATE] at 2:24 PM, revealed she was present on the unit as an oncoming day shift nurse on [DATE] and witnessed the incident. Continued interview revealed when Resident #6 was discovered without a pulse or respirations at 7:00 AM, LPN #15 responded to the room to assist in resuscitation efforts and she also informed RN #1 Resident #6 was a full code. Continued interview revealed .I told (RN #1) the resident was a full code, we needed to code, and (RN #1) said 'No we are not going to code her' .I advised (RN #1) facility policy was to code the resident and (RN #1) refused, even after I advised of facility policy .",2020-03-01
3945,PIGEON FORGE CARE & REHAB CENTER,445382,415 COLE DRIVE,PIGEON FORGE,TN,37863,2017-01-31,226,D,1,0,D7H211,"**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 report an allegation of abuse timely for 1 resident (#3) of 5 residents reviewed for abuse of 8 sampled residents. The findings included: Review of the facility policy Abuse, Neglect and Misappropriation of Property, undated, revealed .Every Stakeholder .immediately shall report any 'allegation of abuse' .to the charge nurse on duty . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #3 had a Brief Interview Mental Status score of 3 (severe cognitive impairment). Review of the facility investigation dated 12/21/16 at 2:30 PM revealed .CNA (Certified Nursing Assistant) slapped resident on the sides of her head with his hands .date allegation was reported: 12/21/16 at 2:30 PM . Interview with CNA #4 on 1/31/17 at 9:00 AM, in the conference room revealed .it (the incident) was right before we went home (12/20/16) close to 10:00 PM . didn't report it .called the Director of Nursing (DON) the next day at the beginning of my shift (approximately 17 hours later) and told her . Interview with the DON on 1/31/17 at 8:20 AM confirmed the facility failed to report an allegation of abuse timely and failed to follow facility policy.",2020-01-01
5419,ETOWAH HEALTH CARE CENTER,445422,"409 GRADY ROAD, PO BOX 957",ETOWAH,TN,37331,2016-03-22,225,D,1,0,MXJV11,"**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 timely initiate an investigation and report an allegation of abuse to the Administrator and Director of Nursing (DON) immediately for 2 residents (#1, #6) of 18 residents reviewed for Abuse. The findings included: Review of facility policy, Abuse, dated 7/17/14 revealed .5. A. 3. All reports of suspected abuse must be reported to the Administrator and Director of Nursing immediately, as well as to the Resident's family .6. Upon receiving the information concerning a report of abuse, the Abuse Prevention Coordinator or designee will: A. Initiate an investigation that will include but not be limited to; 1. Interview the Resident .4. interview employees that worked that day . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 15/15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance for transfer, hygiene, and bathing. Review of a witness statement from Certified Nursing Assistant (CNA #13) dated 12/5/15 revealed Resident #1 was offered a shower around 10:30 AM to 11:00 AM and the resident stated .A shower? No way, I'm not going in the shower room with another female. I was raped the other day in there . CNA #13 stated she immediately reported the allegation to the Licensed Practical Nurse (LPN #2) who told the CNA that if she did not feel comfortable giving Resident #1 a bath then that's was OK. Review of the witness statement by LPN #2 dated 12/5/15 revealed CNA #13 came to the desk at 2:15 PM on 12/5/15 and reported Resident #1 stated she was raped 3 days ago. Further review of the statement revealed the LPN left the facility at 3:10 PM. Review of the Resident Abuse Investigation Report Form revealed the Director of Nursing was notified on 12/5/15 at 4:15 PM and the Administrator was notified at 5:01 PM. Interview with the Director of Nursing on 2/29/16 at 2:05 PM, in the Conference Room confirmed CNA #13 was first notified of the allegation of abuse on 12/5/15 between 10:30 AM-11:00 AM who then reported the allegation to LPN #2. Further interview confirmed the Director of Nursing was not notified until 4:15 PM-4:30 PM between 5 to 6 hours later. Continued interview confirmed the facility did not follow the policy to report the allegation of abuse to the Administrator and DON immediately. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored 14/15 (cognitively intact) on the BIMS. Further review revealed the resident required total assistance for transfer and dressing with extensive assistance required for hygiene/bathing. Review of the Resident Abuse Investigation Report Form dated 1/15/16 revealed on 1/7/16 Resident #6's daughter came to the nurses station at 6:30 PM stating her mother was on the bedpan that was left underneath the resident from the day shift around 2:30 PM. Interview with the DON on 3/2/16 at 9:30 AM, in the Conference Room confirmed the facility failed to initiate an investigation of the incident until after routine chart review of the incident by corporate staff was completed on 1/14/16.",2019-03-01
2563,BETHESDA HEALTH CARE CENTER,445427,444 ONE ELEVEN PLACE,COOKEVILLE,TN,38501,2018-04-24,610,D,1,0,EG0E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility investigation, and interviews the facility failed implement interventions to protect 1 resident (#2) after alleged abuse, of 5 residents reviewed for abuse. The findings included: Review of the facility policy Abuse, Neglect, Exploitation revised 2/18 revealed .Each resident has the right to be free from abuse .Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents .Resident Protection after Alleged Abuse .The facility will make efforts to protect all residents after alleged abuse .Responding immediately to protect the alleged victim .Prevent further potential abuse . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of a 14 day Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of a Comprehensive MDS dated [DATE] revealed a BIMS score of 5 indicating severe cognitive impairment. Review of a facility document Investigation Summary dated 3/29/18, revealed .Root cause of the event: Both residents wandered facility and were on another hall at time of altercation. (Resident #2) is invasive to other residents' personal space. (Resident #1) is easier to agitate and she struck out at (Resident #1) smacking her on back of right hand/wrist .North Hall CN witnessed the event and stated both were on 300 hall in front of bathroom and (Resident #1) smacked (Resident #2) on back of right hand .Residents were separated and brought back to their halls. (Resident #2) was taken back to her room and (Resident #1) was left at nurse's station. Approximately 5 minutes later (Resident #2) had been in (Resident #3)'s room .(Resident #1) was setting at end of 500 hall and grabbed (Resident#2)'s right hand with both of hers when she came out of (Resident #3)'s room. (Resident #2) began yelling let go of me and nurses immediately separated them and took them to their rooms . Interview with LPN #3, on 4/23/18 at 2:13 PM, in the conference room revealed she was on the South hall when CNA #1 brought back (Resident #1). I took (Resident #2) to her room and did ahead to toe assessment. I saw no injury and she didn't appear to be in any pain, but she couldn't tell me what had happened. I left her room, and (Resident #1) was still at the nurse's station. I proceeded down the 500 hall to finish my med pass, but there was a call light going off on the 600 hall in room [ROOM NUMBER] and I answered the call light. When I left the room and was going back to the 500 hall I saw (Resident #1) she had a hold of (Resident #2)'s wrist and hand with both of her hands, and (Resident #2) was pulling away from her. Interview with the Assistant Director of Nursing (ADON), on 4/23/18 at 3:20 PM, in the conference room confirmed Resident #1 willfully slapped Resident #2 on the hand. My expectations would have been for Resident #1 to receive on one on care, and in not doing so the facility had failed to follow their policy by not implementing immediate interventions to protect Resident #2 from further abuse.",2020-09-01
2562,BETHESDA HEALTH CARE CENTER,445427,444 ONE ELEVEN PLACE,COOKEVILLE,TN,38501,2018-04-24,600,D,1,0,EG0E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility investigation, and interviews the facility failed to prevent abuse for 1 resident (#2) of 5 residents reviewed for abuse. The findings included: Review of the facility policy Abuse, Neglect, Exploitation revised 2/18 revealed .Each resident has the right to be free from abuse .Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of a 14 day Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of a Comprehensive MDS dated [DATE] revealed a BIMS score of 5 indicating severe cognitive impairment. Review of a facility document Investigation Summary dated 3/29/18, revealed .Root cause of the event: Both residents wandered facility and were on another hall at time of altercation. (Resident #2) is invasive to other residents' personal space. (Resident #1) is easier to agitate and she struck out at (Resident #1) smacking her on back of right hand/wrist .North Hall CN (charge nurse) witnessed the event and stated both were on 300 hall in front of bathroom and (Resident #1) smacked (Resident #2) on back of right hand .Residents were separated and brought back to their halls. (Resident #2) was taken back to her room and (Resident #1) was left at nurse's station. Interview with LPN #1, on 4/23/18 at 11:35 AM, in the conference room revealed she witnessed the event between Resident #1 and Resident #2. Resident #1 was in a wheelchair, Resident #2 was walking, the residents were coming down the hall together, and when they got to the bathroom on North 2 hall, (Resident #1) appeared to be trying to get (Resident #2) to go with her, she smacked at, and made contact with (Resident #2)'s right hand. Interview with the Assistant Director of Nursing (ADON), on 4/23/18 at 3:20 PM, in the conference room confirmed Resident #1 willfully slapped Resident #2 on her right hand, and the facility failed to prevent Resident #2 from abuse.",2020-09-01
3577,SERENE MANOR MEDICAL CTR.,4.4e+252,970 WRAY ST,KNOXVILLE,TN,37917,2018-04-05,600,D,1,0,H6D411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility investigation, and interviews the facility failed to prevent abuse for 1 resident (#3) of 4 residents reviewed for abuse. The findings included: Review of the facility policy Abuse Policy, False Claims Act, [MEDICATION NAME] Protection updated 7/16 revealed .It is the policy of Serene Manor Medical Center that no abuse, neglect, mistreatment of [REDACTED]. Residents must not be subjected to abuse by anyone .The facility will identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur . Medical record review revealed Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of a Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of a MDS dated [DATE] revealed a BIMS score was unable to be completed, short term and long term memory problems were noted from staff assessment. Behaviors of rejection of care occurred 1 to 3 days, behavior of wandered occurred daily, and no physical or verbal behaviors towards others occurred during the look back period. Review of a care plan for Resident #4 dated 7/18/17 revealed .Resident combative with staff smacked CNA in the face . Staff educated on when resident becomes combative, ensure safety and remove self from agitated resident and reproach later .8/8/17 .can be combative/aggressive is approached inappropriately .approach resident from approximately 6-8 feet away .Staff to keep others away at a safe distance from resident when resident wanders . Review of a facility investigation dated 2/18/18 revealed Staff and resident reported that (Resident #4) slapped (Resident #3) on the left side of the residents face. Observation/interview with Resident #3 on 4/4/18 at 12:20 PM, in her room revealed she was able to recall the incident with Resident #4. She stated she was in her wheel chair at the end of the hall. Resident #4 was coming down the hall in his wheel chair backwards and was going fast. He was coming towards me and I tried to stop him from running into my legs. I put my hands out and stopped his wheel chair. He turned around and I put my finger on his chest and said you hit me and when I did he came around with his hand and slapped the side of my face. It stunned me but it didn't really hurt, it just stung for a minute. Interview with CNA #2 on 4/4/18 at 1:50 PM, via telephone revealed he had been at the other end of the hall and had seen Resident #3 setting in her wheel chair at the end of the hall. Resident #4 had been agitated and confused. Resident #4 was in his wheelchair going backwards down the hall towards Resident #3, and she was hollering at him to stop. She put her hands out and stopped his wheel chair from hitting her legs, when she did that he turned around and they exchanged words, and Resident #4 had come around with his arm and hit her cheek. When he saw what was going on he started down the hall towards the residents but was unable to reach them in time to prevent the incident. The residents had immediately been separated and the charge nurse was informed of the incident. Interview with Licensed Practical Nurse (LPN) #1, on 4/4/18 at 3:00 PM, in the DON's office revealed she had been the nurse on the floor when the incident occurred, but she did not witness the incident. The two residents had been separated. Resident #3 told her he had slapped her on the right side of her face. He was rolling backwards, and she put out her hands and was yelling at him to stop, she said I didn't touch him or anything she just put her hands out to stop him from running over her. Continued interview revealed from the report she had received from the two CNAs she was able to confirm Resident #4 had willfully struck Resident #3, I don't know if he meant to hit her in the face, or if he meant to hurt her, but he did willfully hit her. Interview with the Administrator on 4/5/18 at 12:20 PM, in the DON's office confirmed Resident #4 had willfully struck Resident #3 on the left side of her face., and the facility had failed to prevent Resident #3 from abuse.",2020-09-01
1682,WILLOW RIDGE CENTER,445284,215 RICHARDSON WAY,MAYNARDVILLE,TN,37807,2018-04-16,600,D,1,0,F62311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility investigation, and interviews, the facility failed to prevent abuse for 1 resident (#2) of 8 residents reviewed for abuse. The findings included: Review of the facility policy Abuse Prohibition, last revised 3/2018, revealed .(facility) will prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents .Verbal abuse is any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to patients . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Review of the facility investigation dated 3/26/18 revealed .CNA (Certified Nursing Assistant) reported another CNA talked hateful to a resident stating something smelled, resident told her (CNA) to leave and let other CNA take care of her. CNA reports other CNA said if you kick me out I won't f'n (expletive) have to come back in here. CNA suspended pending investigation .the CNA that made the statements above was terminated . Interview with CNA #1 on 4/10/18 at 10:40 AM, in the conference room, revealed .I was with the roommate (of Resident #2) and I could hear them (Resident #2 and CNA #2) interacting. (CNA #2) was just being hateful, her tone was hateful . she (Resident #2) told her (CNA #2) she was hurting her with the turn sheet, and (CNA #2) said according to you everyone hurts you, then (Resident #2) had a bottle of (cleansing) spray and she (CNA #2) sat it on the TV and (Resident #2) asked for it to be put in the drawer and she (CNA #2) said she would when she wanted to. (Resident #2) asked her (CNA #2) to leave her room and she (CNA #2) said if you kick me out of your room I won't have to f'n (expletive) come back in here. Interview with Resident #2 on 4/10/18 at 11:30 AM, in her room, revealed she was able to identify the accused CNA as CNA #2. Further interview revealed .she (CNA #2) hurt me when she rolled me over and put her hand under my side. When I told her she was hurting me she said I'm not hurting you I'm just holding you over. I ask her not to put something on my TV and she told me to shut up, and I told her she was hurting me and she told me she was doing her job so to [***] ing shut up . Interview with Registered Nurse (RN) #1 on 4/10/18 at 3:30 PM, in the conference room, revealed .I was on the other hall in a resident's room (CNA #1) said 'she needed to talk to me about (Resident #2) and (CNA #2)' .(CNA #2) had said some things to (Resident # 2) .(CNA #2) told the resident if you kick me out of your room I won't ever have to f'n (expletive) come back in here .I did an assessment on the resident right after I was informed of the incident .observed no physical injury at all. There were no reddened areas on the resident's body .She (Resident #2) said the CNA had told her she was incorrigible and she was done . Interview with the Administrator on 4/11/18 at 1:05 PM, in the conference room, confirmed CNA #2 was terminated for Verbal Abuse.",2020-09-01
1496,LAUGHLIN HEALTH CARE CENTER,445264,801 E MCKEE ST,GREENEVILLE,TN,37743,2018-07-21,835,J,1,0,X9GP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility investigation, educational training review, and interviews, the facility's Administrator failed to ensure all staff and contractors received education on procedures for resident elopement and wander guards. The Administrator's failure resulted in the elopement of 1 resident (#1) of 16 residents reviewed with exit seeking behaviors when Resident #1 eloped and sustained an injury. The Administrator's failure resulted in an 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 7/3/18 and is ongoing. The findings included: Review of facility policy Elopement of Resident last revised 1/2007, revealed .an elopement assessment will be done on every resident upon admission .if the assessment indicated a high risk potential .initiate placement of a secure care bracelet (wander guard) .secure care bracelets should be attached to the resident .Charge Nurses and CNAs (Certified Nursing Assistants) on each station must be aware of those residents assigned to each group .notice that you haven't seen a resident for a while, start searching immediately in that area .if you are unable to find the resident, broaden your search .the charge nurse will designate someone to make a search of the grounds .when trying to find a resident who has wandered, look everywhere possible . 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 last updated 11/18/17 and last reviewed on 11/22/17 revealed .Episodes of exit seeking. Episode of wandering when anxious .Wander guard to prevent from exiting building without anyone knowing . Medical record review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8 (moderate cognitive impairment). Continued review revealed the resident needed supervision for transfers and personal hygiene with 1 person assist, and was independent with ambulation. Medical record review of Resident #1's quarterly Elopement Risk evaluation dated 5/30/18 revealed the resident was at risk for elopement and required continued use of a wander guard alarm bracelet. Review of a facility investigation of Resident #1's elopement on 7/3/18 revealed Resident #1 exited the facility through the front doors alongside contracted landscapers. Continued review revealed the resident was wearing a wander guard and the alarm sounded as he exited the front doors. Further review revealed the Receptionist heard the alarm, left her desk and walked to the front lobby, looked out through the doors without exiting the building and because she did not see anyone, reset the alarm, and returned to her desk. Continued review revealed one of the landscapers returned to the receptionist desk and reported he thought a resident had gotten out of a facility and had fallen down the embankment into the woods. Review of the annual in-service document dated 10/26/17 - 10/27/17 revealed the elopement of a resident and management of the wander guard system were not included in the topics discussed. Interview with the Receptionist on 7/11/18 at 10:20 AM, in the front hallway, revealed .I peeped through the doors and didn't see anyone so I reset the alarm . Interview with the Administrator on 7/11/18 at 3:00 PM, in the Administrator's office, revealed .we have annual in-services for our employees and contract workers .we try to get as many contract workers to come as possible .no I don't think the landscape workers attended .we have signs on the doors telling our visitors to not let anyone out they don't know .she (Receptionist) saw a few people pass by then the alarm went off .she looked around and didn't see anything .turned the alarm off .no she did not go outside .probably been better if she had . Interview with the Receptionist on 7/12/18 at 2:00 PM, in the front office, revealed .if the alarm sounds I respond to it .no one ever told me to go outside and look around .but looking back I should have (gone outside) . Interview with the Administrator on 7/17/18 at 1:15 PM, in the conference room, revealed .not sure we have covered that (to check outside when alarm sounds) in the annual in-service . Telephone interview with the Administrator on 7/18/18 at 3:30 PM revealed .yes we tell them to check the area where the alarm sounds and to go outside if they do not see anyone .not sure that is in writing anywhere . Interview with CNA #8 on 7/20/18 at 11:45 AM, in the West Wing Nurses' Station, revealed .during a Code Orange .they usually take one of our residents and hide them in (DON) office .have never gone outside to look for someone .usually by the time I know anything is going on (Administrator) is coming around to have us sign the paper (code orange participation log) .no additional information is shared at that time. Just sign the paper . In summary, the Administrator failed to ensure all employees and contractors were trained/in-serviced on the supervision of residents at risk for elopement and failed to ensure the staff properly responded to the wander guard alarm when a resident eloped. Refer to F-689",2020-09-01
5423,ETOWAH HEALTH CARE CENTER,445422,"409 GRADY ROAD, PO BOX 957",ETOWAH,TN,37331,2016-03-22,323,E,1,0,MXJV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility investigation, incident logs, and interview, the facility failed to provide supervision for persons diagnosed with [REDACTED].#2, #4 and #18 of 18 residents with dementia reviewed for behaviors and failed to ensure a full body mechanical lift (Hoyer) was used for transfer to and from a shower room for bathing for one resident (#5) of 23 residents reviewed. The findings included: Review of facility policy, Dementia Care Guidelines, effective 4/1/15 revealed .residents who exhibit .behavioral or psychological symptoms of dementia (BPSD) will have an evaluation by the interdisciplinary team .to identify and address treatable psychiatric, functional, social and environmental factors .will conduct periodic .screening .behavioral interventions are individualized .including direct care and activities that are provided as part of a supportive .environment .and are directed towards preventing, relieving or accommodating .individualized approaches and treatment .addresses the causes .of .behaviors .staff training includes Hand in Hand in-services and on-going in-service and training .Monitoring, Follow Up and Oversight .staff identifies effectiveness of interventions relative to target behaviors .collaborates .adjustments to the interventions based on effectiveness .Quality Assessment and Assurance (QA) .The QA minutes should reflect any quality deficiencies related to the care of residents with dementia .lists of residents with dementia .pharmacological and nonpharmacological interventions are collected and analyzed .the facility shall attempt to establish root causes .of behaviors . Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident with a Brief Interview of Mental Status (BIMS) Score of 8/15 (moderately severe cognitive impairment), impaired thought processes, depressed mood, physical behaviors directed towards others and was dependent upon a wheelchair for ambulation and dependent for Activities of Daily Living (ADL). Review of facility investigations revealed Resident #2 was involved in 10 separate incidents of resident versus resident altercations between 5/20/15 and 2/14/16 including 4 separate resident altercations reported to the State Agency involving altercations with Resident #4. Review of the Care plan for Resident #2 revealed a generic Care Plan with no individualized behavioral interventions in place to address the resident's documented behaviors which included confusion, combative behaviors towards staff with verbal and physical abusive behaviors and physical altercations with other residents. Continued review of the Care plan revealed no updates related to individualized approaches for prevention of behaviors between 8/3/15 and 2/14/16, even though Resident #2 had been involved in 8 separate resident versus resident altercations during the time period including 2 altercations between 12/6/15 and 12/10/15 and another 3 altercations between 1/15/16 and 1/20/16. Medical record review of Activity Notes, Social Services Progress Notes, Rehabilitation Notes, Nursing Notes, physician progress notes [REDACTED]. disturbances in an effort to reduce the frequency or prevent altercations with other residents. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Comprehensive MDS dated [DATE] revealed Resident #4 was severely cognitively impaired, had depressed mood, physical and verbal behaviors directed towards others, was wheelchair dependent and was dependent for ADL's. Review of facility investigations revealed Resident #4 was involved in a total of 6 resident versus resident altercations including 4 separate altercations with Resident #2 between 5/20/15 and 12/13/15. Medical record review of the Care Plan for Resident #4 revealed a generic care plan with no individualized behavioral interventions to address the resident's documented behaviors which included confusion, wandering, combativeness with showering, and verbal or physical abusive behaviors towards staff and peers. Continued review of the Care Plan for Resident #4 revealed no updates related to individualized approaches for behavioral management in response to altercations with other residents between 5/20/15 and 12/13/15, including 3 altercations between 5/20/15 and 6/18/15, involving altercations with Resident #2. Medical record review of the Nursing Notes, Social Services Notes, Activity Notes, physician progress notes [REDACTED]. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 day MDS dated [DATE] revealed Resident #18 was cognitively impaired, had verbal and physical behaviors directed at others, and was dependent for ADLs. Review of the Certified Nursing Assistant (CNA) behaviors report from 8/17/15 until 9/3/15 revealed the resident continued to wander into other residents rooms waking the resident, cuss and kick at staff, disruptive during bingo, combative during small group program with activity staff, threatened to hit another resident, punches when changing clothes, and pushing wheelchair of other residents. Continued review of the Care Plan for Resident #18 revealed no documented updates related to individualized approaches for behavioral management in response to the continued behaviors exhibited from 8/17/15 to 9/3/15, including a resident to resident altercation on 9/1/15. Medical record review of the Nursing Notes, Social Services Notes, Activity Notes, Physician's Progress Notes, and Pharmacy Notes revealed no indication the Interdisciplinary Team had addressed the resident's behaviors or attempted to determine a root cause of the behavior in an effort to reduce the number of behaviors exhibited toward staff and other residents prior to the resident to resident altercation on 9/1/15. Review of the facility incident logs revealed Residents #2, #4, and #18, were involved in 13 of the facility's 18 incidents of resident versus resident altercations reported to the State Agency between the dates of 5/20/15 and 2/14/16. Interview with the Social Services Director (SSD) on 3/2/16 at 12:45 PM, in the SSD's office revealed the SSD reported she did not participate in investigations of resident versus resident altercations or allegations of abuse as those were managed by the Director of Nursing (DON) and Administrator. Continued interview revealed the SSD was aware of a pattern of increased resident versus resident altercations in the facility over several months many of which involved Resident #2 or Resident #4 and the SSD reported to her knowledge no interdisciplinary team ( IDT) had examined the resident's behaviors in an effort to determine a root cause of the altercations nor had an IDT discussed the behavioral management plans of either resident. Continued interview revealed the SSD had not provided additional resident specific in-service training to staff members related to Resident #2 ,#4 or #18's behaviors and had not been utilized to provide staff training in behavioral management as a component of the facility Dementia Care Program which was to have been implemented fully several months prior but whose implementation had been placed on hold. Interview revealed the SSD reported she had expressed opinions to both the DON and Administrator related to the behavioral management of both residents and stated .I felt those were ignored . Continued interview revealed the Nursing Department had not provided the SSD access to the electronic Behavioral Reports or requested information from the SSD related to behavioral assessments or Care Plans since 9/2015. The SSD stated she had not routinely discussed or followed up with the DON regarding Psychiatric Treatment recommendations for Residents #2, #4, and #18 since 9/3/2015. Interview with the Medical Director on 3/2/16 at 4:00 PM, in the dining room revealed the Medical Director was aware the facility had not implemented its Dementia Care Program and its related staff training protocols due to the loss of the program manager Continued interview revealed the Medical Director stated he was also aware Resident #2 and Resident #4 were involved in a number of altercations between them as well as other peers over several months and stated the frequency of resident versus resident altercations that had occurred in the facility was .higher than it should be . and agreed a lack of staff training and the failure to implement the Dementia Care Program .could contribute . to the elevated frequency of resident versus resident altercations in the facility. Interview with the Rehabilitation Director on 3/3/16 at 1:20 PM, in the Rehabilitation Department revealed the Rehabilitation Director stated the facility Dementia Care Program had not been fully implemented and was currently under management of the Activities Department. Continued interview revealed the Rehabilitation Director reported she had spoken with members of the Corporate Staff on 2/17/16 regarding her concerns the program which was to have begun in 4/2015 had not been implemented as outlined in the policy and stated .corporate gave us a program and no tools to implement it . and expressed concerns the program manager position had not been filled at the time of the interview. Interview with the Activities Director on 3/3/16 at 1:30 PM, in the Activities Department revealed the Activities Director had been informed by the DON of her role in the Dementia Care Program during a meeting with the Rehabilitation Director, DON, and members of the corporate staff .two weeks ago . Continued interview revealed the Activities Director stated .the only corporate guidance given was the manual . and reported she was informed the Dementia Care Program was to be implemented in coordination with the Rehabilitation Department and Restorative Nursing and the Restorative Nursing Department had yet to be informed of their role in the program. Further interview revealed the Activities Director reported the facility had completed Hand In Hand Training over a year prior and many new employees hired after the training was completed had yet to complete Hand in Hand training. The Activities Director reported the last in-service training related to Dementia and Behavioral Management she could recall had been performed in 6/2015 and was not a component of the Hand in Hand program which had been completed months earlier. Interview with the SSD and Admissions Coordinator on 3/3/16 at 2:30 PM, in the SSD office revealed both confirmed the facility had not yet implemented the Dementia Care Program or formed an Interdisciplinary Team comprised of members of the Social Services, Nursing, Rehabilitation, Activities, Restorative Nursing or Nursing Departments to address behaviors as outlined in the policy nor had any staff training in behavioral management occurred in the facility since 6/2015. Interview with the DON and Administrator on 3/8/16 at 3:45 PM, in the conference room confirmed the facility had failed to implement the Dementia Care Program as outlined in facility policy, and as a result the facility had failed to provide resident specific, individualized interventions to prevent behaviors to ensure the highest practicable state of well-being and prevent resident versus resident altercations for Residents #2, #4, and #18. Medical record review revealed Resident #5 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #5's Care Plan with a start date of 11/14/12 revealed the resident was a total assist of two with transfers. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was not scored (severely cognitive impaired) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required total assistance of two for transfer, dressing, hygiene and bathing. Review of a facility investigation dated 11/24/15 revealed on 11/23/15 Certified Nursing Assistants (CNA #6 and #7) failed to follow the Care Plan for transferring Resident #5 by using a sit to stand mechanical lift instead of a full body mechanical lift. Medical record review of the Nursing Kardex (CNA care plan) dated 1/20/16 revealed the support of 2 for bathing and the Hoyer lift. Interview with the Director of Nursing (DON) on 3/1/16 at 1:00 PM, in the Conference Room revealed on 11/23/15 the Kardex specified the use of the total body mechanical lift and 2 persons for bathing was ordered for Resident #5. Interview with CNA #6 on 3/1/16 at 2:00 PM, in the Conference Room revealed on 11/23/15 the CNA assisted with transferring Resident #5 to the shower chair. Continued interview revealed when CNA #6 went back to the room to assist with transfer from the shower chair to the bed and on arrival CNA #7 already had Resident #5 hooked to the sit to stand lift. Continued interview revealed CNA #6 reported she told CNA #7 that the resident was to be lifted in the Hoyer lift but the resident was already hooked to the sit to stand so the CNAs proceeded to use the sit to stand lift to place the resident back to bed. Interview with CNA #7 on 3/2/16 at 10:15 AM, in the Conference Room revealed CNA #6 and CNA #7 used the sit to stand lift to get Resident #5 out of bed for the shower and back to bed after the shower. Further interview revealed CNA #7 gave the resident a shower while CNA #6 was answering call lights. Continued interview revealed the CNA was aware of the Kardex system and confirmed the Kardex stated to use the Hoyer lift at the time of the incident and she made a mistake. Interview with the DON on 3/2/16 at 11:00 AM, in the Conference Room confirmed the two CNAs did not follow Resident #5's Care Plan on 11/23/15 when the 2 CNAs used the sit to stand lift to transfer and bathe Resident #5.",2019-03-01
4920,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2016-06-18,279,J,1,0,153F11,"**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 develop a comprehensive Care Plan to prevent unsafe wandering and elopement from the facility for one Resident (#3) with a [DIAGNOSES REDACTED]. The facility's failure to develop a comprehensive Care Plan resulted in Resident #3 wandering into an area with the potential for access to unsecured chemicals and dangerous equipment and eloping from the facility resulting in lacerations, abrasions, and bruises, and placed Resident #3 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator (NHA) was informed of the Immediate Jeopardy on 6/16/2016 at 6:00 PM in the Conference Room. The findings included: Review of facility policy, Elopement Guidelines, (no date) revealed, .Documentation .Care plan that addresses potential to wander or exit living center and the measures taken to prevent wandering/elopement . Review of facility policy, Elopement Book and Documentation, creation date 5/5/2016, last review date 5/10/2016, effective date 5/10/2016, revealed, .It is (Facility's name) to maintain up to date and accurate 'Elopement Books at each nurse's station and in the business office .Documentation .Care plan that addresses potential to wander or exit living center and the measures taken to prevent wandering/elopement . Medical record review revealed Resident #3 was admitted to the facility 7/12/2010 with [DIAGNOSES REDACTED]. Medical record review of Resident #3's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had short and long term memory problems and cognition was moderately impaired (decisions poor; cues/supervision required). Continued review revealed Resident #3 required extensive assistance for most Activities of Daily Living (ADLs) and a wheelchair was used with limited assistance for mobility. Medical record review of the electronic Nurse's Notes dated 4/23/2015 at 9:12 PM revealed, .Res (Resident #3) was outside in parking lot and found lying face down on the ground with overturned wheelchair . Continued review of the Nurse's Notes at 9:25 PM revealed the Resident had egressed (exited) the facility through the 300 South Hall Door. Medical record review of Resident #3's Risk for Elopement Assessments dated 4/25/2015, 5/7/2015, 7/17/2015, 10/23/2015, 1/14/2016, and 4/25/2016 revealed the Resident was at risk for elopement from the facility. Medical record review of Resident #3's Care Plan revealed the Resident wandered and was at risk for elopement. Continued review revealed interventions were initiated on 5/8/2015. Further review of the interventions initiated revealed, .Check Wander guard placement function Q (every) Shift .Psych (Psychiatric) services to evaluate as ordered/ (or) indicated .Resident pictures placed in elopement books on north nursing station, south nursing station and front office .Wander guard departure bracelet applied as directed to inform staff members of attempts to exit the building . Medical record review of the Nurse's Notes revealed: 5/30/2015 at 9:00 PM, .propelled about the unit today looking for a way out . 6/5/2015 at 4:41 PM, .continues to exit seek . 6/12/2015 at 9:58 PM, .kicked the door .set off the alarm .resident responded I am getting out of here. 6/21/2015 at 11:32 PM, .Pushed on fire doors at beginning of shift . 8/14/2015 at 6:41 PM, .Exit seeking behavior .went to .door and kicked it open . 3/5/2016 at 5:32 PM, .Propelling self throughout the unit in .wheelchair . 4/28/2016 at 9:08 AM, .up in wheelchair, propelling self in hallways .confusion . 4/29/2016 at 9:40 AM, .poor judgement and decision making skills . 5/7/2016 at 1:45 PM, .confusion .Propels self about facility via wheelchair . 5/9/2016 (Late Entry) at 2:13 PM, .confused. Up in wheelchair wheeling self around facility . 5/10/2016 at 9:42 PM, .found resident lying on side in wheelchair across the parking lot .Abrasion and bruising noted on Rt (right) knee. Skin tear and bruising to left elbow. Scratches and abrasions noted around left eye, cheekbone, and temple . Review of a facility investigation dated 5/10/2016 revealed Resident #3 had eloped from the facility by wandering into the unsupervised Service Hall and a visitor exiting the building held the door open for the Resident to exit. Continued review revealed staff found the Resident lying on her side in a wheelchair in the parking lot. Further review revealed Resident #3 told staff I want to go home. Continued review revealed a 4 Point P[NAME] (Plan of Correction) was begun on 5/10/2016, but no individualized interventions for redirection to prevent unsafe wandering or attempts to exit the facility were included. Medical record review of Resident #3's current Care Plan for elopement revealed individualized interventions had not been developed and it remained unchanged from 5/8/2015. Observation of the surveillance video for 5/10/2016 confirmed Resident #3 had wandered onto the Service Hall at 3:22 PM in a wheelchair; staff was not present and the Resident was unsupervised. Continued observation confirmed a male visitor entered the Service Hall, walked past Resident #3 to the Service Hall egress doors, exited through the doors, and held the door open for Resident #3 to exit. Further observation confirmed the visitor exited the building and out of surveillance range. Continued observation confirmed Resident #3 exited the building, rolled onto the downward sloping parking lot, and toward a parked truck. Further observation of the video was not visually clear as Resident #3 neared the edge of the pavement to determine if the Resident flipped over in the wheelchair after dropping off of the pavement or if the Resident impacted with the truck and flipped over in the wheelchair. Observation of Resident #3 on 6/1/2016 at 11:00 AM revealed the Resident was in a wheelchair, wandering on the 300 South Hall (the Resident's room is located on the 200 South Hall) and the Resident was 15 feet from the fire door (where the initial elopement occurred on 4/23/2015). Continued observation confirmed no attempts were made by staff to redirect her. Observation of the facility's Service Hall on 6/1/2016 at 1:15 PM revealed the double doors provided access from inside the facility to the Service Hall and had no signage to instruct no entry for unauthorized persons (visitors, families alert residents with intact cognition); and had no monitoring or equipment to alert staff of unauthorized entry into an unsecured and unsafe area. Continued observation of the Service Hall revealed the laundry area was on the left side of the hallway and the entry door into the laundry area was not locked. Further observation revealed the unsecured laundry area contained 1 regular residential-size washing machine, 2 stainless steel commercial washing machines positioned on elevated platforms (with an uneven flooring surface), and 3 commercial soiled laundry bins (to hold soiled items to be washed). Further observation revealed the far right bin was one-third full of residents' soiled clothing and bed linens (soiled from urine and fecal incontinence; and food spillage). Continued observation revealed the regular washing machine had a shelf over it with an unsecured 12-ounce disposable clear plastic cup setting atop the shelf and was half-full with a blue liquid. Further observation revealed 11 buckets containing unsecured liquid chemicals were setting on the floor and each bucket held 5-gallons. Continued observation revealed 4 buckets contained bleach, 4 buckets contained fabric softener, and the remaining 3 buckets contained laundry detergent. Further observation of the unsecured laundry area revealed an unsecured room adjacent the soiled laundry area contained 3 commercial dryers for drying washed items. Observation of the exterior Service Hall egress area and parking lot on 6/1/2016 at 1:30 PM, in the presence of the Administrator (NHA), confirmed the NHA measured the area from where Resident #3 exited through the Service Hall egress to the point of impact, which measured 60 feet. Interview with Dietary Employee #1 on 6/1/2016 at 1:59 PM in the Conference Room, confirmed she was aware of Resident #3's risk for elopement. Continued interview revealed Dietary Employee #1 stated, (Resident #3) was on the ground off the parking lot (on 5/10/2016) .(Resident #3) is determined .we were all aware she tried frequently to get out (of the facility) .she has gotten into the Service Hall several times before getting out (on 5/10/2016) .she went into the Service Hall again that night (5/10/2016) .I .got the nurse .told her (Resident #3) is at it again, trying to get out . Interview with Dietary Employee #2 on 6/1/2016 at 2:19 PM, in the Conference Room, confirmed she was exiting the building on 5/10/2016 and found Resident #3 outside. Continued interview revealed Dietary Employee #2 stated, .(Resident #3) was on the ground .wheelchair was on its side .(Resident #3) was on (Resident's) left side off the pavement on gravel .(Resident) was beside a truck .fastened in her wheelchair with a lap belt. It looked like (Resident) hit the truck .flipped over and stopped (Resident) from going over the embankment behind the truck . (Resident) lifted her head up .looked at me .(Resident) didn't say anything .just looked at me .(Resident) has been in the Service Hall in the last two-to-three months at least two or three times trying to get out the doors .and sometimes .would come back to the Service Hall on the same night multiple times (prior to 5/10/2016 elopement and again after the elopement . Interview with Laundry Employee #1 on 6/2/2016 at 9:30 AM, in the Conference Room revealed Laundry Employee #1 stated, .During the past year, I have seen (Resident #3) in the Service Hall 10, maybe 15 times .I would take (Resident) to the main hall, nurses station, or to (Resident's) room .nurse's saw me bring her from the Service Hall many times, but they never did anything about it . Continued interview revealed Laundry Employee #1 stated, .There's three, 5-gallon buckets of (laundry detergent), four, 5-gallon buckets of bleach, and four, 5-gallon buckets of (fabric softener) in the laundry (soiled linen area) .The plastic disposable cup contains (laundry detergent) in it .from the 5-gallon bucket .there are chemicals back there they could get into .drink it .get it on their skin .in their eyes .it could cause their skin or eyes to get burned, such as the bleach .the two larger (commercial) washers (washing machines) get hot .190 degrees (Fahrenheit) .the (three) dryers .150-to-170 degrees (Fahrenheit) .hot enough to burn them .they could get hurt .electrical wires, too .this is dangerous and could kill somebody if they did the wrong thing or didn't know what they were doing .the door to the soiled area (from the Service Hall) is never locked . Interview with the Director of Laundry and Housekeeping on 6/2/2016 at 10:03 AM in the Conference Room revealed the Director stated, I'm aware (Resident #3) has been in the Service Hall .I would not want residents in the laundry area .soiled linens .clothes with urine, BM (feces), body fluids .make them very sick. There's chemicals .could kill them if they drank it .could get their hands caught in the washer or dryer doors .cause injury .washers and dryers get hot and could [MEDICAL CONDITION]. Continued interview with the Director of Laundry and Housekeeping confirmed the door from the Service Hall into the soiled linen area is never locked and chemicals were accessible. Interview with Licensed Practical Nurse (LPN) #1 on 6/2/2016 at 2:27 PM, in the Conference Room confirmed LPN #1 worked the 2:00 PM-10:00 PM shift on 5/10/2016 and was assigned to the 200 South Hall when Resident #3 was on the Service Hall and eloped. Continued interview revealed LPN #1 stated, .I was aware (Resident) was an elopement risk .When (Resident) got out (eloped), (Resident) was on the Service Hall unsupervised .rolled down the parking lot .When (Resident) wheelchair went off the pavement it probably threw (Resident) forward. When I got to her (Resident) was on mostly the gravel with (Resident) upper body . (Resident) knees were on the edge of the pavement. (Resident) was beside a white truck . (Resident) may or may not have hit the truck . (Resident) had abrasions on (Resident) face and forehead and knees. (Resident's) arms and knees were bruised .I assessed (Resident) to determine (Resident) was able to get into (Resident's) wheelchair, then to (Resident's) room for further assessment .Later that night, (Resident) was back on the Service Hall without supervision . (Resident) was brought back to the nurse's station (by Dietary Employee #1) and they let me know (Resident) was back on the Service Hall. I did not know (Resident) had gone back .we need to keep a closer eye on (Resident) .check on (Resident) every 15-to-30 minutes (after Resident had eloped on 5/10/2016) .This wasn't effective (keeping a closer eye on Resident by checking on Resident every 15-30 minutes) because (Resident) got back on the Service Hall the same night .All throughout the past year (Resident) has tried multiple times to get out .I felt like it was just a matter of time before (Resident) got out again (after the (MONTH) (YEAR) elopement) . Interview with Certified Nursing Assistant (CNA) #1 on 6/14/2016 at 7:00 PM, in the Conference Room, revealed CNA #1 stated, .If they are trying to get out, I re-direct them to the TV (television) room to watch TV or keep a closer eye on them .when CNAs are assisting other residents .I don't know how to keep a closer eye on them honestly . Continued interview confirmed when asked about the Cardex (CNA Care Plan), CNA #1 stated, .It doesn't tell me what to do (for Resident #3's unsafe wandering or attempts to exit the facility) .they don't help us to keep her in here or her from trying to get out of here. Interview with CNA #2 on 6/14/2016 at 7:17 PM, in the Conference Room confirmed CNA #2 initially worked in the Dietary Department from (MONTH) (YEAR) until (MONTH) (YEAR) and transferred to the Nursing Department. Continued interview revealed CNA #2 stated, .I used to work in Dietary .I saw (Resident #3) back there (Service Hall) 10-to-15 times .(Resident's) Cardex doesn't tell us what to do to prevent wandering or to keep (Resident) from eloping .they are in a binder at the nurse's station .Cardex doesn't help with elopement or wandering . Interview with CNA #3 on 6/14/2016 at 7:45 PM in the Conference Room confirmed CNA #3 worked the 2:00 PM-10:00 PM shift on 5/10/2016 and was assigned to the 200 South Hall when Resident #3 was on the Service Hall and eloped. Continued interview revealed CNA #3 stated, .(Resident) wanders throughout the building and is free to wander. I've seen (Resident) wandering all over the building . Further interview with CNA #3 confirmed the Cardex for Resident #3 did not provide interventions to manage unsafe wandering or attempts to exit the facility and stated, They tell us (Resident) has a bracelet (wanderguard) .but it doesn't tell us how to stop (Resident) from going all over the building or .from trying to get out (elope) . Interview with CNA #4 on 6/14/2016 at 10:22 PM, in the Conference Room, confirmed CNA #4 worked the 2:00 PM-10:00 PM shift on 5/10/2016 and was assigned to the 200 South Hall when Resident #3 was on the Service Hall and eloped. Continued interview revealed CNA #4 stated, .On the day (Resident) eloped (5/10/2016), when I came in I went to get (Resident's) vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure) . (Resident) was saying (Resident) wanted to go home . (Resident) tried to get out .wanted to leave .I knew (Resident) was a wanderer . (Resident) was always trying to get out .I ran into (Resident's) daughter later and .daughter asked where (Resident) was .told her I just did (Resident's) vital signs .daughter said she didn't see (Resident) .I continued to assist my other residents .then I later heard them calling a code yellow (to alert staff a resident has eloped) .The Care Cards (Cardex) don't tell us what to do when (Resident) wanders or tries to get out . Interview with the Resident Nurse Assessment Coordinators (RNACs) #1 and #2 on 6/16/2016 at 7:30, PM in the Conference Room, confirmed RNACs #1 and #2 were responsible for the development of the Comprehensive Care Plans. Continued interview revealed RNAC #2 stated, That's (Resident #3's Elopement Care Plan) just a standard (not individualized) Care Plan . Further interview revealed RNAC #1 agreed with RNAC #2. Continued interview with RNACs #1 and #2 confirmed the facility failed to develop an individualized Comprehensive Care Plan for Resident #3 to provide interventions to prevent unsafe wandering and elopement. Interview with the NHA on 6/16/2016 at 9:30 PM, in the Conference Room, confirmed the NHA was aware Resident #3 was at risk for elopement and consistently wandered onto the Service Hall. Continued interview revealed the NHA reviewed Resident #3's Elopement Care Plan and Care Card (Cardex) and stated, . There are no interventions to re-direct (when wandering or attempting to exit the facility) .it doesn't identify what they (nursing staff) need to do for (Resident) . Continued interview with the NHA confirmed the facility failed to ensure an individualized Comprehensive Care Plan was developed for Resident #3 to prevent unsafe wandering and elopement. The Immediate Jeopardy was effective from 5/10/2016 through 6/17/2016. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated through review of documents, observations, and staff interviews conducted onsite on 6/18/2016. The surveyor verified the allegation of compliance by: 1. Reviewing the facility's in-service records to validate the two RNACs responsible for the development of individualized Comprehensive Care Plans were in-serviced on 6/17/2016. This in-service also included the Nurse Educator and NHA, to ensure oversight and continuity. 2. Conducting interviews on 6/18/2016 at between 1:00 AM-1:45 AM with the two RNACs, Nurse Educator, and NHA to determine the level of comprehension gained through the in-service education conducted on 6/17/2016 regarding the development of an individualized Comprehensive Care Plan to ensure staff have developed individualized interventions and: A. Comprehend the difference between a standardized Comprehensive Care Plan versus an individualized Care Plan. B. The rational for an individualized Comprehensive Care Plan. C. A verbal explanation of (1) goal-directed wandering and (2) aimless wandering. How the difference is determined in the two types of wandering and viable interventions to address the occurrence of both types of wandering behaviors. 3. Reviewing the Comprehensive Care Plans of all Residents (Residents #2, #3, #5, and #6) assessed as at-risk for wandering and elopement developed on 6/17/2016. The review was to ensure the development of a Comprehensive Care Plan with individualized interventions to prevent unsafe wandering and elopement. 4. Observation of staff on 6/17/2016 between 6:45 PM-7:05 PM implementing individualized interventions for Resident #3 and #6's unsafe wandering behavior. Observation of Residents #2 and #5, who are at risk for elopement in addition to #3, revealed no wandering behaviors to require re-directive interventions (#2 was lying on the bed and #5 was in their room visiting with family). Noncompliance continues at a scope and severity of D for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance (QA) Committee. The facility is required to submit a plan of correction. Refer to F-323 (J), Substandard Quality of Care.",2019-06-01
1820,WYNDRIDGE HEALTH AND REHAB CTR,445304,456 WAYNE AVENUE,CROSSVILLE,TN,38555,2019-08-14,600,D,1,1,U0M811,"**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 ensure 1 resident (#1) was free from abuse of 3 residents reviewed for abuse of 37 sampled residents. The findings include: Review of the facility policy, Definitions/Identification, undated, revealed .Abuse is the willful infliction of injury .with resulting physical harm, pain or mental anguish .It includes verbal abuse, sexual abuse, physical abuse .Willful .means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 0, indicating the resident had severe cognitive impairment. The resident required limited assistance for bed mobility, transfer, and dressing, and extensive assistance for toileting and ambulation. Medical record review of the resident's care plan dated 10/26/18, revealed the resident had a history of [REDACTED]. Medical record review of a Nurse's note dated 7/11/19 revealed, .Resident (increased) agitation, verbally toward others (staff and other residents) . Medical record review of a Nurse's note dated 8/7/19 revealed .Resident (#1) was in the dining room when a female resident (Resident #56) walked up to him. They were both conversing when he (Resident #1) suddenly leaned up in his w/c (wheelchair) and punched the female resident (Resident #56) in the mouth. They were both separated immediately . Medical record review of Resident #1's History and Physical dated 8/8/19 revealed .sent to the emergency room due to behavioral issues. Apparently he slapped a friend who was visiting .Patient has advanced dementia . Medical record review revealed Resident #56 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #56's Annual MDS dated [DATE] revealed a BIMS score of 5, indicating the resident had severe cognitive impairment. Resident #56 demonstrated delusions, verbal behavior symptoms, and wandering. Review of the facility investigation report dated 8/7/19 revealed .(Resident #1) hit other resident (#56) on face causing small red area on side of face . Continued review revealed an interview with Registered Nurse (RN) #1, .Res (Resident #1) was in w/c in DR (dining room), resident .(#56) was walking by him. (Resident #1) thought resident (#56) said a 'smart ass remark' and (Resident #1) struck (Resident #56) with a closed fist . Continued review revealed an interview with Resident #1, I hit her because she made a smart ass remark . Observation of Resident #1 on 8/14/19 at 7:22 AM, in the residents room, revealed Resident #1 sleeping in bed. The bed was in low position with the call bell within reach. Observation of Resident #56 on 8/14/19 at 7:28 AM, on the secure unit, revealed the resident sitting in the activity/dining room in a chair. Observation of Resident #1 on 8/14/19 at 12:15 PM, in the secure unit activity room/dining room, revealed the resident sitting in a high back chair at a table with a staff member. Observation of Resident #56 on 8/14/19 at 12:20 PM, on the secure unit, revealed the resident ambulating in the hallway. Interview with RN #1 on 8/14/19 at 7:25 AM, at the secure unit nursing station, confirmed she was working on the secure unit on 8/7/19. Continued interview confirmed Resident #56 walked up to talk to Resident #1 in the dining room, and he suddenly hit her in the face. Further interview confirmed the residents were immediately separated. Further interview confirmed Resident #1 had a history of [REDACTED].#56 at a safe distance from Resident #1. Interview with Certified Nursing Assistant (CNA) #1 on 8/14/19 at 2:35 PM, by phone, confirmed she witnessed Resident #1 hit Resident #56 in the dining room on 8/7/19. Continued interview confirmed Resident #1 was sitting in the dining room and Resident #56 walked up to Resident #1 and struck Resident #56 in the face. Continued interview confirmed Resident #1 had a history of [REDACTED]. Interview with the Director of Nursing (DON) on 8/14/19 at 3:00 PM, in the DON's office, confirmed Resident #1 hit Resident #56. The facility failed to prevent abuse for Resident #56.",2020-09-01
1400,"SUMMIT VIEW OF FARRAGUT, LLC",445258,12823 KINGSTON PIKE,KNOXVILLE,TN,37923,2017-09-05,242,G,1,0,9YDY11,"**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 honor resident choices for bathing and dressing for 1 resident (Resident #2) of 12 residents reviewed for dignity, on 1 of 3 units. Resident #2 sustained physical and psychosocial harm. The findings included: Review of the facility policy, Quality of Life-Dignity, revised (MONTH) 2009, revealed, .residents shall be groomed as they wish to be groomed . Review of the facility policy Shower/Bath, revised (MONTH) 2010, revealed .be sure the bath is at a comfortable temperature for the resident .should the resident become ill .during the procedure .turn off the shower .notify the supervisor if the resident refuses shower/bath .report other information in accordance with .policy and professional standards . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15/15 (cognitively intact), was independent in decision making, and the resident required moderate assistance of one person for activities of daily living (ADLs). Review of the facility investigation dated 8/5/17 revealed around 6:15 PM, the facility was notified of an allegation made by Resident #2 against Certified Nurse Aide (CNA) #17. Resident #2 alleged between 8:00 AM and 10:00 AM, CNA #17 refused to honor the resident's repeated requests to skip a shower; refused to honor Resident #2's repeated requests to have a bed bath instead of a shower; coerced the resident to consent to a shower; refused to honor Resident #2's requests to stop the shower procedure due to physical discomfort; and refused to dress the resident in the clothing of her preference after the shower was completed. Interview with Resident #2 on 8/23/17 at 2:35 PM, in the resident's room, revealed the resident was alert and oriented, was able to name the first name of the alleged perpetrator, and recalled the incident. Continued interview revealed Resident #2 stated, .(CNA #17) began telling me I had to take a shower before breakfast (approximately 8:00 AM) and I told her I didn't want a shower .she told me she would be back around 10:00 . Continued interview revealed CNA #17 returned to her room around 9:00 AM and asked her to shower again, which Resident #2 again refused. Resident #2 requested a bed bath instead of a shower and stated .I told her I didn't feel like a shower and she told me that wasn't acceptable and I wasn't getting clean with a bed bath . Continued interview revealed Resident #2 then explained to CNA #17 normally other staff provided a bed bath on days she declined a shower and Resident #2 informed CNA #17 she desired a bed bath and not a shower. Resident #2 stated CNA #17 again refused to provide a bed bath as requested and CNA #17 informed her (Resident #2) she would return at 10:00 AM to give her a shower. Continued interview revealed CNA #17 returned to her room on 8/5/17 at 10:00 AM, and demanded she shower for a third time. Resident #2 stated .she came back and would not take no for an answer . Resident #2 initially refused to shower a third time and CNA #17 persisted in her demands for Resident #2 to consent to be taken to the shower room. Resident #2 stated .she wouldn't take no for an answer, I just gave up, I felt I had no choice . Continued interview revealed CNA #17 selected a new robe from her closet without her consent, and demanded she wear the robe to the shower room, placing the robe on her, in spite of her requests to be dressed in a hospital gown. Continued interview revealed CNA #17 took her to the West Wing Shower Room and during the shower .she (CNA #17) scrubbed me so hard .I told her to stop scrubbing me so hard and she said it will take me five more minutes . When asked if CNA #17 stopped scrubbing her when asked, Resident #2 stated .no she didn't, she kept right on . Further interview revealed Resident #2 began to experience severe anxiety as a consequence of CNA #17's actions and .the pain made upset and anxious and more short of breath than usual, then she turned the shower head up and that steam made me worse .I told her I couldn't breathe . Continued interview revealed .I told her I couldn't breathe and she said 'why can't you breathe?' .then she said, 'if you couldn't breathe, you wouldn't be yelling' . Continued interview revealed .(CNA #17) . Interview with the Administrator and Director of Nursing (DON) on 8/24/17 at 4:15 PM, in the conference room, confirmed CNA #17 failed to honor the resident's choices and harmed the resident.",2020-09-01
1398,"SUMMIT VIEW OF FARRAGUT, LLC",445258,12823 KINGSTON PIKE,KNOXVILLE,TN,37923,2017-09-05,223,G,1,0,9YDY11,"**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 prevent abuse for 1 resident (Resident #2), of 12 residents reviewed for abuse and neglect, on 1 of 3 units. The facility's failure resulted in multiple bruises to the upper and lower extremities and severe anxiety (Harm) for Resident #2. The findings included: Review of the facility policy, Preventing Resident Abuse, revised (MONTH) 2013 revealed, .Facility will not condone any form of .abuse .inappropriate behaviors towards residents .using derogatory language, rough handling .ignoring residents while giving care . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15/15 (cognitively intact), was independent in decision making, and the resident required moderate assistance of one person for activities of daily living (ADLs). Review of a facility investigation dated 8/5/17 revealed around 6:15 PM, the facility was notified of an allegation of abuse made by Resident #2 against Certified Nurse Aide (CNA) #17. Continued review revealed Resident #2 alleged sometime between 8:00 AM and 10:00 AM, CNA #17 coerced the resident to consent to a shower, then roughly handled the resident while in the shower. Further review revealed Resident #2 alleged she informed CNA #17 the rough handling caused her pain, and the CNA ignored her demands to stop. Continued review revealed Resident #2 reported she experienced severe shortness of breath, anxiety, and physical discomfort, and she sustained a number of bruises to the upper and lower extremities as a consequence of the CNA's actions. Continued review of the facility investigation revealed the facility substantiated Resident #2's allegations and the resident sustained [REDACTED]. Interview with Registered Nurse (RN) #1 on 8/23/17 at 1:15 PM, in the conference room, revealed she was on duty the night the incident was reported to the facility by Resident #2. Further interview revealed RN #1 conducted a physical examination of Resident #2 and noted scattered fresh bruises, reddened areas of skin, which were light red to light purple in color, on the anterior (front) and posterior (rear) surfaces of both arms from below the shoulder to the wrists, and multiple areas of reddened and lightly bruised skin of varying sizes bilaterally on the resident's legs across her inner and outer thighs from the level of her pelvis to her knees. Further interview revealed the resident could distinguish between bruises present prior to the shower versus bruises which occurred after the shower, and the resident stated CNA #17 had roughly handled her in the shower earlier that day. Continued interview revealed Resident #2 informed her (RN #1) she had become severely short of breath and anxious during the incident and her distress was ignored by CNA #17, who also ignored Resident #2's demands to stop scrubbing her skin harshly. Further interview revealed the injuries present on the resident's skin were consistent with the resident's allegations. Observation and interview with Resident #2 on 8/23/17 at 2:35 PM, in the resident's room, revealed the resident was alert and oriented, was able to state the first name of the alleged perpetrator, and recalled the incident. Continued interview revealed, at 10:00 AM on 8/5/17, CNA #17 came to her room and demanded the resident take a shower, despite the resident having refused twice earlier that morning. Resident #2 stated .she wouldn't take no for an answer. I just gave up, I felt I had no choice . Resident #2 stated she felt intimidated by CNA #17's actions. Continued interview revealed CNA #17 took her to the West Wing Shower Room and during the shower .she (CNA #17) scrubbed me so hard, I was nearly screaming .I told her to stop scrubbing me so hard and she said it will take me five more minutes . When asked if CNA #17 stopped scrubbing her hard at the time, Resident #2 stated .no she didn't, she kept right on . Further interview revealed CNA #17 kept scrubbing her skin roughly and Resident #2 began to cry out, scream, was in pain at the time, and .Yes, I yelled for her to stop . Further interview revealed CNA #17 continued to clean her skin and Resident #2 began to experience severe anxiety. Resident #2 stated .the pain made me upset and anxious and more short of breath than usual, then she turned the shower head up and that steam made me worse .I told her I couldn't breathe and she said, 'Why can't you breathe?' .then she said, 'if you couldn't breathe, you wouldn't be yelling' . Further interview revealed the resident felt belittled by CNA #17's statements and .after that I got so upset and short of breath, I couldn't talk, and she just kept right on and finished .she took my robe and pulled it down over my head with the buttons still buttoned and that hurt my head and face too . Further interview revealed .I lost nearly everything I have when I came here .I felt she took the last thing I did have left, my dignity . Observation and interview revealed Resident #2 was able to point to specific areas of healing bruises on her arms and legs and identify which bruises had been inflicted by CNA #17 during the shower on 8/5/17. Observation revealed Resident #2 pointed to bruises which were faint and yellow to light purple in color, in the late stages of healing, and were scattered about on her bilateral upper thighs and bilaterally on her arms. Interview with the Administrator and Director of Nursing (DON) on 8/24/17 at 4:15 PM, in the conference room, confirmed the facility investigation substantiated Resident #2's allegations and CNA #17's actions were in violation of facility policies. Continued interview revealed, based on the physical evidence present (bruises on the residents skin), the facility had concluded CNA #17 had roughly handled and verbally abused Resident #2 as alleged. Further interview confirmed the facility failed to prevent resident abuse.",2020-09-01
4816,BEECH TREE MANOR,445292,"240 HOSPITAL LANE, PO BOX 300",JELLICO,TN,37762,2016-07-07,323,D,1,0,TDWC11,"**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 provide sufficient supervision to prevent 3 (#5, #6, #7) wandering residents from entering into the room of one (#5) resident with known desire to not have others in the room, of five residents reviewed for behaviors affecting others. The findings included: Review of facility policy titled Behavioral Assessment, Intervention, and Monitoring, revised 1/2016, revealed .The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to resident, and develop a plan of care accordingly . Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Re-entry Minimum Data Set ((MDS) dated [DATE], revealed Resident #5 had the ability to understand others, scored a 12 on the Brief Interview for Mental Status (BIMS) and verbal behavioral symptoms directed toward others occurred less than daily. Continued review revealed the resident required limited assistance for bed mobility, transfers, walk in room, dressing and toilet use; extensive assistance for personal hygiene; was totally dependent on staff for bathing; and the resident used the wheelchair as a mobility device. Medical record review of the Annual MDS dated [DATE], revealed Resident #5 had a BIMS score of 10, had one episode of physical and verbal behavior symptoms directed toward others putting others at significant risk for injury. Review of the Care Plan revised 11/5/15, revealed, I have a [DIAGNOSES REDACTED].I like my door to remain closed, I need a stop sign wander strip placed over my door to decrease other resident from wandering in my room .Provide me with frequent reminders to ask for assistance if a resident wanders in my room and I need them removed . provide resident with cues and redirection. Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] and 4/19/16, revealed the resident had short and long term memory problems, moderately impaired cognitive skills and behaviors of inattention and disorganized thinking indicating Delirium. Continued review revealed the resident walked in room independently, required supervision to walk in the corridor and locomotion on the unit, and used a wheelchair as a mobility device. Further review revealed wandering was not exhibited for the resident. Review of the Care Plan (undated) revealed the focus 'I have impaired cognitive function and I usually understand others related to my Alzheimer's Dementia. I wander at times'. Review of the Care Plan revealed (undated) interventions including encourage me to attend activities .I am easily redirected and enjoy being around other people. Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Significant Change MDS dated [DATE], revealed an ability to sometimes understand others; had a score of 1 on the BIMS; required limited assistance for bed mobility, walking in room and corridor, extensive assistance for transfers, dressing, toilet use, and personal hygiene; and was totally dependent on the staff for bathing. Continued review revealed the resident did wander 1-3 days; the wandering did not place the resident at significant risk of getting to a potentially dangerous place and the wandering did not significantly intrude on the privacy or activity of others. Medical record review of the Care Plan dated 11/17/14 and revised 4/13/16, revealed .I have impaired cognitive function related to my severe Dementia and I may unknowingly wander into another resident's personal space .check placement of my wander guard each shift .provide me with frequent cues and direction as needed. Review of a Resident to Resident Altercation Report dated 3/18/16, revealed Resident #6 wandered into Resident #5's room and Resident #5 and started twisting the arm of Resident #6. Continued review revealed the immediate intervention included the residents were separated and placed on every 15 minute checks. Continued review revealed no physical injury present on assessment for Resident #5 or Resident #6. Continued review of the facility investigation revealed the cause as Resident (#5) does not like other residents in his room. Medical record review of the Care Plan for Resident #5 revealed the intervention dated 3/18/16 included I need ongoing reinforcement to ring my light if anyone wanders into my personal space with an original intervention date of (MONTH) 28, (YEAR). Interview with the Director of Nursing (DON) in the conference room on 6 /23/16, at 12:15 PM, confirmed the investigation is not sufficient to determine if the stop sign was in place at the time of the incident. Review of a Resident to Resident Altercation Report dated 5/12/16, revealed Resident #5 had an altercation when a resident removed the 'stop sign' and wandered into his room. Review of the report revealed Resident #7 came out of Resident #5's room yelling 'Help, Help' and Resident #5 stated Resident #7 attempted to climb in bed with Resident #5. Review revealed Resident #7 had scratches/skin tears on left side of face, nose and lower lip. Review revealed the residents were separated and placed on 15 minute checks. Review revealed both residents remained in the facility and not require additional outside intervention. Review of the Care Plan for Resident #5 revealed Related to event on 5-12-16-Ensure that my wander strip is up in front of my door. Review of the Psychiatric Progress Note dated 5/16/16, revealed Resident #5 was seen for follow up per facility request for concerns including refusing care and increased agitation. The progress note indicated the resident displayed no symptoms of psychosis, anxiety, or depression and no worsening of the ongoing diagnoses. Review of the recommendations included the addition of Lamictal 25 milligrams (mg) daily for mood lability, impulse control, and agitation; and Ativan 0.5 mg to be administered twice daily. Review of the Resident to Resident Altercation Report dated 6/4/16, revealed staff heard Resident #6 scream, staff entered room of Resident #5 and saw Resident #5 holding the hands of Resident #6's behind her head and smiling, and Resident (#6) was crying out in distress. Review of the Resident to Resident report revealed the immediate intervention included both residents were separated and placed on 1:1 observation. Continued review of the report revealed Resident #5 had no injuries and Resident #6 had red marks on the front, sides, and back of neck. Continued review revealed the family and physician were notified and the physician recommended Resident #5 be sent out for a psychiatric and medication evaluation. Continued review revealed Resident #5 remained on 15 minute checks when in the room and on 1:1 supervision when out of the room until transferred to a Geropsychiatric unit on 6/6/16. Review revealed Resident #6 remained in the facility on 15 minute checks for 24 hours. Review of the Care Plan for Resident #5 revealed the interventions dated 6/4/16 for 1:1 supervision, 6/6/16 transferred out to Geropsych unit, and 6/15/16 was moved to a room off of the Secure unit to a less wandering population. Interview with the DON on 6/22/16, at 2:45 PM, in the conference room, confirmed the facility was aware Resident #5 did not want residents to enter the room; and confirmed the facility failed to supervise and prevent Resident #6 and Resident #7 from entering the room of Resident #5.",2019-07-01
4815,BEECH TREE MANOR,445292,"240 HOSPITAL LANE, PO BOX 300",JELLICO,TN,37762,2016-07-07,280,E,1,0,TDWC11,"**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 revise the care plan following an altercation for 3 (#5, #6, #7) of five residents reviewed for behaviors affecting others; and failed to revise the Care Plan following a fall one (#1) of 3 residents reviewed for falls. The findings included: Review of facility policy titled Behavioral Assessment, Intervention, and Monitoring, revised 1/2016, revealed .The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to resident, and develop a plan of care accordingly . Review of facility policy Falls and Fall Risk, Managing, revised 6/2016, revealed, 1.The staff, with the input of the attending physician, will identify appropriate interventions to reduce the risk of falls .4. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant . Resident #5 was admitted to the facility on (MONTH) 16, 2013, with [DIAGNOSES REDACTED]. Medical record review of the Re-entry Minimum Data Set ((MDS) dated [DATE], revealed Resident #5 had the ability to understand others, scored a 12 on the Brief Interview for Mental Status (BIMS) and verbal behavioral symptoms directed toward others occurred less than daily. Continued review revealed the resident required limited assistance for bed mobility, transfers, walk in room, dressing and toilet use; extensive assistance for personal hygiene; was totally dependent on staff for bathing; and the resident used the wheelchair as a mobility device. Review of the Care Plan revised 11/5/15, revealed, I have a [DIAGNOSES REDACTED].I like my door to remain closed, I need a stop sign wander strip placed over my door to decrease other resident from wandering in my room ( dated 7/17/15) .Provide me with frequent reminders to ask for assistance if a resident wanders in my room and I need them removed (dated 10/28/15) . provide resident with cues and redirection (dated 11/5/15). Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] and 4/19/16, revealed the resident had short and long term memory problems, moderately impaired cognitive skills and behaviors of inattention and disorganized thinking indicating [MEDICAL CONDITION]. Continued review revealed the resident walked in room independently, required supervision to walk in the corridor and locomotion on the unit, and used a wheelchair as a mobility device. Further review revealed wandering was not exhibited for the resident. Review of the Care Plan (undated) revealed the focus 'I have impaired cognitive function and I usually understand others related to my Alzheimer's Dementia. I wander at times'. Review of the Care Plan revealed (undated) interventions including encourage me to attend activities .I am easily redirected and enjoy being around other people. Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Significant Change MDS dated [DATE], revealed an ability to sometimes understand others; had a score of 1 on the BIMS; required limited assistance for bed mobility, walking in room and corridor, extensive assistance for transfers, dressing, toilet use, and personal hygiene; and was totally dependent on the staff for bathing. Continued review revealed the resident did wander 1-3 days; the wandering did not place the resident at significant risk of getting to a potentially dangerous place and the wandering did not significantly intrude on the privacy or activity of others. Medical record review of the Care Plan dated 11/17/14, revealed .I have impaired cognitive function related to my severe Dementia and I may unknowingly wander into another resident's personal space .check placement of my wander guard each shift (dated 11/17/14) .provide me with frequent cues and direction as needed (dated 11/16/15). Review of a Resident to Resident Altercation Report dated 3/18/16, revealed Resident #6 wandered into Resident #5's room and Resident #5 and started twisting the arm of Resident #6. Continued review revealed the immediate intervention included the residents were separated and placed on every 15 minute checks. Continued review revealed no physical injury present on assessment for Resident #5 or Resident #6. Continued review of the facility investigation revealed the cause as Resident (#5) does not like other residents in his room. Medical record rview of the Care Plan for Resident #5 revealed the intervention dated 3/18/16 included I need ongoing reinforcement to ring my light if anyone wanders into my personal space with an original intervention date of (MONTH) 28, (YEAR). Review of the Care Plan for Resident #6 revealed the resident was placed on 15 minute checks for 24 hours and no additional intervention beyond 24 hours was implemented to reduce the risk of an altercation. Interview with the Director of Nursing (DON) in the conference room on 6 /23/16, at 12:15 PM, confirmed the investigation is not sufficient to determine if the stop sign was in place at the time of the incident; and confirmed there is no new intervention on the Care Plan following the altercation for Resident #5 or Resident #6 to reduce the risk of an altercation. Medical record review of the Annual MDS dated [DATE], revealed Resident #5 had a BIMS score of 10, had one episode of physical and verbal behavior symptoms directed toward others putting others at significant risk for injury. Continued review revealed the resident required limited assistance for bed mobility, transfers, dressing and toilet use; extensive assistance personal hygiene; was totally dependent on staff for bathing; and the resident used the wheelchair as a mobility device. Review of a Resident to Resident Altercation Report dated 5/12/16, revealed Resident #5 had an altercation when a resident removed the 'stop sign' and wandered into his room. Review of the report revealed Resident #7 came out of Resident #5's room yelling 'Help, Help' and Resident #5 stated Resident #7 attempted to climb in bed with Resident #5. Review revealed Resident #7 had scratches/skin tears on left side of face, nose and lower lip. Review revealed the residents were separated and placed on 15 minute checks. Review revealed both residents remained in the facility and not require additional outside intervention. Review of the Care Plan for Resident #5 revealed Related to event on 5-12-16-Ensure that my wander strip is up in front of my door. Review of the Care Plan for Resident #7 revealed 15 minute checks as ordered for 24 hours, and treatment to scratch areas to face. Review of the Care Plan revealed no intervention beyond 24 hours for the reduction in risk of an altercation. Review of the Psychiatric Progress Note dated 5/16/16, revealed Resident #5 was seen for follow up per facility request for concerns including refusing care and increased agitation. The progress note indicated the resident displayed no symptoms of [MEDICAL CONDITION], anxiety, or depression and no worsening of the ongoing diagnoses. Review of the recommendations included the addition of [MEDICATION NAME] 25 milligrams (mg) daily for mood lability, impulse control, and agitation; and [MEDICATION NAME] 0.5 mg to be administered twice daily. Interview with the DON in the conference room on 6/23/16, at 3:35 PM, confirmed the Care Plan for Resident #7 did not include a new intervention following the incident to reduce the risk of an altercation. Review of the Resident to Resident Altercation Report dated 6/4/16, revealed staff heard Resident #6 scream, staff entered room of Resident #5 and saw Resident #5 holding the hands of Resident #6's behind her head and smiling, and Resident (#6) was crying out in distress. Review of the Resident to Resident report revealed the immediate intervention included both residents were separated and placed on 1:1 observation. Continued review of the report revealed Resident #5 had no injuries and Resident #6 had red marks on the front, sides, and back of neck. Review revealed the family and physician were notified and the physician recommended Resident #5 be sent out for a psychiatric and medication evaluation. Continued review revealed Resident #5 remained on 15 minute checks when in the room and on 1:1 supervision when out of the room until transferred to a Geropsychiatric unit on 6/6/16. Review revealed Resident #6 remained in the facility on 15 minute checks for 24 hours. Review of the Care Plan for Resident #5 revealed the interventions dated 6/4/16 for 1:1 supervision, 6/6/16 transferred out to Geropsych unit, and 6/15/16 was moved to a room off of the Secure unit to a less wandering population. Review of the care plan for Resident #6 revealed 15 minute checks for 24 hours and 'resident separated and calmed.' Review of the care plan revealed no additional intervention following the altercation was put in place to reduce the risk of an altercation. Interview with the DON on 6/22/16, at 2:45 PM, in the conference room, confirmed the facility failed to implement a new or different intervention for Resident #5 following the altercations on (MONTH) 18; and failed to implement a new or different intervention for Resident #6 following altercations on 3/18/16; and failed to implement a new or different care plan intervention for Resident #7 following the altercation on 3/12/16. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Re-entry Minimum Data Set ((MDS) dated [DATE], revealed the resident had the ability to usually make others understand and usually understands others; a BIMS score of 6 indicating poor recall ability and temporal orientation; and sign of [MEDICAL CONDITION] (disorganized thinking) was continuously present. Continued review revealed the resident required supervision to eat, limited assistance to walk in the room and locomotion on the unit, extensive assistance to walk in the corridor, dressing, toileting, and personal hygiene, and was totally dependent on staff for bathing. Continued interview revealed the resident was incontinent of bladder and bowel and was on a toileting program. Review of the Care Plan (undated) revealed .I am at risk for falls related to my weakness and use of [MEDICAL CONDITION] medications .Remind and encourage resident to ask for assistance before getting up unassisted (dated 5/22/15); Keep my bed in low position and call light within reach (undated); Provide me with frequent reminders to use assistive devices or use call light when needing assistance (undated); and remind and encourage me to ask for assistance before getting up (undated). Review of the facility's Accident/Incident Investigation Report dated (MONTH) 13, (YEAR), revealed the resident was observed on the floor on the left side with complaint of left shoulder and head pain; the call bell was in reach; the resident had an assist device of a wheelchair; and was not using it when the fall occurred. Review of the staff statement in the investigation report revealed the resident had no signs or symptoms of head injury or fracture and was sent to the emergency room (ER) for evaluation, and was returned to the facility without injury. Review of the care plan for falls revealed the intervention dated 8/13/15, 'Bed and chair alarm and check function and placement every shift'. Review of the facility investigation dated 8/25/15, revealed the resident was found sitting on the bathroom floor crying and holding head .and stated I was going to pack my clothes to go teach, I fell and hit my head. Continued review revealed the resident had been walking in the room and had lost balance prior the fall. Continued review revealed the resident was sent to the emergency room for evaluation and returned to the facility without injury. Review of the facility investigation revealed the alarm was sounding at the time of the fall and the intervention of a Therapy evaluation was implemented after the fall. Review of the Fall Risk Assessment completed 8/25/15, revealed a score of 12 indicating a high risk for falls. Review of the Quarterly MDS dated [DATE], revealed the resident's BIMS score of 6, had continuously present disorganized thinking, and the level of assistance required for activities of daily living remained unchanged as the resident required supervision to eat, limited assistance to walk in the room and locomotion on the unit, extensive assistance to walk in the corridor, dressing, toileting, personal hygiene, and was totally dependent on staff for bathing. Review of the facility investigation dated 9/22/15, revealed the resident was observed sitting in the resident's room on the floor, no injuries, no (complaints) of pain or distress . Continued review revealed the resident stated, I just sit down. Continued review revealed the alarm was in use, but was not functioning . the resident had turned it off. Continued review revealed the resident had been sitting in the chair prior to the fall. Continued review of the facility investigation revealed the intervention to reduce resident time alone. Review of the Fall Risk Assessment completed 9/22/15, revealed a score of 12 indicating a high risk for falls. Review of the Care Plan for falls revealed, Event 9/22/16 see IDT (Interdisciplinary Team) note. Review of the Progress Note dated 9/23/15, revealed,(Resident) has a bed and chair alarm, staff provide her with frequent reminders to use the call lite and ask for assistance. (Resident) will use .wheelchair and will walk occasionally as desires . IDT (Interdisciplinary) team feels that best intervention at this time is to continue with current interventions and for (resident) to continue to ambulate as .desires and to help maintain .sense of independence . Review of a facility investigation dated 9/28/15, (6 days after previous fall) revealed the resident was observed sitting in the resident's room on the floor next to the wall. The resident stated, I slid down the wall and sit in the floor. Continued review revealed the alarm was in use, the resident had turned alarm off and took it out of . wheelchair. Continued review revealed the resident had been walking in the room prior the fall and had loss of balance. Continued review revealed the resident had no assessed injuries and had no complaints of pain. Continued review revealed the interventions in place at the time of the fall were chair alarm and bed alarm. Continued review of the facility investigation revealed the intervention to Reduce resident time alone: develop a team plan, watch resident more closely if possible. Review of the Care Plan for falls revealed the alarms were not discontinued and the entry See IDT note dated 9-30-15 related to event on 9/28/15. Review of the Progress Note dated 9/30/15 revealed, IDT note related to event on 9/28/15, (resident #1) has impaired memory and thought process.has interventions in place to help prevent falls .uses a wheelchair and will use a cane when walking at times .prefers to be as independent as much as possible. Placing a restraint to .wheelchair could possibly cause a decline in .adl (activities of daily living) function and could increase behaviors. IDT team feel to continue with all current interventions and provide frequent reminder and cues for assistance and encourage activity participation. Review of the Care Plan for falls revealed Activities to help decrease my time alone and dated 9/28/15. Review of the Fall Risk Assessment completed 9/28/15, revealed a score of '21' indicating a high risk for falls. Review of the facility investigation dated 10/2/15, (5 days after previous fall) revealed the resident was observed lying on floor in the resident room and complained of Hip pain. Continued review revealed the resident had been walking in the room prior the fall. Continued review revealed the X-Rays of both hips were negative for fracture. Review of the Care Plan for falls revealed the intervention of Related to event dated 10/2/15, continue to provide frequent reminders to ask for assistance and provide me frequent visual checks was implemented. Review of the Fall Risk Assessment completed 10/2/15, revealed a score of 24 indicating a high risk for falls. Interview and review of the fall Care Plan with the DON on 6/22/16, at 12:45 PM, confirmrd the resident had 5 unwitnessed falls in less than 2 months and had no major injury from the falls. Continued interview confirmed the resident had a low BIMS score indicating poor recall therefore the repeated intervention to remind the resident to use the call light or call for assistance was not appropriate. Continued interview with the DON verified the intervention of the chair alarm was not discontinued when the resident turned it off therefore making it an ineffective intervention. Interview with the DON confirmed the facililty failed to revise the care plan with new, different, effective or appropriate interventions to reduce the risk of a fall.",2019-07-01
4922,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2016-06-18,490,J,1,0,153F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility investigation, observation, review of Material Safety Data Sheets (MSDS), and interview, the facility failed to be administered in a manner to ensure the development of an individualized Comprehensive Care Plan for unsafe wandering and attempts to elope from the facility; to provide adequate supervision to prevent unsafe wandering and elopement from the facility for one Resident (#3) with a [DIAGNOSES REDACTED].#1); to revise the Certified Nursing Assistant Care Cards for one Resident (#2) at-risk for falls; and to ensure neurological assessments were completed with unwitnessed falls for two Residents (#1, #2) of six residents reviewed. The facility's administrative failure to develop an individualized Comprehensive Care Plan and failure to provide supervision resulted in Resident #3 wandering into an area with the potential for access to unsecured chemicals and dangerous equipment and eloping from the facility, resulting in lacerations, abrasions, and bruises, and placed Resident #3 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator (NHA) was informed of the Immediate Jeopardy on 6/16/2016 at 6:00 PM in the Conference Room. The findings included: Interview with the NHA on 6/16/2016 at 9:30 PM, in the Conference Room, confirmed the NHA was aware Resident #3 was at risk for elopement and had consistently wandered onto the unsupervised Service Hall since the NHA had worked at the facility (3 years effective (MONTH) (YEAR)). Continued interview confirmed the laundry area was unsecured and contained multiple and various hazardous chemicals; and was accessible from the Service Hall. Further interview confirmed the NHA installed fencing with gates (2015) around areas of egress as an elopement deterrent, but failed to ensure a positive non-locking latch to securely close the gates. Continued interview confirmed at one point in the past, the gates had a non-locking stop-plate to help secure the gates' position with the gate posts (to stabilize the gate and prevent it from swinging inward and outward); however, he had them removed due to employee injuries from bumping their arms on the plate during entry and egress through the gates. Further interview confirmed previous safety rounds were not effective in identifying unsafe, unsupervised, or hazardous or the potential for hazardous areas, specifically, the Service Hall and laundry area. Continued interview with the NHA confirmed the facility failed to be administered in a manner to prevent Resident #3 from unsafe and unsupervised wandering on the Service Hall and elopement. The Immediate Jeopardy was effective from 5/10/2016 through 6/17/2016. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated through review of documents, observations, and staff interviews conducted onsite on 6/18/2016. The surveyor verified the allegation of compliance by: 1. Observing a door monitor posted at the interior Service Hall Doors on 6/1/2016 at 6:20 PM. 2. Observing the normal and proper functioning of the alarm system (completed on 6/2/2016 at 7:00 PM) on the interior Service Hall doors and removal of the door monitor at 7:30 PM. 3. Observing all egress doors on 6/17/2016 for Red Stop signage (implemented 4/23/2015); Notice to Visitors (not to let residents out of the facility without staff notification) implemented on 5/11/2016; and proper functioning of anti-elopement systems on the following doors: A. 100, 200, 300 North Hall Fire Doors B. 100, 200, 300 South Halls Fire Doors C. 200 South Alcove Fire Doors D. 200 North Alcove Egress Doors D. Dining Room Egress Doors E. Main Entry Egress Doors F. Service Hall Egress Doors G. Interior Service Hall Doors (leading into the Service Hall from inside the facility). All Egress Doors (excluding the interior Service Hall Doors) had (1) Red laminated Stop signage (implemented 4/23/2015); (2) signage to not let any resident out of the facility without nursing notification and consent to do so implemented on 5/10/2016; (3) a 15 second delayed mag lock with key code pad implemented prior to the elopements; and (4) a wanderguard alarm system (if a resident with a wanderguard bracelet attempts to exit the door locks, alarms sound, and the door will not open until the resident with the wanderguard is removed from the door area). The wanderguard alarm system in place did not have the upgraded version (tail gate feature) on the Service Hall Egress Doors and the 200 North Alcove Egress Doors. The Service Hall and 200 North Alcove Egress Doors were upgraded to include the tail gate feature. Installation of the upgraded wanderguard system was initiated on 5/13/2016 and completed on 5/14/2016. The interior Service Hall Doors had a key code pad and required a specific code to be entered by authorized facility personnel only for entry into the Service Hall from the inside of the facility. If the interior Service Hall Doors are opened without first entering the code, a bright strobe light will flash and an audible alarm will sound and can be heard facility-wide. Installation completed on 6/2/2016. All visual and audible door alarms placed on all Fire, Egress, and interior Service Hall Doors will continuously emit visually and/or audibly until staff respond to the specific alarm and manually deactivate. 2. Observing the exterior Fire and Egress areas with fencing and gates on 6/17/2016 to ensure the gates closed securely to a positive non-locking latch (installation competed on 6/7/2016) on the following: A. Fire Doors-200 and 300 North Fire Doors, totaling 3 gates B. Fire Doors-300 South, totaling 1 gate C. Egress Doors- Service Hall and Main Entry, totaling 3 gates 3. Observing the staff's response to the interior Service Hall alarms which were triggered by the surveyor on 6/17/2016 at 7:15 PM. 4. Interviewing 12 Responsible Parties of non-elopement risk residents and 3 Vendors on 6/16/2016 between 6:55 PM-9:00 PM, and 6/17/2016 between 9:20 AM-1:20 PM, to confirm receipt of written notice sent on 5/10/2016 and determine their level of comprehension regarding not letting resident(s) out of the facility without nursing notification, consent to do so, and signing the resident out. 5. Interviewing 5 visitors 6/16/2016 between 6:55 PM-9:00 PM, and 6/17/2016 between 9:20 AM-1:20 PM, to determine their level of comprehension regarding not letting resident(s) out of the facility without nursing notification, consent to do so, and signing the resident out. 6. Reviewing the facility's in-service records to validate facility staff were in-serviced on 6/17/2016 regarding the new alarm system on the interior Service Hall Entry Doors and the following facility policies: Elopement Elopement Book and Documentation Door Alarms and Access Codes 7. Reviewing in-service records to validate the NHA was in-serviced on 6/16/2016 by the Corporate Field Services Clinical Director regarding the completion of daily safety (environmental hazard) rounds, determining safe versus non-safe areas 8. Conducting interviews beginning on 6/17/2016 at 7:25 PM and ending on 6/18/2016 at 12:30 AM, with nursing staff to include the NHA, 6 Registered Nurses (including the Assistant Director of Nursing and Nurse Educator), 14 Licensed Practical Nurses, 10 Certified Nursing Assistants, 3 Nurse Aides, 4 Dietary Staff, 1 Business Office Staff, 1 Maintenance Staff, 4 Housekeeping and Laundry Staff for a total of 37 facility staff to determine the level of comprehension gained through in-service education conducted regarding the facility's policies; and changes to and implementation of the facility's policies, Elopement, Elopement Book and Documentation; and Door Alarms and Access Codes to ensure staff recognize and respond to the following: A. What constitutes a resident being At-Risk for elopement, how are At-Risk residents identified by facility staff. B. The rationale for preventative daily and monthly environmental hazard rounds (implemented 6/16/2016); what constitutes unsafe (hazardous) and unsupervised areas, what type of observations during rounds would require immediate intervention and follow-up, who is responsible for conducting the rounds, who oversees the rounds and ensures follow-up, location of facility's unsafe and unsupervised areas. Including, but not limited to any accessible unsupervised area with (1) means of egress, (2) unsecured chemicals, (3) equipment, or (4) objects with the potential to cause serious injury, harm, impairment, or death. C. A verbal explanation of what the Elopement Books are and their location, what constitutes a resident being placed in the Elopement Book, when and by whom are the Elopement Books updated, when and by whom the Elopement Books are used. D. The facility's policy and procedural requirement for the security of access codes for entry into the Service Hall from inside the facility; and all other access codes for entry and egress into and from the facility. Interviews included a verbal explanation to ensure (1) codes must not be posted or shared with unauthorized persons; (2) who are unauthorized persons; (3) facility areas which prohibit unauthorized persons (residents, families, visitors) from entering unsafe and unsupervised areas due to a potential risk of serious injury, harm, impairment, or death to a resident; and (4) why the response to all door alarms must be immediate. Noncompliance continues at a scope and severity of 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-279 (J) and F-323 (J), Substandard Quality of Care.",2019-06-01
4923,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2016-06-18,520,J,1,0,153F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility investigation, observation, review of Material Safety Data Sheets (MSDS), and interview, the facility's Quality Assurance (QA) Committee failed to ensure the development of an individualized Comprehensive Care Plan for unsafe wandering and attempts to elope from the facility and failed to provide adequate supervision to prevent unsafe wandering and elopement from the facility for one Resident (#3) with a [DIAGNOSES REDACTED].#1); failed to revise the Certified Nursing Assistant Care Cards for one Resident (#2) at-risk for falls; and failed to ensure neurological assessments were completed with unwitnessed falls for two Residents (#1, #2) of six residents reviewed. The facility's failure to develop an individualized Comprehensive Care Plan, and failure to provide supervision, resulted in Resident #3 wandering into an area with the potential for access to unsecured chemicals and dangerous equipment and eloping from the facility, resulting in lacerations, abrasions, and bruises, and placed Resident #3 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator (NHA) was informed of the Immediate Jeopardy on 6/16/2016 at 6:00 PM in the Conference Room. The findings included: Interview with the NHA on 6/16/2016 at 9:30 PM, in the Conference Room, confirmed the NHA was aware Resident #3 was at risk for elopement, consistently wandered onto the Service Hall, and had wandered onto the Service Hall for almost three years (2.9 years). Continued interview confirmed the soiled laundry area was unsecure and contained multiple and various unsecured hazardous chemicals and equipment which had the potential to create serious harm or death with exposure and/or ingestion. Continued interview with the NHA confirmed previous safety rounds were done monthly, but the QA Committee failed to identify the Service Hall being an unsafe and unsupervised area. Telephone interview with the Medical Director on 6/17/2016 at 2:09 PM, confirmed the Medical Director was unaware Resident #3 was consistently wandering onto the Service Hall; and was unaware the laundry area was unsecured and contained unsecured hazardous chemicals and equipment. Continued interview with the Medical Director confirmed he was a member of the QA Committee. Further interview confirmed prior to the complaint survey initiated on 6/1/2016, the Medical Director was unaware of any surveillance rounds (Safety Rounds) being completed to identify risks and/or hazards, or potential risks and/or hazards brought to the QA Committee for evaluation, analysis, and implementation of corrective actions. The Immediate Jeopardy was effective from 5/10/2016 through 6/17/2016. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated through review of documents, observations, and staff interviews conducted onsite on 6/18/2016. The surveyor verified the allegation of compliance by: 1. Observing a door monitor posted at the interior Service Hall Doors on 6/1/2016 at 6:20 PM, to prevent residents from unsupervised wandering onto the Service Hall. 2. Observing a Commercial Door Company in the process of installing an alarm system on the interior Service Hall Doors to alert the facility of unauthorized entry from inside the facility into the Service Hall on 6/2/2016 at 5:00 PM (installation completed at 7:00 PM). Observing the normal and proper functioning of the alarm system on the interior Service Hall doors and the removal of the door monitor at 7:30 PM. 3. Observing all egress doors on 6/17/2016 for signage (Red Stop signage implemented on 4/23/2015); Notice to Visitors (not to let residents out of the facility without staff notification) implemented on 5/11/2016; and proper functioning of anti-elopement systems on the following doors: A. 100, 200, 300 North Hall Fire Doors B. 100, 200, 300 South Halls Fire Doors C. 200 South Alcove Fire Doors D. 200 North Alcove Egress Doors D. Dining Room Egress Doors E. Main Entry Egress Doors F. Service Hall Egress Doors G. Interior Service Hall Doors (leading into the Service Hall from inside the facility). All Egress Doors (excluding the interior Service Hall Doors) had (1) Red laminated Stop signage (implemented 4/23/2015); (2) signage to not let any resident out of the facility without nursing notification and consent to do so implemented on 5/10/2016; (3) a 15 second delayed mag lock with key code pad implemented prior to the elopements; and (4) a wanderguard alarm system (if a resident with a wanderguard bracelet attempts to exit the door locks, alarms sound, and the door will not open until the resident with the wanderguard is removed from the door area). The wanderguard alarm system in place did not have the upgraded version (tail gate feature) on the Service Hall Egress Doors and the 200 North Alcove Egress Doors. The Service Hall and 200 North Alcove Egress Doors were upgraded to include the tail gate feature. Installation of the upgraded wanderguard system was initiated on 5/13/2016 and completed on 5/14/2016. The interior Service Hall Doors had a key code pad which required a specific code to be entered by authorized facility personnel only for entry into the Service Hall from the inside of the facility. If the interior Service Hall Doors are opened without first entering the code, a bright strobe light will flash and an audible alarm will sound and can be heard facility-wide. Installation completed on 6/2/2016. All visual and audible door alarms placed on all Fire, Egress, and interior Service Hall Doors will continuously emit visually and/or audibly until staff respond to the specific alarm and manually deactivate. 2. Observing the exterior Fire and Egress areas with fencing and gates on 6/17/2016 to ensure the gates closed securely to a positive non-locking latch on the following: A. Fire Doors-200 and 300 North Fire Doors, totaling 3 gates B. Fire Doors-300 South, totaling 1 gate C. Egress Doors- Service Hall and Main Entry, totaling 3 gates 3. Observing the staff's response to the interior Service Hall alarms which were triggered by the surveyor on 6/17/2016 at 7:15 PM. 4. Interviewing 12 Responsible Parties of non-elopement risk residents and 3 Vendors on 6/16/2016 between 6:55 PM-9:00 PM, and 6/17/2016 between 9:20 AM-1:20 PM, to confirm receipt of written notice sent on 5/10/2016 and determine their level of comprehension regarding not letting resident(s) out of the facility without nursing notification, consent to do so, and signing the resident out. 5. Interviewing 5 visitors 6/16/2016 between 6:55 PM-9:00 PM, and 6/17/2016 between 9:20 AM-1:20 PM, to determine their level of comprehension regarding not letting resident(s) out of the facility without nursing notification, consent to do so, and signing the resident out. 6. Reviewing the facility's in-service records to validate facility staff were in-serviced on 6/17/2016 regarding the new alarm system on the interior Service Hall Entry Doors and the following facility policies: Elopement Elopement Book and Documentation Door Alarms and Access Codes 7. Reviewing in-service records to validate the NHA was in-serviced on 6/16/2016 by the Corporate Field Services Clinical Director regarding the completion of daily safety (environmental hazard) rounds, determining safe versus non-safe areas 8. Conducting interviews beginning on 6/17/2016 at 7:25 PM and ending on 6/18/2016 at 12:30 AM, with nursing staff to include the NHA, 6 Registered Nurses (including the Assistant Director of Nursing and Nurse Educator), 14 Licensed Practical Nurses, 10 Certified Nursing Assistants, 3 Nurse Aides, 4 Dietary Staff, 1 Business Office Staff, 1 Maintenance Staff, 4 Housekeeping and Laundry Staff for a total of 37 facility staff to determine the level of comprehension gained through in-service education conducted regarding the facility's policies; and changes to and implementation of the facility's policies, Elopement, Elopement Book and Documentation; and Door Alarms and Access Codes to ensure staff recognize and respond to the following: A. What constitutes a resident being At-Risk for elopement, how are At-Risk residents identified by facility staff. B. The rationale for preventative daily and monthly environmental hazard rounds (implemented 6/16/2016); what constitutes unsafe (hazardous) and unsupervised areas, what type of observations during rounds would require immediate intervention and follow-up, who is responsible for conducting the rounds, who oversees the rounds and ensures follow-up, location of facility's unsafe and unsupervised areas. Including, but not limited to any accessible unsupervised area with (1) means of egress, (2) unsecured chemicals, (3) equipment, or (4) objects with the potential to cause serious injury, harm, impairment, or death. C. A verbal explanation of what the Elopement Books are and their location, what constitutes a resident being placed in the Elopement Book, when and by whom are the Elopement Books updated, when and by whom the Elopement Books are used. D. The facility's policy and procedural requirement for the security of access codes for entry into the Service Hall from inside the facility; and all other access codes for entry and egress into and from the facility. Interviews included a verbal explanation to ensure (1) codes must not be posted or shared with unauthorized persons; (2) who are unauthorized persons; (3) facility areas which prohibit unauthorized persons (residents, families, visitors) from entering unsafe and unsupervised areas due to a potential risk of serious injury, harm, impairment, or death to a resident; and (4) why the response to all door alarms must be immediate. Noncompliance continues at a scope and severity of 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-279 (J); and F-323 (J), Substandard Quality of Care; and F-490 (J).",2019-06-01
951,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,223,D,1,0,SMVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility investigation, observation, review of a Tek-Care Report and interview, the facility failed to prevent Verbal Abuse for 1 resident (#5) and Neglect for 1 resident (#6) of 7 residents reviewed for abuse. The findings included: Review of facility policy, Abuse Prevention, revised 4/1/17 revealed, .Abuse .will not be tolerated by anyone, including staff .Neglect occurs when facility staff fails to monitor and/or supervise the delivery of patient care and services to assure the care is provided as needed for the resident .Verbal Abuse: The use of oral .language that willfully includes disparaging and derogatory terms to the residents .or within hearing distance . Medical record review revealed Resident #5 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact, bed bound, and required extensive assistance from 2 or more people for bed mobility; extensive assistance from 1 person for dressing, eating, and hygiene; was totally dependent with 2 or more people needed for bathing and toileting. Continued review revealed the resident was always incontinent of bladder and frequently incontinent of bowel. Review of a facility investigation dated 6/27/17 at 2:45 PM revealed Certified Nurse Aide (CNA) #6 was providing incontinence care to Resident #5 when 2 Licensed Practical Nurses (LPNs) and another CNA entered the resident's room and CNA #6 told them she was not catering to her ass, the resident got on her nerves, and she had been on the call light all day. Continued review of a handwritten statement from LPN #5 dated 6/27/17 revealed, .walked into (Resident #5's) room and (CNA #6) was changing her. I overheard her say to (Resident #5) .she doesn't have time for this[***]and I'm not catering to her ass. She gets on my nerves, she's been on the call light all day .(CNA #6) said 'f*** this[***] packed up the dirty linen and left .(Resident #5) was in tears . Continued review revealed handwritten statements from LPN #6 and CNA #8 dated 6/27/17 corroborated the same details. Further review of a statement from Resident #5 taken by the Director of Nursing (DON) on 6/28/17 revealed the resident stated, .(CNA #6) kept yelling at her and saying she cannot keep coming in there and change her .when other staff named (LPN #6, LPN #5, and CNA #8) were in the room that (CNA #6) stated she didn't have time to cater to her ass . Observation and interview of Resident #5 on 9/19/17 at 8:55 AM in the resident's room revealed the resident was awake, alert, oriented, on the ventilator and unable to speak out loud. Continued observation revealed the resident was able to nod yes or no and mouthed words when spoken to. Interview with the resident revealed she was able to confirm the facts were the same as written by LPN #5. Interview with LPN #5 on 9/18/17 at 10:30 AM in the conference room revealed, .(Resident #5) was crying and (CNA #6) was cleaning her up and telling her she wasn't catering to her ass .asked her (CNA #6) to leave because she was being aggressive and she said 'F*** this[***] and left .(Resident #5) was still crying and pointed to the door and mouthed 'I don't want her back in my room . Continued interview confirmed the interaction between the resident and CNA #6 was reported immediately to the DON and LPN #5 wrote a statement of the event. Interview with the DON on 9/19/17 at 10:50 AM in the conference room confirmed allegations of verbal abuse to Resident #5 from CNA #6 were substantiated by the facility and CNA #6 was terminated. Continued interview revealed the DON confirmed the facility failed to prevent verbal abuse to Resident #5. Medical record review revealed Resident #6 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 30 day MDS dated [DATE] revealed Resident #6 was cognitively intact with modified independence, and altered level of consciousness that fluctuated; was bed bound and was dependent with assistance of 1 person required for bed mobility, dressing, eating, hygiene, bathing and toileting. Continued review revealed the resident had bilateral upper extremity impairments and received services from Respiratory Therapy for oxygen, suctioning, [MEDICAL CONDITION] care and ventilator care. Review of a facility investigation dated 7/26/17 revealed Resident #6 pushed his call light between 8:00 AM and 8:30 AM and told CNA #5 he needed Respiratory Therapy. The CNA told Respiratory Therapist (RT) #1 the resident requested him and he said OK. The resident pushed his call light a 2nd time and CNA #8 answered the call light and was told he needed respiratory because he couldn't breathe. The CNA informed RT #1 and he said OK, thanks. Approximately 5 minutes later the call light went off a 3rd time and CNA #8 answered it and the resident again stated he needed respiratory and he couldn't breathe. The CNA asked if RT #1 had made it in yet and the resident said No. The CNA said she would let him know again and found RT #1 sitting at a table in the hallway charting. CNA #8 told him Resident #6 still needed him because he said he couldn't breathe, and the RT smiled and said OK, thanks. The resident pushed his call light a 4th time and CNA #5 and LPN #7 entered the resident's room and he asked to be transferred out of the facility because he didn't feel safe. Review of handwritten statements in the facility investigation from CNA #5, and CNA #8 dated 7/26/17 corroborated the allegations above. Continued review of LPN #7's written statement revealed, .Resident requested to be 'sent out' .asked what was going on Resident stated, 'I don't feel safe here' .asked why he felt unsafe and who made him feel unsafe .(RT #1) .made him feel uneasy .Resident stated, 'I couldn't breathe and the alarm was going off.' The tech entered the room and resident asked for (RT #1) and he never came. A 2nd tech came and resident requested to see (RT #1) and he finally came. Resident stated, '(RT #1) chewed me out. He told me it was the same people everyday and he wasn't dealing with this crap today.' He turned off the alarm and walked out.' The resident stated, 'I'd rather die than feel the way he makes me feel' . Interview with the RT Director on 9/20/17 at 1:20 PM in the 2nd floor dining room stated she took over RT #1's assignment the morning of 7/26/17. Continued interview revealed the Nurse Practitioner asked her to assess Resident #6's respiratory status as she had heard wheezes in his lungs. Continued interview confirmed the resident had coarse wheezes and the RT Director gave him a PRN (as needed) breathing treatment per the physician's orders [REDACTED].#6 to be believable, she stated, Yes, I do with this situation. Interview with CNA #5 on 9/20/17 at 1:35 PM in the 2nd floor dining room confirmed she had answered the call light of Resident #6 on 7/26/17 between 8:00 AM and 8:30 AM the first time and told RT #1 the resident needed him. Continued review revealed CNA #5 and CNA #8 were working together in another resident's room and CNA #5 was able to confirm CNA #8 answered the resident's call light 2 more times and reported to RT #1 the resident needed him both times. Further interview revealed when the resident's call light went off a 4th time both she and LPN #7 entered the resident's room together and the CNA heard the resident say I want to be moved out, I don't feel safe here. Continued interview revealed LPN #7 asked the resident what was the problem, and the resident said (RT #1) said I'm not dealing with this crap today and turned off my alarms and left. Review of a Tek-Care Report dated 7/31/17 revealed the ventilator alarm for Resident #6 went off on 7/26/17 at 8:49:42 AM and alarmed for 5 minutes, 18 seconds. Continued review revealed the oxygen saturation alarm went off on 7/26/17 at 8:49:53 AM and alarmed for 3 minutes, 44 seconds. Interview with the DON on 9/20/17 at 3:36 PM in the conference room revealed RT #1 was terminated. Continued interview confirmed the DON found the written statements dated 7/26/17 by facility staff regarding events occurring to Resident #6 to be truthful. Continued interview confirmed the facility failed to respond to ventilator and oxygen saturation alarms timely, and failed to provide care and assistance to Resident #6 as requested resulting in neglect to the resident.",2020-09-01
3720,SIGNATURE HEALTHCARE OF FENTRESS COUNTY,445362,208 DUNCAN ST N,JAMESTOWN,TN,38556,2017-03-28,282,J,1,0,Q88111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility investigation, review of personnel files, and interview, the facility failed to ensure qualified staff implemented the resident's care plan for 1 resident (#6) of 6 resident deaths reviewed, of 13 sampled residents. The failure of qualified staff to provide Cardiopulmonary Resuscitation (CPR) in accordance with the Care Plan on [DATE] at 7:00 AM, for Resident #6, who was in cardiac and respiratory arrest, placed the resident in Immediate Jeopardy (a situation where the providers noncompliance with one or more requirements of participation, has caused, or is likely to cause, serious injury, harm, impairment or death). The Administrator, Director of Nursing (DON), and Corporate Nurse were informed of the Immediate Jeopardy (IJ) on [DATE] at 3:25 PM, in the conference room. The IJ was effective [DATE] - [DATE]. The facility's corrective action plan which removed the IJ was received and corrective actions validated onsite by the surveyor on ,[DATE] and [DATE]. The IJ was cited as past noncompliance for F-282 and the facility is not required to submit a plan of correction. The findings included: Review of the facility policy, Cardiopulmonary Resuscitation, (CPR, undated) revealed .Upon identifying a resident with a change of condition which presents as an unresponsive condition .check the medical record for advance directive status .if resident record indicates CPR is to be instituted, then initiate Basic Life Support if a pulse and/or respirations are undetectable .if a resident is found unresponsive and without respirations, a licensed staff member who is certified in CPR .shall promptly initiate CPR for residents .who have requested CPR in their advance directives .who do not have a valid Do Not Resuscitate DNR order . Review of the facility policy Care Plans- Comprehensive (undated) revealed .Care Plan interventions are implemented after consideration of the resident's problem areas and their causes . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Admission Consent Forms and the Tennessee Physicians Orders for Scope of Treatment (POST, or advanced directives form), executed on [DATE], revealed Resident #6, a [AGE] year old resident, was to receive CPR, Intubation (insertion of a breathing tube), advanced airway interventions, mechanical ventilation as indicated, transfer to a hospital or intensive care unit if indicated, and full treatment in an intensive care unit if indicated, in the event of a respiratory or [MEDICAL CONDITION]. Medical record review of the Interim Plan of Care dated [DATE], revealed .Will follow Advanced Directives . Medical record review of the Nursing Progress Notes Report dated [DATE] at 7:00 AM, revealed Resident #6 was found by Registered Nurse (RN) #1 slumped over in bed, gray in color, and without a pulse or respirations (cardiac and respiratory arrest). Continued review revealed RN #1 did not attempt to perform CPR on Resident #6 in accordance with the Residents' Advance Directives and Care Plan, and instead pronounced the resident deceased at 7:06 AM. Continued review revealed .Despite elder being full code I (RN #1) did not perform CPR on elder who was clearly passed and stated that to Dr (doctor) .DON and ADON (assistant director of nursing) .notified . Review of the Record of Death signed, by the Physician and dated [DATE], revealed .immediate cause of death .Respiratory Arrest .pronounced by .(RN #1). Review of RN #1's investigative interview (the findings of the investigative interview conducted by the facility's attorney) summary dated [DATE], revealed .walked back to resident room .found resident slumped over with her head down to the end of bed .this was approximately 30 minutes after I had left resident .yelled for stethoscope .two other nurses nearby .one went to call resident's daughter .assessed resident .no pulse or respirations .skin dusky, eyes 1/2 open, lips and nails blue tinge .Nurse (LPN #1) said resident is full code .I responded resident has clearly passed, nothing to do .Spoke with Doctor, told him resident expired and I would not initiate code, would pronounce her at 7:06 AM . Review of the personnel file for RN #1 revealed she had completed all training and passed competency tests related to the facility policies on Advance Directives, CPR, Changes in Resident Condition, Resident Rights, Abuse and Neglect Prohibition, Following Physician Orders, Care Plans and all other required training on hire, 3 months prior to the incident. Interview with LPN #1 on [DATE] at 11:36 AM, in the conference room, revealed on [DATE] around 7:00 AM, she observed Resident #6 in [MEDICAL CONDITION] with RN #1 present. Further interview revealed LPN #1 stated .the day shift nurses came in the room, asked 'Are we gonna (going to) code her?' and (RN #1) said 'No we aren't gonna do anything' .no one else questioned it .(RN #1) was guarding the body, standing between us and everyone else and the body, arms outstretched and said to everybody, 'No, we aren't going to do a thing' . Continued interview confirmed no CPR was performed on Resident #6 and RN #1 pronounced the resident deceased . Telephone interview with Physician #3 (the attending Physician for Resident #6) on [DATE], at 10:57 AM, revealed when he was contacted by RN #1 on [DATE] between 7:00 and 7:15 am, he questioned the nurse if CPR had been initiated or was in progress and was informed by RN #1 CPR had not been attempted at all. Continued interview revealed Physician #3 advised RN #1 the resident was full code status and CPR was to have been initiated. Continued interview revealed RN #1 stated .you can take my license all the way to the state if you want, I'm not doing CPR on a dead person . Continued interview revealed she had declared the resident deceased at 7:06 AM. Interview with the DON on [DATE] at 2:45 PM, in the conference room, confirmed Resident #6 had valid Advance Directives to Perform CPR in the event of cardiac or respiratory arrest and confirmed RN #1 had failed to provide CPR in accordance with the Care Plan. Interview with the Assistant Director of Nursing (ADON) on [DATE] at 3:45 PM, in the conference room, confirmed RN #1 had informed the DON in the presence of the ADON she had not performed CPR on Resident #6. Interview with Respiratory Therapist (RT) #4 on [DATE] at 1:40 PM, in the conference room, revealed on [DATE] around 7:00 AM, she had entered Resident #6's room and observed her to be slumped sideways in the bed with her head tilted backwards, mouth open, not breathing, and ashen in color. Continued interview revealed RT #4 informed RN #1 the resident was a full code. Continued interview revealed when she informed RN #1 Resident #6 was a full code, and CPR was to begin at once, the RN stated to her .absolutely not, we are not doing a code, she has been down too long . Interview with the Administrator on [DATE] at 12:41 PM, in the conference room, confirmed on [DATE] around 7:45 AM, RN #1 informed him she did not perform CPR on Resident #6 in accordance with the Care Plan. Telephone interview with LPN #15 on [DATE] at 2:24 PM, revealed she was present on the unit as an oncoming day shift nurse on [DATE] and witnessed the incident. Continued interview revealed when Resident #6 was discovered without a pulse or respirations at 7:00 AM, LPN #15 responded to the room to assist in resuscitation efforts and she also informed RN #1 Resident #6 was a full code. Continued interview revealed .I told (RN #1) the resident was a full code, we needed to code, and (RN #1) said 'No we are not going to code her' .I advised (RN #1) facility policy was to code the resident and (RN #1) refused, even after I advised of facility policy . The facility's corrective action plan included the following: On [DATE] the facility did the following: [NAME] Held an ad hoc Quality Assurance (QA) meeting during the daily stand up meeting and reviewed the incident. Incident was reported to the State Agency. Follow up QA meeting was scheduled for [DATE]. Responsible party was the Administrator. B. The regional nurse consultant reviewed with the DON and the Administrator the education to be provided to all staff on [DATE] to include Abuse, Resident Rights, Advance Directives, Where to Locate the Advance Directives in the Medical Record, Cardiopulmonary Resuscitation (CPR), Following Physician Orders, Change in Condition and Following Care Plans. Responsible party was the Director of Nursing (DON). C. Once the Administrator and DON were educated, they were assigned to educate the Nursing Administration team Assistant Director of Nursing (DON), Unit Managers, Minimum Data Set (MDS) Nurses, and Staff Development Coordinator), who in turn were assigned to educate all the staff on Abuse, Neglect, Resident Rights, Advance Directives, Where to Locate Advance Directives in the Medical Record, CPR, Following Physician Orders, Change in Condition, and Following Care Plans. Responsible party was the DON). D. Began written competency testing of all staff educated on Abuse, Neglect, Resident Rights, Advance Directives, Where to Locate Advance Directives, CPR, Following Physician Orders, Change in Condition and following Care Plans. Responsible party was the Director of Nursing (DON). E. All staff educated, were required to submit written post-tests with scores of 100% before being permitted to work. All staff who failed to score 100% on the post-tests were immediately re-educated and re-tested until all staff scored 100% on the post tests. Responsible party was the Director of Nursing (DON). F. Initiated the first Mock Code Drill conducted by the DON, ADON, Unit Manager (UM) and the Staff Development Coordinator (SDC) to ensure staff understanding and compliance with the facility code blue policy (policy related to emergency resuscitation) and procedures. No irregularities noted. Mock codes were then planned to be completed for every shift (7 A-7P, 7P-7A) for 72 hours through [DATE], then twice weekly on rotating shifts for 4 weeks starting on [DATE] through [DATE] (scheduled to occur on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and on [DATE] on both shifts) to ensure staff understanding and compliance with the facility code blue policy. The first two Mock Codes were conducted by members of the Nursing Administration Team under observation of the DON, then Mock codes were conducted by nursing staff members under observation of members of the Nursing Administration team. Findings were to be reported to the QA committee weekly for 4 weeks to determine compliance and any further need of continued education or revision of the plan. Responsible party was the Director of Nursing (DON). [NAME] Began ongoing monitoring of staff compliance with abuse, advanced directives, resident rights, CPR, location of advanced directives and Do Not Resuscitate (DNR) forms in the medical record, following physician orders, change in condition reporting and following Care Plans. Responsible party was the Administrator. On [DATE] the facility did the following: [NAME] Resident #6's chart and care plan were reviewed by the Regional Nurse Consultant and Director of Clinical Operations. Registered Nurse (RN) #1 was to have been terminated concluding the investigation but resigned prior to termination. Licensed Practical Nurses (LPN) LPN #1 LPN #3, LPN #15 and Respiratory Therapist (RT) #4 received disciplinary action related to not following facility policy. Responsible party was the DON. B. Began audits of the medical records for all residents in the facility, by the Regional Nurse Consultant and Director of Clinical Operations, to ensure advance directives were in the medical record, were addressed on the care plan, and had current Physician orders related to each resident's code status. Responsible party was the DON. C. All residents were assessed for any possible resident rights violations. Those residents with Brief Interview of Mental Status (BIMS scores, a measure of cognitive function), greater or equal to 8 (cognitively intact) were interviewed by the DON, ADON, UM, Social Services Director (SSD), Social Services Assistant (SSA) for quality of life or resident rights violations. No issues were identified. Responsible party was the DON. D. All residents with BIMS scores less or equal to 7 (cognitively impaired) had skin assessments completed on [DATE] for any concerns by ADONs and UMs for any possible abuse or neglect issues. All residents with a BIMS greater or equal to 8 were interviewed for possible abuse or neglect violations. No issues were identified. Responsible party was the DON. E. Held a Resident Council Meeting (a group of residents who reside in the facility and meet regularly, discuss resident concerns, and discuss resident concerns with Administration) and the SSD and Activities Director reviewed the Resident Rights Statement and Policies for Prohibition of Abuse, Neglect and Misappropriation of Property and provided a copy to each resident. Responsible party was the DON. F. All deaths in the facility for the past 30 days were reviewed by the Regional Nurse to ensure advanced directives were honored with no irregularities noted. The DON reviewed all resident deaths in the facility for the prior 12 months with no irregularities noted. Results were discussed in the QA meeting. Responsible party was the Administrator. [NAME] Held first formal QA meeting to address the incident. DON, ADON, UM, Nursing Supervisors or Medical Records staff were to review all new admissions/readmits and residents with DNR related changes, 24 hour shift reports, and incidents accidents daily for 2 weeks, then Monday through Friday ongoing, starting during morning clinical meeting, to ensure sustained compliance with physician notification, physician orders, interim care plan, advance directives, and resident rights. Corporate administrative oversight of the QA meeting was completed by the Regional Vice President or member of the regional staff weekly for 4 weeks beginning [DATE], then monthly for one quarter. The facility allegation of compliance (A[NAME]) was reviewed by the committee. Responsible party was the Administrator. H. Continued staff education and post testing on Abuse and Neglect, Advanced Directives, Where to find Advanced Directives in the chart, CPR, Resident Rights, following Physician orders, Notification of Change in Condition, and Following Care plans. Responsible party was the DON. I. Grievance logs were reviewed by the Director of Clinical Operation with no irregularities noted. [NAME] Continued Mock Code drills as outlined. Responsbile party was the DON. K. Corrective actions were reviewed by the Administrator, DON, Medical Director and Regional Consultants. Responsible party was the Administrator. On [DATE] the facility did the following: [NAME] The DON, ADON, UM, Administrator and Department Heads continued advance directive/abuse post-tests with 10 random Nursing staff members daily on rotating shifts for 2 weeks through [DATE]. Then 5 random nursing staff members on rotating shifts daily for 2 weeks through [DATE], then 5 random Nursing staff members weekly for 3 weeks through [DATE], with all staff required to score 100% on the post tests. Staff members who failed to achieve 100% scores on the tests were immediately re-educated and required to re-test until 100% scores were achieved. Responsible party was the DON. B. Continued education of all staff members on the facility Abuse and Neglect Policy, Resident Rights, CPR, Advance Directives and Where to find them in the medical record, Notification of Change in Condition, Physician Orders, and Care plans. Responsible party was the DON. C. Continued Mock Code drills on every shift through [DATE] as outlined. Responsible party was the DON. On [DATE] the facility did the following: [NAME] Completed review of all residents medical records by the Director of Clinical Operations and the Regional Nurse to ensure advance directives were in the medical records, addressed on the care plans, and had a current Physician Order regarding code status. No irregularities noted. Responsible party was the Director of Clinical Operations. B. Completed a 100% audit of licensed clinical staff CPR certifications by the Regional Vice President and Regional Nurse Consultant. C. Completed 100% audit of all licensed staff to verify valid Tennessee professional licensure completed by the Regional Vice President. No irregularities were noted. D. Completed 100% audit to ensure staff were not listed on the abuse registry by the Regional Vice President with no irregularities noted. E. Mailed certified letters to all employees who had not completed mandatory training and education and advised completion of training was required prior to any return to work at the facility. The letters included all employees on vacation or paid leave, part time or prn (as needed status). Responsible party was the DON. F. The Administrator began reviews of completed audits for new admissions, readmissions and residents with DNR to ensure sustained compliance with all advanced directives. [NAME] DON, ADON, UM or Weekend Manager on duty began interviews with 5 residents with BIMS scores equal or greater than 8 and 5 family members of residents with BIMS scores less than 8 daily for 2 weeks ([DATE] to [DATE]) for any possible resident rights violations; then 3 residents and 3 family members daily for 2 weeks ([DATE] to [DATE]), then 2 residents and 2 family members daily for 4 weeks ([DATE] to [DATE]), then 1 resident and 1 family member daily for 4 weeks ([DATE] to [DATE]). Results of the interviews and assessments forwarded to the QA committee. Responsible party was the DON. H. All deaths in the facility were reviewed by the DON, ADON, UM or Administrator to ensure code status was implemented correctly as per the resident's wishes and documented on the advance directives daily for 2 weeks through [DATE]; then weekly for 4 weeks from [DATE] to [DATE], then continuing as part of the daily stand up meetings attended by the Administrator, DON, ADONs, UM, MDS Coordinator, Treatment Nurses, Chaplain, SDC, Quality of Life Department Head, SSD, Dietary Manager and Formulary Nurse (the nurse in charge of the central supply office) to ensure sustained compliance. Responsible party was the DON. I. Began Administrative oversight of the facility by a member of Senior Regional Team twice weekly for 2 weeks, beginning [DATE] to [DATE]; then weekly for 4 weeks beginning [DATE] through [DATE], then monthly for one quarter. Responsible party was the Director of Clinical Operations. [NAME] Continued Mock Code drills as outlined above. Responsible party was the DON. K. The DON and SDC began tracking all licensed staff members for CPR certification monthly for 3 months; then every 6 months to ensure all licensed nurses maintained CPR certifications. Findings documented and forwarded to the QA committee monthly to determine any need for education or revision of the process. Responsible party was the DON. L. Established plans for daily contact between the facility and nurses from the regional team or corporate office for 2 weeks, then 2 times weekly for 4 weeks. Nurses from the regional team or home office reviewed compliance with the Plan of Correction and Policy and Procedures, compliance of any code blue to occur, and review of compliance with all new/readmissions. Responsible party was the DON. On [DATE] the facility did the following: [NAME] Completed the twice daily mock code drills as outlined above with no irregularities noted. Initiated the plan for transition to twice weekly Mock Code drills to occur on rotating shifts for another 4 weeks. Responsible party was the DON. B. Continued staff education and competency testing on Abuse and Neglect, Resident Rights, Advance Directives and Where to find them in the Chart, CPR, Notification of Change in Condition, Physician Orders, and Care Plans. Responsible party was the DON. C. Held a follow up QA meeting to review findings from initial audits, scheduled weekly QA meetings for 4 weeks, then monthly, for recommendations and further follow up regarding the Corrective Action Plan. At that time, based upon evaluation, the QA committee would determine at what frequency any ongoing audits would be continued. Responsible party was the Administrator. On [DATE] the facility did the following: [NAME] Completed education and competency testing of all staff, with the exception of those on Family Medical Leave (FMLA) or PRN status who had not worked, with 100% scores attained on all post-tests for facility Abuse and Neglect Policy, Resident Rights, CPR and Advance Directives, Where to Locate Advance Directives in the Medical Records, Physician Orders, Notification of Change in Condition, and Care Plans. Employees on FMLA or PRN status were not permitted to work until all education and competency testing completed. Responsible party was the DON. B. Continued all random audits, staff and resident interviews, and competency testing as outlined above. Responsible party was the DON. C. Continued daily stand up meeting reviews as outlined above, which included reports to Administration on the progress of the facility corrective action plans and changes in resident condition. Responsible party was the DON.",2020-03-01
3573,BLEDSOE COUNTY NURSING HOME,4.4e+233,107 WHEELERTOWN AVENUE,PIKEVILLE,TN,37367,2017-12-20,609,D,1,0,VZ8X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility investigations, and interview, the facility failed to follow their abuse policy for reporting allegations of abuse to administration for 1 resident (#3), and failed to report an allegation of abuse to the State Survey Agency within the federally required time frame for 2 residents (#3 and #6) of 7 residents reviewed for abuse. The findings included: Review of the facility's abuse policy Abuse, Neglect, Misappropriation Protocol dated 8/17 revealed .Any individual observing an incident of resident abuse or suspected abuse must immediately report such incident to the Administrator or Director of Nursing . Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident had severely impaired cognitive skills for decision making and short and long term memory problems. Review of the facility's Resident Abuse Investigation Report Form dated 11/27/17 revealed .date incident occurred 11/23/17 .Individual reporting incident (Activity Assistant) .Wasn't reported until following Monday . Interview with the Activities Assistant on 12/18/17 at 1:33 PM, in the chapel, revealed on 11/23/17 at approximately 4:53 PM, she finished an activity and down the hall overheard Resident #3 saying I'm hungry I want some ice cream. Then she heard Licensed Practical Nurse #1 (LPN #1) say in a very hateful way '(Resident #3) you are not getting any ice cream so just be quite'. Further interview confirmed she did not immediately report the incident to anyone; she had just wrote it down and put it under the Social Service Director's office door and the Administrator's office door. Resident #6 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed a Brief Interview of Mental Status of 15 indicating the resident was cognitively intact. Review of the facility's Resident Abuse Investigation revealed on 5/24/17 at 5:30 PM, Resident #6 reported .she was woke up by (Resident #7) rubbing/patting her leg above cover and hand down his pants. She pushed her call light and verbally yelled for help . Further review revealed the incident was reported to the state agency on 5/25/17 at 1:35 PM. Interview with the Administrator on 12/20/17 at 10:20 AM, in the Social Service Directors office, confirmed the facility failed to follow their policy for immediately reporting abuse to administration for Resident #3, and failed to report allegations of abuse to the state agency within the required time frame of 2 hours for Residents #3 and #6.",2020-09-01
2497,"NHC HEALTHCARE, FARRAGUT",445415,120 CAVETT HILL LANE,KNOXVILLE,TN,37922,2017-06-20,282,J,1,0,MVUF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility investigations, and interview, the facility failed to implement individualized care plan interventions to prevent falls for 6 residents (#1, #3, #2, #5, #7, and #9) of 10 residents reviewed for falls. Resident #1 sustained a fractured wrist and [MEDICAL CONDITION] requiring sutures and Resident #3 sustained a [MEDICAL CONDITION]. The facility's failure to implement individualized care plans for falls placed Residents #1 and #3 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, Assistant Administrator, Assistant Regional Director of Clinical Services, Director of Nursing, Assistant Director of Nursing, and the Health Information/Quality Assurance Quality Improvement Coordinator were notified of the Immediate Jeopardy on 6/19/17 at 2:40 PM, in the conference room. The findings included: Review of the facility policy Assessing Falls and Their Causes revised 10/2010, revealed .Review the resident's care plan to assess for any special needs of the resident . Review of the facility policy Falls-Clinical Protocol last revised 9/2012, revealed .the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling .the staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling .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 re-evaluate the continued relevance of current interventions . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Interim Care Plan (ICP) dated 5/8/17 revealed .Problem: Fall Risk/Potential for injury .Interventions .Falls Risk Assessment; Instruct resident and family to call for assistance with mobility/transfers .Keep often used items and call light within easy reach .Provide reminders and cues regarding safety as needed .Offer frequent toileting .Alarm pressure pad on: Bed Wheelchair .Scheduled Toileting Program .Medication Review .Assist with mobility between therapy sessions .WC (Wheelchair) seating assessment/WC seat cushion/Adaptive equipment . Medical record review of the Falls Risk Assessment and document dated 5/8/17 revealed .Total score of 10-13 represents High Risk. Total score of 14 or more represents Severe Risk . Continued review revealed Resident #1 scored a 23 (severe risk). Medical record review of the 5 Day Minimum Data Set ((MDS) dated [DATE] revealed the resident had short term memory problems and had moderate impairment of cognitive skills for daily decision making. Continued review revealed the resident required extensive assist for transfers, dressing, and personal hygiene with 1 person assist. Further review revealed the resident had a fall with a fracture in the past month (prior to admission). Medical record review of the facility's Post Falls Nursing assessment dated [DATE] at 1:20 PM, revealed .found in her room on the floor next to her bed on the right side with her feet facing the bed and her head toward the door. Patient had a laceration on her head above her left eye near her eye brow .Safety devices in use .Alarm .Patient was wearing following devices: Footwear/nonskid socks .What immediate interventions were initiated to prevent future falls? .Clear walking pathway . Review of the facility's Post Falls Investigation dated 5/20/17 revealed Resident #1 had an alarm in place and it was not sounding. Continued review revealed .Needed care plan changes: Nonskid socks added to help pt (patient), clear walking path . (Investigation indicated resident was wearing nonskid socks at the time of the fall.) Medical record review revealed the ICP was updated on 5/20/17 with handwritten [DIAGNOSES REDACTED]. Interview with Registered Nurse (RN) #3 on 6/8/17 at 10:40 AM, on the second floor hallway, revealed .the alarm on the wheelchair was not sounding .it was unplugged .she (Resident #1) would not have unplugged it and it couldn't have been disconnected by pulling on it (cord) . Continued interview confirmed the resident was wearing nonskid socks at the time of the fall. Telephone interview with Occupational Therapist (OT) #2 on 6/8/17 at 11:50 AM revealed .I returned her (Resident #1) to her room .I did notice during therapy when she stood up the alarm did not sound .no did not report it (alarm not working) to the nurse . Interview with the Director of Nursing (DON) on 6/12/17 at 8:45 AM, in the conference room, revealed .don't have scheduled toileting (falls intervention listed on the ICP) .staff makes rounds if observe someone is restless will take them to the bathroom . Interview with the Risk Manager (RM) on 6/12/17 at 3:00 PM, in the conference room, confirmed the care plan interventions of non-skid socks and clear pathways were not appropriate interventions after Resident #1's fall. Interview with the Director of Nursing (DON) on 6/19/17 at 2:00 PM, in the conference room, confirmed the facility failed to ensure the alarm was in place as care planned. In summary, Resident #1 was admitted to the facility for rehabilitation therapy after having a fall at home resulting in a [MEDICAL CONDITION] and surgical repair. The resident was identified as at a severe risk for falls upon admission 5/8/17. The facility had care planned safety interventions of scheduled toileting and pressure pad alarms to the bed and wheelchair. The facility did not implement scheduled toileting, even though it was an intervention on the care plan. On 5/20/17 the resident was assisted by the therapist back to her room after therapy. Interview with the therapist confirmed she was aware the alarm was not functioning and she failed to report it to the nurse. Because the facility failed to follow the ICP, the Resident was found lying on the floor on her stomach with a laceration to her left brow requiring sutures and a wrist fracture. After the fall on 5/20/17, the facility failed to implement a care plan with appropriate interventions to prevent additional falls. Medical record review revealed Resident #3 was admitted to the facility 5/18/17 with [DIAGNOSES REDACTED]. Medical record review of the Admission Nursing Assessment Report dated 5/18/17 revealed the resident was alert and confused. Continued review revealed the resident required extensive assist for transfers with 2 person assist. Medical record review of the ICP for Resident #3 dated 5/18/17 revealed .Problem: Falls Risk/Potential for injury .Interventions .Fall Risk Assessment .Instruct resident and family to call for assistance with mobility/transfers .Keep often used items and call light within easy reach .Provide reminders and cues regarding safety as needed .Offer frequent toileting .Alarm pressure pad on Bed Wheelchair .Scheduled Toileting Program .Medication Review .Assist with mobility between therapy sessions . Medical record review of the Falls Risk assessment dated [DATE] revealed Resident #3 scored a 21 (severe risk). Medical record review of a nurse's note dated 5/22/17 revealed .20:35 (8:35 PM) Resident has set off bed alarm twice this shift (7 PM/7 AM) getting out of bed. No sitter present. Nurse contacted daughter .inquired where is sitter .Nurse told daughter the resident has gotten out of bed unassisted twice .setting off alarms . Medical record review of a nurse's note dated 5/22/17 revealed .20:45 (8:45 PM) staff heard bed alarm sounding and found resident lying on floor at foot of her bed on her back. Nurse elicited significant pain response with minimal range of motion to left hip . Review of a facility's fall investigation dated 5/22/17 at 8:45 PM revealed the resident fell and was sent to the hospital for evaluation of hip pain. Medical record review of the hospital History and Physical dated 5/23/17 revealed the resident was admitted to the hospital with [REDACTED]. Medical record review of the ICP updated 5/23/17 revealed the handwritten intervention .Add clip alarm . Medical record review of the 5-day MDS assessment dated [DATE] revealed Resident #3 had severely impaired cognition, required extensive assistance of two persons for transfers, toileting, and hygiene, and had a history of [REDACTED]. Interview with the RM on 6/8/17 at 11:30, in the conference room, revealed Resident #3 .previously had a sitter (family provided) .she was trying to climb out bed .we don't provide one to one (1:1) care . Telephone interview with RN #5 on 6/8/17 at 12:20 PM revealed .we just continued to listen for her (Resident #3) alarm and when we would hear it we would go back in there .I was hoping it would make her daughter think she really does need a sitter when I called her and told her she had gotten out of bed twice already .what else could we have done . Interview with the DON on 6/12/17 at 8:45 AM, in the conference room revealed .don't have scheduled toileting (intervention listed on the care plan) . Interview with the DON on 6/19/17 at 2:00 PM, in the conference room, revealed .I think he (RN #5) had good intentions .there was not enough time for him to implement a new intervention . Interview with the Assistant Regional Director of Clinical Services on 6/19/17 at 2:05 PM, in the conference room, revealed .if they (residents) require one to one supervision would consider them inappropriate for our facility . In summary, the facility was aware of Resident #3's risk for falls and the resident's attempts to get out of bed. The facility did not implement scheduled toileting, as care planned, and the RN expectations were the family would provide a sitter for the resident, although not care planned. The facility failed to implement care plan interventions, based on the resident's behaviors, to prevent a fall, resulting in a [MEDICAL CONDITION]. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 was discharged from the facility to an Assisted Living Facility (ALF) on 6/8/17. Medical record review of the ICP dated 5/11/17 revealed .Problem: Fall Risk/Potential for injury .Interventions .Falls Risk Assessment .Instruct resident and family to call for assistance with mobility/transfers .Keep often used items and call light within easy reach .Provide reminders and cues regarding safety as needed .Offer frequent toileting .Clip alarm .Assist with mobility between therapy sessions . Medical record review of the Falls Risk assessment dated [DATE] revealed the resident scored an 18 (severe risk). Medical record review of the 5 Day MDS dated [DATE] revealed the resident had a Brief Interview Mental Status (BIMS) score of 7 (severe impairment). Continued review revealed the resident required extensive assist for transfers, dressing and personal hygiene with 1-2 person assist. Further review revealed the resident had 1 fall in the last month (prior to admission to the facility). Review of the facility investigations revealed the resident had 3 falls on 5/19/17, 5/24/17, and 6/2/17, without injuries. Review of the facility's Post Falls Investigation dated 5/19/17 revealed .Interventions: Teach PT (patient) to rise slowly from sitting position . Medical record review of the ICP revealed this intervention was not on the ICP. Review of the POS [REDACTED].Needed care plan changes: Walking assessment and or wheelchair assessment . Medical record review of the ICP revealed this intervention was not on the ICP. Medical record review of the ICP revealed the care plan was updated with handwritten interventions, and no dates for the revisions, .keep pt (patient) in high traffic areas .nonskid socks or shoes .Make sure alarm functioning properly . Medical record review of Resident #2's Complete Patient Care Plan dated 5/31/17, revealed, .Instruct patient to call for assistance with mobility, transfers and other needs .Patient requires verbal cueing for recall and reminders .Keep call light and often used items within easy reach .Instruct patient on safety issues including use of call light, proper foot wear and to keep environment uncluttered .Pressure pad alarms in bed and W/C (wheel chair); check batteries q (every) shift and replace batteries as needed . Review of a facility Post Falls Nursing assessment dated [DATE] revealed .safety devices in use: Alarm . Review of a facility Post Falls Investigation dated 6/2/17 revealed .Educated pt (patient) to use call light before getting up and if needs assistance . Review of the care plan updated 6/2/17, revealed a handwritten intervention .educate patient on proper use of call light and to call for assistance w/ (with) mobility and transfers-Ask pt (patient) to demonstrate back correct use of call light and reasons why they should use the call light . (This intervention was already in place on the ICP since 5/11/17.) Interview with Physical Therapist #1 on 6/8/17 at 12:15 PM, in the conference room, revealed .Do not have a walking assessment or wheelchair assessment that we complete .that is just something we look at every day when working with a resident . Interview with the RM on 6/12/17 at 3:00 PM, in the conference room, revealed .nurse suggested that as an intervention .was not aware it was something they (therapist) do every day . Interview with the Assistant Director of Nursing (ADON) on 6/15/17 at 10:20 AM, in the conference room, confirmed the care plan interventions of education to rise slowly when standing and to use the call light before getting up were not appropriate interventions for the resident. In summary, Resident #2 had a BIMS score of 7. Fall interventions of resident education and use of a call light were not appropriate due to the resident's cognition. The intervention of a walking and/or wheelchair assessment was not an appropriate falls intervention since they were a routine assessment being conducted by therapy. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5 discharged from the facility to an ALF on 6/13/17. Medical record review of the Admission Nursing Assessment Report dated 5/23/17 revealed the resident was oriented to self only. Continued review revealed the resident required extensive assist with transfers and 2 person assist. Medical record review of the Falls Risk assessment dated [DATE] revealed the resident scored a 17 (severe risk). Medical record review of the ICP dated 5/24/17 revealed .Problem Falls Risk/Potential for injury .Interventions .Falls Risk Assessment .Instruct resident and family to call for assistance with mobility/transfers .Keep often used items and call light within easy reach .Provide reminders and cues regarding safety as needed .Offer frequent toileting .Alarm pressure pad Bed Wheelchair .Scheduled Toileting Program .Assist with mobility between therapy sessions . Review of a facility investigation dated 5/25/17 revealed Resident #5 had attempted to stand from his wheelchair, lost his balance, and fell . Medical record review of a facility Post Falls Nursing assessment dated [DATE] revealed .Interventions: Medication Review by Pharmacist . Medical record review of the ICP updated 5/25/17 revealed the handwritten intervention . Pharmacist to review meds (medications) . Medical record review of the Consultant Pharmacist Patient Evaluation dated 5/30/17 revealed the medications were reviewed by the pharmacist and there were no recommendations for medication changes or adjustments. Interview with the DON on 6/12/17 at 8:45 AM, in the conference room, revealed .don't have scheduled toileting (intervention on the ICP) . Interview with the DON on 6/19/17 at 9:00 AM, in the conference room, confirmed no medication changes were made and no additional interventions were implemented on the care plan. In summary, Resident #5 fell on [DATE] with the care plan updated to include a pharmacist medication review after the fall. The medications were reviewed by the pharmacist with no changes made. The facility failed to re-evaluate and implement care plan interventions to prevent falls after it was determined the medications had not contributed to the fall. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Falls Risk assessment dated [DATE] revealed the resident scored a 19 (severe risk). Medical record review of the ICP dated 3/3/17 revealed .Problem: Fall Risk/Potential for injury .Interventions .Falls Risk Assessment .Instruct resident and family to call for assistance with mobility/transfers .Keep often used items and call light within easy reach .Provide reminders and cues regarding safety as needed .Offer frequent toileting .Alarm pressure pad Bed Wheelchair .Scheduled Toileting Program .Medication Review .Assist with mobility between therapy sessions .WC (wheelchair) seating assessment/WC seat cushion/Adaptive equipment .Activities . Medical record review of the 5 Day MDS dated [DATE] revealed the resident had short-term memory problem and moderate impaired cognition. Continued review revealed the resident required extensive assistance for transfers, dressing, and bathing with 1-2 person assist. Review of facility investigations revealed Resident #7 had 4 falls (3/9/17, 3/10/17, 3/13/17, and 3/15/17). Review of the facility's Post Falls Investigation dated 3/9/17 revealed .Someone needs to be with the patient while he is toileting . Medical record review of the ICP revealed these interventions were not implemented on the care plan. Medical record Review of the POS [REDACTED].was found sitting on the floor beside the bed .stated he needed to go to the bathroom .Intervention: Re-educated PT (patient) on the use of the call light and importance of calling for assistance . Review of the facility's Post Falls Investigation dated 3/10/17 revealed .Patient needs not to be left unattended while toileting . Medical record review of the ICP updated 3/10/17 revealed the handwritten intervention .reeducated the PT (patient) on proper use of call light and importance of calling for assistance . The intervention of instruct resident and family to call for assist with mobility/transfers was initiated on 3/3/17. Interview with the DON on 6/12/17 at 8:45 AM, in the conference room, revealed .don't have scheduled toileting .(intervention implemented on the ICP) . Interview with the ADON on 6/15/17 at 10:20 AM, in the conference room, revealed .we can try to re-educate in hopes that something takes .but not appropriate as an intervention .should have done something else . Continued interview revealed .I think attend while toileting was for a different fall . Further interview confirmed the facility failed to implement appropriate care plan interventions post fall for Resident #7 on 3/10/17. In summary, Resident #7 had moderate cognitive impairment. The facility failed to implement the new intervention to not be left unattended while toileting on the ICP. The intervention of re-education to use the call light was not an appropriate intervention for this resident. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9 discharged from the facility to ALF on 5/1/17. Medical record review of the Admission Nursing Assessment Report dated 3/20/17 revealed the resident was alert and oriented with occasional confusion/forgetfulness. Continued review revealed the resident required extensive assist with transfers with 2 person assist. Medical record review of the ICP dated 3/20/17 revealed .Problem: Falls Risk/Potential for injury .Interventions .Fall Risk Assessment .Instruct resident and family to call for assistance with mobility/transfers .Provide reminders and cues regarding safety as need .Alarm pressure pad Bed Wheelchair . Medical record review of the Falls Risk assessment dated [DATE] revealed the resident scored a 16 (severe risk). Review of facility investigations revealed Resident #9 had 4 falls (3/23/17, 3/25/17, 4/18/17, and 4/24/17). Medical record review of the ICP updated 3/23/17 revealed the handwritten intervention .scheduled toileting . Review of a Post Falls Investigation dated 3/25/17 revealed .scheduled toileting . Medical record review of the ICP revealed no new care plan interventions were implemented after the 3/25/17 fall. Medical record review of the 5 day MDS dated [DATE] revealed the resident scored a 10 (moderate impairment) on the BIMS. Continued review revealed the resident required extensive assist with transfers, dressing, and personal hygiene with 1 person assist. Further review revealed the resident had a fall history prior to admission and had 2 falls since admission to the facility. Medical record review of the Complete Patient Care Plan dated 4/7/17, revealed, .At increased risk for falls r/t (related to) history of falls and Subdural Hemorrhage .Instruct patient to call for assistance with mobility, transfers, and other needs .Keep call light and often used items within easy reach .Instruct patient on safety issues including use of call light, proper foot wear and to keep environment uncluttered .Obtain standing blood pressure daily .Pressure pad alarms in bed and W/C; check batteries q shift and replace batteries as needed . Medical record review of a Post Falls Nursing assessment dated [DATE] revealed .fall mat . Medical record review of the ICP updated 4/18/17 revealed the handwritten intervention .fall mats . Medical record Review of the POS [REDACTED].staff heard pressure alarm sounding. Resident found on knees on floor beside his bed .fell from bed to go to bathroom .Skin tear to left knee .Safety devices in use: Alarm .Immediate intervention bed tab alarm (type of personal safety alarm) . Review of the facility's Post Falls Investigation dated 4/24/17 revealed . Apply tab alarm to patient . Medical record review of the ICP updated 4/24/17 revealed .tab alarm to bed and wheelchair . Interview with the DON on 6/12/17 at 8:45 AM, in the conference room, revealed .don't have scheduled toileting .(intervention implemented on the ICP) . Telephone interview with Licensed Practical Nurse (LPN) #7 on 6/15/17 at 9:30 AM, revealed .the alarm was not sounding (at the time of the fall on 4/24/17) .we pressed on it and it didn't sound .we replaced it .had worked at beginning of shift .I don't know if we put it (fall mat) there that night or if they did it the next day .let the supervisor take care of that .Do not remember ever seeing a mat in his room before he discharged (5/1/17) . Telephone Interview with RN #5 on 6/15/17 at 1:40 PM revealed .don't recall if the fall mat was at bedside or not . Interview with the ADON on 6/15/17 at 10:20 AM, in the conference room, confirmed no new intervention was implemented post fall 3/25/17 and the Post Falls Investigation for 4/24/17 did not indicate if the fall mat was in place as care planned. In summary, Resident #9 fell on [DATE] with the intervention of scheduled toileting added to the ICP, but scheduled toileting was not implemented; on 3/25/17 no new care plan interventions were added post fall; and on 4/18/17 the ICP was updated with the intervention of a fall mat. However, there was no evidence to support the fall mat had been placed at the bedside, at the time of the fall on 4/24/17, as care planned on 4/18/17. The Immediate Jeopardy was effective 5/20/17 through 6/20/17. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on 6/20/17. The corrective actions were validated on site through review of documents, observations, and staff interviews by the surveyor on 6/20/17. 1. The Administrator, Physician, Director of Nursing, Assistant Director of Nursing, Risk Manager, Maintenance Director, Social Worker, Activities Director, Dietitian, Director of Rehabilitation, and a Certified Nurse Assistant reviewed and updated Resident #3's care plan with the intervention of a concave mattress. Resident #1 had discharged home on[DATE]. 2. Review of a facility document and interview with the DON on 6/20/17 confirmed the DON, ADON, Risk Manager, and Regional Nurses conducted a review of all residents and verified all safety devices were in place and functional as care planned. 3. Reviewed facility in-service records dated 6/19/17 and 6/20/17, and observations and interviews were conducted on 6/20/17 from 4:40 PM to 7:15 PM with 7 RNs, 2 LPNs, 4 CNAs, 2 Therapists, covering both shifts, and the DON, ADON, and the Risk Manager, to validate the nursing and therapy staff had been educated on the use of the alarms. Staff was in-serviced on ensuring interventions were in place, what to do if an alarm is not functioning and staff responsibility to implement additional interventions as needed based on resident needs. Staff received training on procedures for identifying orthostatic [MEDICAL CONDITION] and reporting concerns to the medical staff. Staff was in-serviced on a new electronic tool used to verify alarms and safety equipment are in use and working properly. The electronic tool can be updated 24/7 and is a communication tool between all disciplines. 4. Observations on 6/20/17 beginning at 5:15 PM confirmed the safety measures for 3 additional residents at risk for falls were listed on the Kardex located in the resident's inside door closet and the electronic communication tool was available with safety devices in use and measures had been implemented as assessed and care planned. 5. Review of the facility audit tool, medical record reviews, and observations revealed the facility had implemented evaluation and monitoring of safety interventions/devices, and updated care plans and the electronic communication tool by 6/20/17. The noncompliance continues at a scope and severity of D for monitoring of the effectiveness of collective actions to ensure sustained compliance. Refer to F-323",2020-09-01
4040,BROOKHAVEN MANOR,445174,2035 STONEBROOK PLACE,KINGSPORT,TN,37660,2016-12-07,520,K,1,0,E8N511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility investigations, observation, and interview, and review of Quality Assurance and Performance Improvement (QAPI) meeting documentation, the facility failed to ensure the QAPI committee identified issues and implemented corrective action plans to ensure wound care protocols were available and followed to assess and treat all wounds; to ensure residents with medical devices (immobilizers) did not develop pressure ulcers related to use of the device; to ensure the physician was notified for changes in condition and to obtain treatment orders; to ensure facility policy was followed so all residents were protected from neglect and abuse and all allegations of neglect and abuse were reported and investigated; to ensure residents were safe from accidents; and to ensure adequate staffing to provide care and services to residents according to their needs and care plans. The facility's failure placed 11 residents (#106, #123, #75, #103, #65, #27, #68, #21, #45, #12, #145) in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirement of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Corporate Director of Clinical Services and the Administrator were informed of the Immediate Jeopardy (IJ) in the conference room on 12/7/16 at 9:30 AM. The facility was cited an Immediate Jeopardy at F-157 (J); F-223 (K); F-224 (J); F-225 (K); F-280 (J); F-309 (J); F-312 (J); F-314 (J); F-353 (K); F-490 (K); F-493 (K); F-501 (K); and F-520 (K). The facility was cited Substandard Quality of Care (SQC) at F-223 (K), F-224 (J), F-225 (K), F-241 (J), F-309 (J), F-312 (J), F-314 (J). The IJ was effective on 2/6/16 and is ongoing. The findings included: Interview with the Director of Nursing (DON) on 11/8/16 at 5:05 PM, in her office, confirmed the facility did not have a protocol the nursing staff could refer to for the identification, assessment and treatment of [REDACTED]. Interview with the Nurse Practitioner on 11/9/16 at 10:25 AM, in the small conference room, revealed she thought standing orders for Decubitus Care stated refer to wound care protocol and were to be followed. She was unaware the facility did not have a wound care protocol to follow. Interview with the Nurse Practitioner revealed .not notified of the shearing .I know they use turning and repositioning for stage I pressure ulcers .should have been treated with something . Interview with the Administrator on 11/28/16 at 3:55 PM, in the conference room, confirmed he would expect the facility to follow the procedures outlined in the facility Abuse policy. Interview with the DON on 12/5/16 at 11:40 AM, in the conference room, confirmed the facility had failed to obtain an order for [REDACTED].#106's wound declined between the time it was first identified and the time treatment was initiated. Further interview revealed the DON was unaware of the online protocols for the treatment of [REDACTED]. Interview with the Medical Director on 12/5/16, in his office, confirmed he was unaware the facility did not have protocols in place for wound care. Continued interview confirmed he does not do training or teaching on wound care with the Director of Nursing or the Treatment Nurse. Continued interview confirmed the facility did not have enough staff to care for the residents. Further interview confirmed he has been the Medical Director at this facility for [AGE] years and it had always been an issue. Review of the Quality Assurance (QA) meeting attendees and interview with the Medical Director on 12/5/16 at 1:55 PM, in his office, confirmed he had not attended a QA meeting in the second quarter of (YEAR). Continued interview revealed he was not aware the treatment nurse did not have a certification in wound care. Interview with the DON on 12/6/16 at 8:15 AM, in the conference room, confirmed she did not have formal training in wound management. Continued interview confirmed she was not aware Resident #106's pressure ulcer was identified on 11/13/16 instead of 11/15/16. Further interview confirmed no wound treatment was initiated until 11/15/16. The DON was asked about the Nurse Practitioner (NP) and Physician notes on 11/15/16 and 11/17/16 stating eschar (dead tissue) and a 2 cm (centimers)ulceration to the calf. Continued interview confirmed .I don't remember seeing eschar . Further interview confirmed the treatment nurse completed the measurement and treatments .I pop in and do the staging . Interview with the Regional Director on Clinical Services on 12/6/16 at 10:00 AM, at the 100-200 hall nurses station, confirmed the facility did have access to wound care protocols and they were located on the company's website portal, available to staff, and could be printed out. Refer to F-157 (J); F-223 (K); F-224 (J); F-225 (K); F-280 (J); F-309 (J); F-312 (J); F-314 (J); F-323 (G); F-353 (K); F-490 (K); F-493 (K); F-501 (K).",2019-11-01
575,DIVERSICARE OF CLAIBORNE,445156,902 BUCHANAN RD,NEW TAZEWELL,TN,37825,2018-03-21,600,K,1,0,TIWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility investigations, review of personnel files, review of employee attendance records (time punch), and interview, the facility failed to prevent mental, physical, and verbal abuse for 6 residents (#4, #2, #3, #1, #17 and #18) of 15 residents reviewed. The facility's failure to prevent abuse resulted in psychological abuse to Resident #4 and placed Residents #4, #2, #3, #1, #17 and #18 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The facility was cited F 600 at a scope and severity of K, which constitutes Substandard Quality of Care (SQC). The Immediate Jeopardy was effective 2/14/18 and is ongoing. The findings included: Review of the facility's Abuse Policy effective (MONTH) (YEAR), revealed, . 'Abuse' means the willful (the individual must have acted deliberately, not that they must have intent to injury or harm) infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish .'Verbal abuse' is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to resident/patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident/patient .'Physical abuse' includes hitting, slapping .It also includes controlling behavior through corporal punishment .'Mental Abuse' includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .'Neglect' means failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, indicating Resident #4 was moderately cognitively impaired. Continued review revealed Resident #4 required limited assistance for all Activities of Daily Living (ADLs). Medical record review of Resident #4's current Care Plan initiated on 5/15/17 indicated the resident was at risk for dehydration and was to be provided diet and liquids as ordered. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #4 was on a regular diet and not on fluid restrictions. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed several team members were interviewed on 2/16/18, and Certified Nursing Assistant (CNA) #7 and CNA #2 denied seeing anything that would be considered abusive behavior toward a resident and denied witnessing any food or drink being withheld from a resident. Continued review of the facility's investigation for allegations of abuse which began on 2/16/18, revealed Licensed Practical Nurse (LPN) #1 was talking in a demeaning way and restricting drinks from Resident #4. Continued review revealed on 2/20/18, CNA #4 reported .I have not witnessed any form of abuse to any of the residents .I do not know of any instances that residents are talked to rudely .There have been several occasions that (LPN #1) told (Resident #4) that she had to come out of her room to eat .(LPN #1) also told CNAs that (Resident #4) is not allowed to have coffee. I would take it to her anyways .Anytime that (LPN #1) tells me that residents can't do or have certain things, I always check with someone else .(Resident #4) has said that she does not want to go and take a shower because every time she does (LPN #1) would raid her room and take everything out .(Resident #4) has said 'I don't understand why (LPN #1) treats me this way, if you could find out will you please let me know' .(LPN #1) will not let (Resident #2) or (Resident #4) lay in bed during the day, she tells them this is not a resort. (LPN #1) allows other residents to lie in bed throughout the day but not (Resident #2) or (Resident #4) .(LPN #1) is a good nurse but she does seem to focus on the two residents (Resident #2) and (Resident #4) . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #2, who initially denied witnessing any abusive behaviors on 2/16/18, reported on 2/20/18 .(LPN #1) will not allow (Resident #4) to have (artificial sweetener) or any packet in her room. (LPN #1) recently made the rule that residents are not allowed to have coffee only at meal time. I have been sneaking and giving coffee to the residents if they ask. (Resident #4) asked the staff to find out what she did to (LPN #1) and she would try to fix it. Since (LPN #1) has been gone (Resident #4) now takes a shower . Continued review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #7 reported on 2/20/18 she was not aware of any abuse in the facility, but LPN #1 would not allow Resident #4 to keep her drinks in her room, .(Resident #4) got to where she would not come out of her room because she was afraid (LPN #1) would go into her room and take her things . Further review revealed LPN #4 reported on 2/20/18 . (LPN #1) would make me go into (Resident #4's) room and clean out her room. (LPN #1) would make me take any food item out of the room such as food, pops, creamer, sugar, cakes, pop tarts, etc. (Resident #4) got to where she would not come out of her room .Since (LPN #1) has not been here (Resident #4) now attends activities and comes out of her room more. (Resident #4) now takes a shower since (LPN #1) has been gone . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed, in an interview conducted on 2/21/18 between Resident #4 and the Director of Nursing (DON), Resident #4 was crying and reported she felt like LPN #1 did not like her. Resident #4 further reported she did not leave her room while LPN #1 was working because LPN #1 would go through her stuff and when she would come out of her room to ask for a drink, LPN #1 would tell her to go back to her room. Further review revealed Resident #4 did not report it to anyone sooner because she was afraid of retaliation from LPN #1. Continued review of the facility investigation revealed the facility substantiated the allegation of abuse and terminated LPN #1. Interview with Resident #4 on 3/13/18 at 11:20 AM, in the resident's room, confirmed, .The only challenge I had .1 of the nurses was less than nice to me .(LPN #1) .she was always so mean .I asked others have I done something to her .once I had a rash and she reached across grabbed my arm and almost jerked me out of bed to look at it . Continued interview confirmed, while she was at physical therapy, .someone had ransacked my purse .garment bag .happened 2-3 times .the CNAs told me who it was .and it was (LPN #1) .it got to where I was refusing to go to physical therapy .refusing to go out to eat .I felt so violated .now that I am working out (working with physical therapy) my headaches are getting better .less intense .activities helping .and coffee .(LPN #1) would say 'you didn't eat your meal so no coffee' .went a week or two without coffee .if she was here I wouldn't come out of my room .didn't say anything initially because I didn't want to have repercussions .I honestly felt hatred from her .I asked to make a call .she just yelled and pointed 'go back to your room' . Continued interview confirmed Resident #4 told LPN #1 about her room being .ransacked . and LPN #1 responded .well is anything missing . and when Resident #4 said No LPN #1 responded .well what's the problem then . Further interview confirmed since LPN #1 had been gone, Resident #4 had been getting out of her room for meals and physical therapy. Interview with the DON on 3/14/18 at 10:40 AM, in the conference room, confirmed she was made aware of abuse allegations by LPN #1 during an interview with Resident #4 on 2/21/18. Continued interview confirmed .a lot of these girls (on the locked unit) are new .no excuse .(LPN #1's abusive behavior) was brought to my attention on the 21st .brought (Resident #4) to my office on the 21st . where Resident #4 alleged LPN #1 had restricted her fluids, verbally abused her, and made her fearful to leave her room. Further interview confirmed LPN #1 had been dealing with stress and the facility offered her counseling and .provided her with everything we (the facility) could for stress . Continued interview confirmed the facility discussed allegations of abuse in morning meetings with department heads and clinical staff, did daily rounds where she talked with staff and residents, and did not know why the staff did not report LPN #1's abusive behavior prior to her investigation. Further interview confirmed Resident #4 had been more active in therapy and the DON had noticed a difference in Resident #4's mood since LPN #1 had been terminated. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Quarterly MDS dated [DATE] revealed Resident #2 had a BIMS score of 6 out of a possible 15, indicating the resident was severely cognitively impaired. Continued review revealed Resident #2 required limited assistance for all ADLs except toileting, which required extensive assistance. Further review revealed Resident #2 did not have a swallowing disorder. Medical record review of Resident #2's current Care Plan initiated on 8/12/16 indicated the resident was at risk for dehydration. Continued review revealed Resident #2 was a vegetarian, under her ideal body weight, prefers to sleep late, and likes to eat paper and styrofoam. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #2 was on a vegetarian diet, not on fluid restrictions, and was to be provided diet and liquids as ordered. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed several team members were interviewed on 2/16/18, and LPN #4 and CNA #2 denied seeing anything that would be considered abusive behavior toward a resident and denied witnessing any food or drink being withheld from a resident. Continued review of the facility's investigation for allegations of abuse which began on 2/16/18, revealed LPN #1 was talking in a demeaning way and restricting drinks from Resident #2. Continued review revealed on 2/20/18, CNA #4 reported .I have not witnessed any form of abuse to any of the residents .I do not know of any instances that residents are talked to rudely .Anytime that (LPN #1) tells me that residents can't do or have certain things, I always check with someone else .(LPN #1) will not let (Resident #2) or (Resident #4) lay in bed during the day, she tells them this is not a resort. (LPN #1) allows other residents to lie in bed throughout the day but not (Resident #2) or (Resident #4) .(LPN #1) is a good nurse but she does seem to focus on the two residents (Resident #2) and (Resident #4) . Further review revealed CNA #4 reported .I have seen (LPN #1) take water away from (Resident #2) and tell her she can't have it .(LPN #1) says that (Resident #2) plays in the drinking water that she is given but I have never seen her playing in it . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #2, who initially denied witnessing any abusive behaviors on 2/16/18, reported on 2/20/18 .(LPN #1) screams at (Resident #2) and you can hear her yelling at her from down the hallway if you are standing at the nurse's station .(LPN #1) will yell for (Resident #2) not to do that because she knows better, to get closer to her walker, and stop screaming. (LPN #1) talks to her sternly and talks to her rudely. (LPN #1) will not allow her to have any water other than at meal times . Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed LPN #4, who initially denied witnessing any abusive behaviors on 2/16/18, reported on 2/19/18 .(LPN #1) talks mean to (Resident #2) .will not give (Resident #2) any water when she asks for it .understands (LPN #1) will not give her water in her room because (Resident #2) picks at her buttock and will wash her hands in her drinking water but she does not pick her buttock when she is at a table .not sure why (Resident #2) was not allowed to have water when she was in the dining room . Further review revealed in a second interview, LPN #4 reported on 2/20/18 .(Resident #2) was not allowed to have water (LPN #1) would not let her. (LPN #1) would yell at (Resident #2) and tell her to go to her room, be quiet, don't do that you know better, stand up straight, or don't do your feet like that . Continued review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #8 reported on 2/19/18 .(LPN #1) was verbally abusive to (Resident #2) .(LPN #1) is mean to her and she has seen her 'jerk her up from a chair, grab her walker' and push (Resident #2) and the walker very fast to her room . Interview with CNA #3 on 3/12/18 at 11:04 AM, in the Lighthouse Dining Room, confirmed the CNA had knowledge of the facility's abuse policies. Continued interview confirmed .One of the nurses that worked here .(LPN #1) .it's a fine line as far as verbal .she would make her (Resident #2) get out of bed .she (Resident #2) didn't want to get up .kind of thought it was abuse .thought they (Administration) knew .(Resident #2) likes to play in water .I gave it to her anyway . Continued interview confirmed CNA #3 did not report the abuse but .we've (CNAs on the Lighthouse unit) all talked about it .yeah .that's abuse .still gave it (water to Resident #2) .(continued) for 2 weeks .(LPN #1) has a stern voice . Interview with CNA #4 on 3/12/18 at 11:14 AM, in the Lighthouse Dining Room, confirmed the CNA had knowledge of the facility's abuse policies .It's not tolerated .see it stop it .remove the abuse and report it . Continued interview confirmed .(LPN#1) used to work here .she'd tell us (Resident #2) couldn't have water because she would play in it .I gave it anyway .(LPN #1) would make (Resident #2) get out of bed and come out of her room every morning .every time it happened I reported it to (Assistant Director of Nursing (ADON)) .she would just say 'ok' .happened a couple of times .I don't know what they would do or done with situation .told (DON) twice .then (LPN #1) wasn't here after that . Interview with CNA #6 on 3/13/18 at 10:27 AM, at the Lighthouse nurses' station, confirmed the CNA had knowledge of the facility abuse policy and chain of command. Continued interview confirmed she was instructed to withhold fluids from Resident #2 who .likes to wash her hands (in her drinking water) .doesn't like anything sticky . Continued interview confirmed CNA #6 .didn't tell anyone .other CNAs say they told them (Administration) before and it doesn't get fixed . Medical record review revealed Resident #3 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Annual MDS dated [DATE] revealed Resident #3 had a BIMS score of 12 indicating the resident was moderately cognitively impaired. Continued review revealed Resident #3 required limited assistance for all ADLs except personal hygiene, which required extensive assistance. Further review revealed Resident #3 did not have a swallowing disorder. Medical record review of Resident #3's current Care Plan initiated on 3/20/18 indicated the resident was at risk for dehydration and was to be provided diet and liquids as ordered. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #3 was not on fluid restrictions. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed several team members were interviewed on 2/16/18, and LPN #4 denied seeing anything that would be considered abusive behavior toward a resident and denied witnessing any food or drink being withheld from a resident. Further review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed LPN #4, who initially denied witnessing any abusive behaviors on 2/16/18, reported on 2/20/18 .(LPN #1) would not allow (Resident #3) anything to drink other than at meal times. I would sneak and give (Resident #3) water but if (LPN #1) caught you she would make us go and take it away from the resident . Continued review of the facility's investigation for allegations of abuse which began on 2/16/18 revealed CNA #5 reported he had not witnessed any abuse occur in the facility and had no knowledge of anyone not being allowed food or drink when the residents ask. CNA #5 continued to report Resident #3's fluids were limited per LPN #1, because she was washing out her medication (diluting her medication from drinking too much water). Interview with CNA #5 on 3/13/18 at 10:13 AM, at the Lighthouse nurses' station, confirmed .in-services (education) quarterly .go over what would be considered abuse .denying rights .deny food drink .going outside .I have not witnessed abuse .have heard about it . Continued interview confirmed he was instructed by LPN #1 to restrict fluids for Resident #3 because she was .flushing out her medication (diluting medication effects by drinking too much water) .I didn't feel well with it .I talked to other nurses .they told me that we really cannot deny that .I proceeded giving it (water) to (Resident #3) .not sure if there was a (physician's) order .I took her word for it . Continued interview confirmed he did not report an allegation of abuse to anyone .I have not talked with anyone .I trusted the nurse .I didn't really like it .but there's a lot of things in the nursing field .don't like it but do it anyway .Only happened a couple of times .month or so ago .don't remember the time period .it was a once or twice type of thing .everybody here are very good people . Review of LPN #1's Personnel File revealed LPN #1 was employed at the facility beginning 10/23/09, was placed on administrative leave on 2/20/18, and terminated on 3/8/18, following a planned medical leave initiated on 2/17/18. Continued review revealed LPN #1's last day worked was 2/16/18. Further review revealed LPN #1 completed Preventing, Recognizing, and Reporting Abuse education on 1/12/18 and Resident Rights education on 12/6/17. Continued review revealed no documentation a background check had been completed. Interview with the Administrator on 3/14/18 at 5:23 PM, in the conference room, confirmed he was made aware of abuse allegations .from a call on the hotline .it was verbally given to me .didn't have a whole lot of information at that time .first time hearing about it was on Friday (2/16/18) based on telephone call from the hotline . Continued interview confirmed .come to believe at different occasions (LPN #1) has lied to me .had to move her .it was related to interactions with other staff members . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #1's BIMS score was 3, indicating the resident was severely cognitively impaired. Continued review revealed Resident #1 required extensive 2 person physical assistance for bed mobility, transfers, dressing, bathing, and required limited assistance for eating. Medical record review of Resident #1's current Care Plan initiated on 9/22/17 indicated the resident required assistance from staff with grooming and personal hygiene, displayed socially inappropriate/disruptive behavior, and frequently yelled out. Continued review revealed interventions including .Do not argue with (Resident #1) .Discuss with (Resident #1) options for appropriate channeling of anger .Talk with (Resident #1) in calm voice when behavior is disruptive . Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA Trainee #1 witnessed CNA #1 smack Resident #1's hand twice during a shower on 2/14/18, and after Resident #1 smacked CNA #1 back, CNA #1 said .don't smack me, I smack back . Further review revealed CNA Trainee #1 reported the allegation to the Activities Director on 2/15/18. Further review revealed CNA #6 witnessed the alleged abuse of Resident #1 in the shower, but did not report it to anyone until an interview with Registered Nurse (RN) #1 on 2/16/18. Continued review revealed the facility terminated CNA #1 for violation of the facility abuse policy. Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed .I was helping in shower room (on 2/14/18) .(CNA #6) was giving (Resident #1) a bath .(Resident #1) was being combative .I was holding the water sprayer and trying to block (Resident #1's) hand because she was trying to hit (CNA #6) then (CNA #1) comes in stands there for just a second .takes sprayer out of my hand and then I step back observing them give her a bath .(Resident #1) went down to touch her private area and (CNA #1) smacks her hand .(Resident #1) smacks (CNA #1) back .and then (CNA #1) smacks (Resident #1) back again and says 'don't smack me I smack back' .in a stern manner . Further interview confirmed CNA Trainee #1 stated .didn't really discuss it with (CNA #6) .I already knew I was going to make a report .don't know how (CNA #6) could not have heard it .maybe she didn't see it . Interview with CNA #6 on 3/14/18 at 9:32 AM, in the conference room, confirmed .it was me and a student (CNA Trainee #1) at the time .I could hear a slap .I can't remember if the resident reacted .I didn't say anything .I know I should have .I was kind of shocked at first .I work with her (CNA #1) every day .(ADON) came to me .I told her everything .the truth .I'm not going to lie .honestly I have no excuse .I apologized to the resident and the facility . Medical record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #17 was severely cognitively impaired. Continued review revealed Resident #17 required extensive 2 person physical assistance for all ADLs. Medical record review of Resident #17's current Care Plan initiated on 6/2/14 indicated the resident was at risk for decline in social interaction related to Dementia and at risk for elopement. Continued review revealed Resident #17 required staff to approach resident in a positive and calm accepting manner. Medical record review of the Physician Recapitulation orders dated (MONTH) (YEAR) revealed Resident #17 was ordered an appetite stimulant by mouth twice daily to increase appetite for 30 days. Continued review revealed Resident #17 was on a pureed diet with nectar thick liquid and not on fluid restrictions. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA Trainee #1 witnessed CNA #1 smack Resident #17's hand in the dining room on 2/14/18. Further review revealed CNA Trainee #1 reported the allegation to the Activities Director on 2/15/18. Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed .(2/14/18) after breakfast .saw (CNA #1) .and she was taking lunch tray from (Resident #17) .(Resident #17) had her finger hooked into (CNA#1's) scrub pocket .(CNA #1) looked down at (Resident #17's) hand and smacked it really hard .(Resident #17) said 'oooh' .I could describe (Resident #17's) reaction as surprised .it all happened so fast .I made eye contact with (CNA #1) .(Resident #17) didn't scream or yell .was like 'ooooh' . Medical record review revealed Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review the Quarterly MDS dated [DATE] revealed Resident #18 was severely cognitively impaired. Continued review revealed Resident #18 required extensive assistance for all ADLs and 1 person physical assistance for eating. Further review revealed Resident #18 did not have a swallowing disorder and was on a mechanically altered therapeutic diet. Medical record review of Resident #18's current Care Plan initiated on 7/13/16 indicated the resident was at risk for dehydration and required encouragement for good nutritional intake and was to be provided diet, snacks, and liquids as ordered. Continued review revealed Resident #18 had a history of [REDACTED]. Medical record review of Physician Recapitulation Orders dated (MONTH) (YEAR)-March (YEAR) revealed Resident #18 was on a pureed no added salt diet with low concentrated sweets, nectar thick liquid and not on fluid restrictions. Review of the facility's investigation for allegations of abuse reported on 2/16/18 revealed CNA Trainee #1 witnessed CNA #1 take a food tray from Resident #18 before her meal was finished on 2/14/18, and Resident #18 became upset. Further review revealed CNA Trainee #1 reported the allegation to the Activities Director on 2/15/18. Continued review revealed the facility terminated CNA #1 for violation of the facility abuse policy. Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, confirmed .(2/14/18) lunch time .(CNA #1) was taking up lunch trays .(CNA #1) took (Resident #18's) tray away from her .(Resident #18) said 'I'm not done with it' .(CNA #1) was leaning across the table and said 'you're playing, you're done' .then hands were flying .(Resident #18) was trying to get her tray .(CNA #1) appeared to go to smack at her .didn't hear or see contact. Review of CNA #1's Personnel File revealed CNA #1 was employed at the facility beginning 4/12/16, was placed on administrative leave on 2/15/18, and terminated on 2/23/18. Further review revealed CNA #1 completed Preventing, Recognizing, and Reporting Abuse education on 3/16/17. Review of CNA #1's employee attendance record ending the week of 2/21/18 revealed her last shift ended on 2/15/18 at 2:05 PM, 1 day after the allegations of abuse on 2/14/18 occurred. Interview with the ADON on 3/13/18 at 2:59 PM, in the conference room, confirmed .I was told by (LPN #5) that (CNA Trainee #1) reported (CNA #1) smacked a resident .not sure if that was the correct terminology .was not 100% sure . Interview with the Activities Director on 3/14/18 at 8:45 AM, in the conference room, confirmed .(CNA Trainee #1) went to (Activities Assistant) on 2/15/18 .then me .it happened the day before .(CNA Trainee #1) came to me on Thursday .she wasn't 100% sure if she witnessed abuse .I asked her why she did not come and report even if you thought it .she said she went home and thought about it .I then took it to .her floor supervisor (LPN #5) . Interview with RN #1 (RN responsible for the CNA Training Program) on 3/14/18 at 9:02 AM, in the conference room, confirmed, .(CNA Trainee #1) .went through the CNA class here .before they go on the floor they are trained .2 times .hand in hand when hired on and review abuse policy . Continued interview confirmed RN #1 and the ADON were investigating the hot line call allegation of abuse for LPN #1 when allegations of CNA #1's abuse were brought to their attention .I didn't know until later that night . Continued interview confirmed RN #1 had a telephone conversation with CNA Trainee #1 and was told about 3 different incidents of abuse .2 where she was sure (CNA #1) made contact . Further interview confirmed CNA #6 also witnessed abuse on the 2/14/18. Continued interview confirmed RN #1 did not ask why CNA Trainee #1 and CNA #6 did not report abuse. Further interview confirmed during her last in-service education held on 2/16/18, she felt the staff were not able to identify specific examples of abuse, such as restricting fluids, because it is .kind of a fine line . Telephone interview with CNA Trainee #1 on 3/14/18 at 9:47 PM, revealed .when you report to the person you're supposed to .it gets swept under the rug .wanted to go to the highest person .only one in her office .(DON or ADON) that's who I tried to go to first but they were not in . Interview with the DON on 3/14/18 at 10:40 AM, in the conference room, confirmed .I didn't understand it (the allegations reported by CNA Trainee #1) to be abuse at that time .I took it as a complaint .I can't remember the specifics .she could've said smacked .never asked specifics . Interview with the Administrator on 3/14/18 at 5:23 PM, in the conference room, confirmed he did not know why staff on the locked unit did not report abusive behaviors. Further interview revealed the Administrator stated, staff were educated to .observe .teach .only way you can do that is through observation .they watch videos .give you tips on how to do that .we don't have cameras .I don't know why .they have been told .they take the same education I do .3 times I had to see an abuse video .no reason why somebody wouldn't know that was abuse .",2020-09-01
1847,SIGNATURE HEALTH OF PORTLAND REHAB & WELLNESS CENT,445306,215 HIGHLAND CIRCLE DRIVE,PORTLAND,TN,37148,2017-09-21,225,E,1,0,DUCD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of skin reports, interview, and review of facility investigation, the facility failed to have evidence all alleged violations were thoroughly investigated for 8 residents (#3, #6, #9, #10, #11, #12, #13, #15) of 18 residents reviewed for abuse allegations which included injury of unknown origin, sexual abuse, misappropriation of resident's property and resident to resident altercations. The findings included: Review of facility policy, Abuse, Neglect and Exploitation and Misappropriation of Property, undated, revealed all alleged violations were to be investigated. The policy revealed the Administrator was the facility's designated Abuse Coordinator. Investigation guidelines documented .The facility Administrator will investigate all .incidents that potentially could constitute allegations of abuse, injuries unknown source, exploitation, or suspicion of crime .The Administrator may delegate some or all of the investigation to the Director of Nursing .but the facility Administrator retains the ultimate responsibility to oversee and complete the investigation and to draw conclusions regarding the nature of the incident .the investigation should include interviews of persons who may have knowledge of the alleged incidents . In the case of alleged resident abuse, the Director of Nursing (DON) will conduct interviews of interviewable residents on the resident's unit or the entire facility as appropriate. Review of facility policy, Abuse, Neglect, Exploitation and Misappropriation of Property, reviewed [DATE] and retired [DATE] (due to change in ownership), revealed .Abuse Prevention and Protection .if a Stakeholder (facility employee) observes a resident exhibiting any form of abuse toward another resident, the Stakeholder will intervene immediately to interrupt the incident and remove and/or separate the residents involved and move them to an environment where the resident's safety can be assured. The charge nurse and/or the DON will ensure that the resident's do not have access to one another until the circumstances of the incident can be determined . Further review revealed .Investigation Guidelines .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 #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident expired on [DATE]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 required extensive 1 person assistance with hygiene, was total dependence with 1 person assistance for bathing, and had no pressure ulcers or any other type wound or skin problems. Review of the Quarterly MDS dated [DATE] revealed Resident #3 was total dependence with 1 person assistance for hygiene and bathing, and had no pressure ulcers or any other type wound or skin problems. Review of the Weekly Skin form dated [DATE] written by Licensed Practical Nurse (LPN) #9 revealed .Left Popliteal (hollow back of knee) .Bruise .Resolved . Further review revealed no other bruise or discoloration sites. Medical record review of the Progress Notes Report dated [DATE] written by LPN #9 revealed .(Resident) also has some purplish discolored bruising noted around left great toe and 2nd toe on left foot . Review of the Weekly Skin forms revealed no forms were completed after [DATE] until [DATE], which was written by LPN #9. Interview with LPN #9 on [DATE] at 9:25 AM in her office confirmed the LPN had been the Wound Nurse during ,[DATE] to ,[DATE] and had written the [DATE] Progress Note. Further interview confirmed the Weekly Skin forms were not completed after [DATE] until [DATE] due to the LPN working on the unit. Further interview confirmed the facility had not investigated the cause of the bruise located on the toes of the left foot. Interview with the Director of Nursing (DON) on [DATE] at 2:35 PM in the conference room and on [DATE] at 7:30 AM in her office revealed the DON expected nursing to complete the Weekly Skin forms. Further interview confirmed the facility failed to investigate the cause of the bruising, an injury of unknown origin, located on the toes of the left foot per facility policy. Review of Resident #6's facility investigation dated [DATE] submitted by the DON revealed on [DATE] at 9:00 PM, the .allegation made by Elder (Resident #6) that a male had touched her breast. Multiple interviews with the Elder revealed different statements. The first description of the alleged was a 'short light/dark male' then 'a light dark male with a hat', 'then' a male and he was not a tech'. Interview with police revealed inconsistent statements also .currently they have been no witness to any of the details that have been revealed per the Elder .The initial alleged stakeholders were suspended pending investigation . Review of the facility investigation revealed no documentation to indicate which stakeholders were suspended. Review of Resident #6's Quarterly MDS dated [DATE] revealed Resident #6 communicated with clear speech, made herself understood and understood others. Continued review revealed she had moderate cognitive impairment per her BIMS score was ,[DATE] and required extensive assistance of one staff for dressing and personal hygiene. She had medical [DIAGNOSES REDACTED]. Review of the Resident Investigation Tool for Allegation of Abuse, Neglect, Misappropriation of Resident Property form, including Resident #6, dated [DATE], revealed the form had been completed by the DON. Continued review revealed an allegation of sexual abuse on [DATE] at 7:00 PM that a male touched her breast. Further review revealed .a male came and touched her breast, first black then white, then stated that she liked the black tech. and stories conflicting . Further review revealed Resident #6's statements were conflicting and summary of findings indicated, unable to substantiate concern. Interview with the DON on [DATE] at 2:45 PM, in the DON's office revealed Resident #6's family called and reported to the former Assistant DON (ADON) a male staff had touched the resident's breast on [DATE] around 6:00 or 7:00 PM. The family reported Resident #6 could not identify the male staff. The DON stated there had been no male staff taking care of Resident #6 that day who fit the description of the alleged perpetrator. The DON stated Certified Nurse Aide (CNA) #7 worked on contract and was identified as the possible alleged perpetrator based on the multiple/vague descriptions Resident #6 had given during the investigation. There was no evidence the facility had interviewed CNA #7 or any of the other male staff per facility policy. Interview with the Administrator on [DATE] at 4:00 PM in the conference room confirmed the investigation file contained a total of three facility staff interviews and the investigation failed to include a written statement from CNA #7 or any other male staff member per facility policy. Review of the Resident Investigation Tool for Allegation of Abuse, Neglect, Misappropriation of Resident Property form dated [DATE] revealed the form had been completed by the DON. Continued review of the form revealed LPN #2 reported the misappropriation of Resident #9's narcotics by LPN #6 on [DATE] . Review of CNA #1's witness statement dated [DATE] revealed, .This morning ([DATE]) Resident in room (identified resident room number) asked me to come to his door. He was talking very quiet, he was staring at the nurse's station (cart) on the Bridge (secure unit). He said that nurse right their (there) in the glasses has been taking dope all night. I said (Resident #21) exactly which nurse are you talking about. (Resident #21) said the one with red hair or the other nurse. He said the one in the glasses .I then asked him if what he was telling me was the truth and he said yes hunny (honey) she's been doing dope all night . Interview in the conference room on [DATE] at 10:32 AM, LPN #2 revealed during the day shift of [DATE], LPN #2 had ordered [MEDICATION NAME] pain medication for Resident #9 from the pharmacy because she was out of medication. The pharmacy did not deliver the medications by the end of LPN #2's day shift. The next morning LPN #6 was in the hallway of the secure unit giving report to LPN #2 as LPN #2 was coming on duty. Everything was going fine with the narcotic count until they checked Resident #9's narcotics. Resident #9 had two cards of [MEDICATION NAME]. The pharmacy had sent two cards the previous evening on [DATE]. When LPN #2 examined the cards on the morning of [DATE], one card had 60 tablets, but the other card had a lot of tablets missing. LPN #2 revealed LPN #6 stated the card had been received with only 57 tablets in it. LPN #2 stated it was obvious that pills had been popped out of the individual blisters identified as #58, #59, and #60 as well as additional blisters. LPN #2 stated LPN #6 then began an illogical explanation that Resident #9 got one tablet, then got one prn (as needed), and then LPN #6 dropped a pill. LPN #2 stated when she examined the blister pack and the documentation, it became evident that two pills were missing and had not been signed out at all. They finished the count without any other irregularities found. LPN #2 then locked the medication cart. CNA #1 approached her and told her a resident reported seeing LPN #6 taking drugs the previous night. LPN #2 had a conference call with the DON and reported her findings. LPN #2 stated she was not interviewed except during the initial telephone interview with the DON during the conference call. LPN #2 stated the DON asked her to get CNA #1's written statement which she did. Review of the facility investigation revealed there was no documentation of a direct statement from Resident #21 beyond what was recounted in CNA #1's witness statement. Review of Resident #21's Electronic Medical Record (EMR) notes from [DATE] through [DATE] did not document any entry regarding his verbal report of witnessing a nurse taking medications off the medication cart. Further review of the facility's investigative documents revealed there was no documentation that other residents had been interviewed regarding this incident. Review of Resident #9's 14-day MDS dated [DATE], revealed she was admitted to the facility on [DATE], exhibited severe impaired cognitive skills, did not speak and was rarely understood others, and demonstrated wandering behavior. Continued review revealed she exhibited indicators of pain by non-verbal sound and facial expression, and received scheduled and as-needed pain medication. Review of Resident #9's undated EMR investigation for the misappropriation occurring on [DATE] revealed resident (#9) was unable to state. Interview in the DON's office on [DATE] at 2:45 PM with the DON confirmed she was unable to provide any evidence she had taken a statement from Resident #21 or any other residents per policy. The DON stated Resident #21 should have been interviewed. Review of the record for Resident #10 of the facility investigation dated [DATE] revealed Resident #10 was involved as the aggressor in a witnessed resident to resident altercation with Resident #13 on [DATE]. However, no written witness statements were included with the investigation. Review of Resident #10's Admission MDS dated [DATE], revealed the resident was admitted to the facility on [DATE] with Dementia with Behavioral Disturbances. Review of the the MDS revealed a BIMS score as 8 out of 15, indicating moderate cognitive impairment. Resident #10 exhibited physical and verbal behavioral symptoms toward others and exhibited behavioral symptoms which impacted himself, resisting care and wandering. Resident #10's locomotion on the unit was coded as limited assistance and was able to ambulate on the unit independently. Review of the facility investigation dated [DATE], revealed this was the first resident to resident incident for Resident #10. Interventions to be implemented were, .referral to social services, psychiatric services and the chaplain . for Resident #10 and Resident #13. Additionally, the concern would be carried through the Quality Assurance Performance Improvement Committee (QAPI) for resolution. Resident #10 was also .monitored every 15 minutes for 12 hours and will be kept away from Resident #13 . Record review revealed Resident #10 did not have a psychiatric consult until [DATE], almost 3 months after the incident. Additional record review revealed no Social Service note, or visit to Resident #10 or Resident #13 after the incident. Furthermore, there was no Chaplain referral made. Review of Resident #10's Behavior Care Plan dated [DATE], revealed his physical and verbally aggressive behaviors were present on admission. No new interventions were noted on Resident #10's Behavior Care Plan, except for every 15-minute monitoring for 12 hours to prevent further incidents. Review of the facility investigation dated [DATE] for Resident #11 and record review revealed Resident #11 was involved as the aggressor in a witnessed resident to resident altercation with Resident #13 on [DATE]. Further review revealed no written witness statements were included with the investigation. Review of Resident #11's Admission MDS, dated [DATE], revealed the resident was admitted to the facility on [DATE] with Dementia with Behavioral Disturbances, Restlessness and Agitation and [MEDICAL CONDITION]. Further review revealed the resident's BIMS score was 0 out of 15 indicated severe cognitive impairment; exhibited physical and verbal behavioral symptoms toward others and behavioral symptoms which impacted himself, resisting care and wandering and as having Delusions. Further review revealed Resident #11's locomotion on the unit was coded as extensive assistance and was able to ambulate on the unit with assistance. Review of the facility investigation, dated [DATE], revealed this was the first resident to resident incident for Resident #11. The documented interventions to be implemented were, .referral to social services, psychiatric services and the chaplain . for Resident #11 and Resident #13. Additionally, the concern would be carried through the QAPI committee for resolution. Resident #11 was also .referred to an outside psychiatric facility and currently one on one monitored . No documentation could be found in the record, or provided by the facility, of the one to one monitoring provided for Resident #11. Medical record review revealed no Social Service note, or visit to Resident #11 or Resident #13 after the incident. Further review revealed no Chaplain referral made for Resident #11. Review of Resident #11's Behavior Care Plan, dated [DATE] revealed his physical and verbally aggressive behaviors were present on admission. No new interventions were noted on Resident #11's Behavior Care Plan after the incident with Resident #13 to prevent further incidents and protect the residents from abuse. Review of the facility investigation dated [DATE] revealed Resident #12 was the victim in a witnessed resident to resident altercation with Resident #13 on [DATE]. Further review revealed no written witness statements were included with the investigation. Medical record review of Resident #12's Quarterly MDS dated [DATE] revealed the resident was admitted to the facility on [DATE] with Dementia without Behavioral Disturbances, [MEDICAL CONDITION] and [MEDICAL CONDITION], both eyes. Further review revealed the resident's BIMS score was 10 out of 15, indicating moderate cognitive impairment. Further review revealed Resident #12 exhibited physical and verbal behavioral symptoms toward others and behavioral symptoms which impacted her, resisting care and wandering; and her locomotion on the unit was coded as limited assistance and was able to ambulate on the unit independently with her cane. Review of the facility investigation dated [DATE] (however the record for Resident #12 and Resident #13 reflected the incident occurred on [DATE] at 8:00 PM) the interventions to be implemented were, .referral to social services, psychiatric services and the chaplain . for Resident #12 and Resident #13. Additionally, the concern would be carried through the QAPI committee for resolution. Medical record review revealed no Social Service note, or visit to Resident #12 or Resident #13 after the incident and there was no referral made to the Chaplain. Review of Resident #12's Behavior Care Plan, dated [DATE], revealed her physical and verbally aggressive behaviors were present on admission. No new interventions were noted on Resident #12's Behavior Care Plan after the incident with Resident #13 to provide protection from abuse. Review of the facility investigation dated [DATE] revealed Resident #13 was involved as the aggressor in a witnessed resident to resident altercation with Resident #12 on [DATE]. Further review revealed no written witness statements were included with the investigation. Review of Resident #13's Quarterly MDS, dated [DATE], revealed the resident was admitted to the facility on [DATE] with Dementia with Behavioral Disturbances, [MEDICAL CONDITION] and history of Alcohol and Opioid Abuse. Further review revealed the resident's BIMS score indicated severe cognitive impairment; and the resident exhibited physical and verbal behavioral symptoms toward others and behavioral symptoms which impacted himself, resisting care, wandering and had frequent hallucinations and delusions. Further review revealed Resident #13's locomotion on the unit was coded as limited assistance and was able to ambulate on the unit independently. Review of the facility investigation dated [DATE] (however the record for Resident #12 and Resident #13 reflected the incident occurred on [DATE] at 8:00 PM) the documented interventions to be implemented were, .referral to social services, psychiatric services and the chaplain . for Resident #12 and Resident #13. Additionally, the concern would be carried through the QAPI committee for resolution. Medical record review revealed no Social Service note, or visit to Resident #13 after the incident. Further review revealed no Chaplain referral was made and no interventions were put in place to protect other residents from abuse. Review of Resident #13's Behavior Care Plan, dated [DATE], revealed his physical and verbally aggressive behaviors were present on admission. No new interventions were noted on Resident #13's Behavior Care Plan after the incident with Resident #12. Review of a facility investigation dated [DATE] and medical record review revealed Resident #13 was involved as the aggressor in a witnessed resident to resident altercation with an additional Resident #15 on [DATE]. Review of the facility investigation, dated [DATE], revealed Resident #13 was .immediately removed from the area and placed on 1:1 (one to one) . No documentation could be found in the record or provided by the facility upon request of Resident #13's one to one intervention implementation. The facility investigation revealed Resident #13 had a history of [REDACTED].when provoked . Further review of the facility investigation revealed the interventions to be implemented were, .referral to social services, psychiatric services and the chaplain . for Resident #13 and the resident's victim. Additionally, the concern would be carried through the QAPI committee for resolution. Resident #13 was transferred to an inpatient psychiatric unit on [DATE] and returned to the facility on [DATE]. Review of a facility investigation dated [DATE] revealed Resident #15 was the victim of a witnessed resident to resident altercation with Resident #13 on [DATE]. Further review revealed no written witness statements were included with the investigation. Review of Resident #15's Quarterly MDS dated [DATE] revealed the resident was admitted to the facility on [DATE] with Dementia and Anxiety Disorder. The resident's BIMS score was 6 out of 15 indicating severe cognitive impairment. Further review revealed Resident #15 had behaviors of wandering; locomotion on the unit was coded as limited assistance, and could ambulate on the unit independently in her wheelchair. Review of the facility investigation dated [DATE] revealed the interventions to be implemented were .referral to social services, psychiatric services and the chaplain . for Resident #15 and Resident #13. Additionally, the concern would be carried through the QAPI committee for resolution. No intervention was put in place to protect Resident #15 from Resident #13. Medical record review revealed no Social Service note, or visit to Resident #15 after the incident and no Chaplain referral was made. Further review revealed the psychiatric referral was not done until [DATE], almost 4 months after the incident. Review of Resident #15's Behavior Care Plan, dated [DATE], revealed no new interventions were noted on Resident #15's Behavior Care Plan after the incident with Resident #13 to ensure protection for Resident #15 from further abuse. Observations of Resident #15 on the secure unit on [DATE] at 9:30 AM; [DATE] at 5:30 PM; [DATE] at 12:30 PM; [DATE] at 3:00 PM; and [DATE] at 11:00 AM, revealed the resident in her wheelchair moving freely throughout the unit and asking everyone she encountered for her .nerve pill and some coffee . None of the 5 resident-to-resident incidents, which involved Resident #10, Resident #11, Resident #12, Resident #13 and Resident #15, had any assessment as to the root cause, or reasonable explanation as to the cause of the incident per facility policy. Additionally, interventions beyond referrals to Social Services, Psychiatric Services and the Chaplain were not explored by the facility nor was there evidence they were completed or provided by the facility. Interview with the DON on [DATE] at 2:20 PM, in the conference room, revealed written witness statements were not obtained per policy, only .verbal statements . She also stated the facility .attempts to determine a root cause . during the investigation, but it's not documented. Additionally, the DON could not state how they track or monitor resident-to-resident altercations, in which to determine correct interventions have been implemented. The DON further stated they .take reportable to their Quality Assurance meeting to determine root causes . Interview with the Administrator, and review of the investigations which involved Resident #10, Resident #11, Resident #12, Resident #13 and Resident #15, on [DATE] at 4:00 PM, in the conference room, revealed the Administrator would not be able to .conclusively . determine outcomes of the resident-to-resident incidents based on the information in the facility investigation documentation. Additionally, he stated .The details are not here .",2020-09-01
3390,NASHVILLE CENTER FOR REHABILITATION AND HEALING LL,445512,832 WEDGEWOOD AVENUE,NASHVILLE,TN,37203,2017-09-27,314,G,1,0,9IDG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of the Weekly Skin form, and interview, the facility failed to ensure appropriate care and services to prevent the development of pressure ulcers for 1 resident (#24) of 22 sampled residents. The failure contributed to the development of a Stage III pressure ulcer resulting in HARM for Resident #24. The findings included: Review of facility policy, The Skin Assessment and Evaluations, undated revealed the admission nurse would identify alteration in resident's skin integrity. The nurse would notify the Physician for a treatment order and document in the resident's record. The Admission Nurse would generate a skin Interim Care Plan. Weekly skin assessment would be documented. The Physician and family notification would be made with all newly identified alterations in resident skin integrity and documented in the medical record by the nurse identifying the new skin alteration. If a new alteration in resident skin integrity was identified, the CNA (Certified Nursing Assistant) would report it to the charge nurse. At the time a new alteration in skin integrity was identified, the resident's Care plan should be revised. All resident alterations in skin integrity would be tracked weekly. Medical record review revealed Resident #24 was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 4/19/17 revealed the resident required assistance with Activities of Daily Living (ADLs) had a suprapubic catheter due to [MEDICAL CONDITION] Bladder, [MEDICAL CONDITION], Overactive Bladder, and Bowel Incontinence; was at risk for developing skin breakdown related to impaired mobility, and occasional suprapubic catheter leakage and occasional bowel incontinence. There was no skin breakdown included on the care plan and no specific interventions to address the resident's needs to prevent skin breakdown. There were no interventions that addressed the leaking catheter. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a BIMS (Brief Interview for Mental Status) score of 15 out of 15 indicating the resident was cognitively intact. Continued review revealed the resident required extensive assistance to total dependence for activities of daily living except for eating, always incontinent of bowel and had an indwelling catheter for the bladder. Further review of the assessment revealed the resident had no skin integrity concerns. Medical record review of the Weekly Skin form dated 9/22/17 by Registerd Nurse (RN #4) revealed there was friction [MEDICAL CONDITION] on the resident's posterior left thigh, an abrasion on the coccyx, and an abrasion on the right thigh. Further review of the Weekly Skin form dated 9/26/17 at 6:13 AM revealed the same documentation as the 9/22/17 form. Interview with Resident #24 on 9/26/17 at 10:15 AM in her room revealed the staffing was low. She stated the Certified Nursing Assistants (CNAs) had told her they could not get her up due to not enough staff. She stated last night (9/25/17) at 10:00 PM she had been incontinent of stool and her indwelling urinary catheter had a large amount of leakage. Resident #24 stated CNA #8, while cleaning the resident, informed the resident she would only clean her up once during the night shift. The resident stated she did not get checked or changed until the dayshift when CNA #5 came in this morning at 7:30 AM and changed and repositioned her. Resident #24 stated the CNA told her she was still dirty on her buttocks. Interview with CNA #5 on 9/26/17 at 10:30 AM in the 500 unit hall revealed Resident #24 was drenched with urine and stool when he went to change her at 7:30 AM today. He stated there was a large amount of stool and urine that was almost the consistency of mud. The resident told him what CNA #8 had told her last night, about only clean(ing) her up once during the night shift, and that no one had checked or changed her since 10:00 PM the previous night. CNA #5 stated he changed and repositioned the resident, then reported the resident's condition to Registered Nurse (RN) #4. Continued interview revealed he stated he did not tell the RN what CNA #8 said to Resident #24, about only clean(ing) her up once during the night shift. CNA #5 stated the resident had an indwelling urinary catheter that consistently leaked urine, her buttocks and the back of her thighs were red and there had been an open area on the back of the upper left thigh for a week. The CNA stated the resident did not get up due to the lack of staff. Interview with RN #4 on 9/26/17 at 10:35 AM in the 500 unit hall revealed CNA #5 had reported the resident's condition at 8:00 AM this morning. Upon the request of the surveyor the RN went to assess Resident #24's skin condition. Observation with RN #4 revealed an open area on the left upper posterior thigh with some slough. The buttocks and thighs bilaterally were very red and unblanchable. RN #4 stated the wound nurse took care of those type of things. The RN confirmed she was unaware the resident had any open areas or skin integrity concerns. RN #4 stated CNA #5 had reported the resident's condition to her at 8:00 AM. She confirmed she did not assess the resident until the surveyor's request. Continued interview with RN #4 confirmed the resident did not get up into the chair because there were not enough staff. RN #4 confirmed the staff was aware the indwelling urinary catheter consistently leaked. Interview with the Licensed Practical Nurse (LPN) #13, who was the Wound Nurse, on 9/26/17 at 1:40 PM in the conference room revealed she was unaware of any open areas regarding Resident #24. She confirmed there was no documentation regarding any open areas and there was no documentation regarding the resident's skin integrity after 6:13 AM on 9/26/17. LPN #13 confirmed RN #4 did not enter any documentation (into the computer) regarding the observations made on 9/26/17 at 10:30 AM. She stated the expectation was the floor nurses would assess/evaluate, document, call the Physician and get orders when the Wound Nurse was not there. LPN #13 stated she looked in the computer for updates regarding skin issues. Interview with LPN #13 revealed she did not do wounds full time. Medical record review of a physician's orders [REDACTED].cleanse with normal saline and apply duoderm patch one a day and as needed . The order was received by RN #4. Medical record review of a Non Ulcer Skin Condition form dated 9/26/17 at 4:38 PM by LPN #13 revealed the left thigh wound was Friction [MEDICAL CONDITION] that measured 1.5 centimeters (cm) long, 0.8 cm wide and 0.1 cm deep. Interview with the Assistant Director of Nursing (ADON) on 9/26/17 at 5:30 PM in the Director of Nursing's office confirmed the documentation made by LPN #13. They confirmed RN #4 had not documented any observations regarding the wound. The ADON and LPN/Talent Manager revealed they would assess the wound and the reddened areas. Medical record review of an Initial Weekly Wound form dated 9/26/17 at 6:19 PM by the LPN/Talent Manager revealed a pressure ulcer on the left thigh that measured 1.5 cm long, 0.8 cm wide and no depth. The wound was documented as a Stage III pressure ulcer. Medical record review of the Physician order [REDACTED].cleanse with normal saline, apply Santyl (prescription ointment that cleans wounds to clear the way for healthy tissue) and a dry dressing each day and as needed . Interview with the ADON on 9/27/17 at 9:30 AM in the conference room confirmed Resident #24's Stage III pressure ulcer was not assessed or treated properly. She revealed the Physician was notified and new orders were received to treat the Stage III pressure ulcer. Continued interview confirmed the Stage III pressure ulcer was not documented per facility policy until surveyor intervention on 9/26/17. The failure to ensure care was provided to prenvent the development of a Stage III pressure ulcer resulted in HARM for Resident #24.",2020-09-01
2499,"NHC HEALTHCARE, FARRAGUT",445415,120 CAVETT HILL LANE,KNOXVILLE,TN,37922,2017-06-20,520,J,1,0,MVUF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of the facility incident/accident investigations, and interview, the facility's Quality Assurance Committee failed to ensure timely development of an effective evaluation, implementation, and monitoring system to ensure residents were free from accidents/incidents and were provided adequate supervision to prevent falls for 6 residents (#1, #2, #3, #5, #7, and #9) of 10 residents reviewed. The facility's failure placed Residents #1 and #3 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirement of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The facility was cited Substandard Quality of Care at F-323 (J). The Administrator, Assistant Administrator, Assistant Regional Director of Clinical Services, Director of Nursing, Assistant Director of Nursing, and the Health Information/Quality Assurance Quality Improvement Coordinator were notified of the Immediate Jeopardy on 6/19/17 at 2:40 PM, in the conference room. The findings included: Resident #1 was admitted to the facility for rehabilitation therapy after a fall with a [MEDICAL CONDITION] requiring surgical repair, with the goal to return home with her husband. The resident was identified as a severe risk for falls upon admission 5/8/17. The facility had care planned safety interventions, including the use of pressure pad alarms to the bed and wheelchair. On 5/20/17 the resident was assisted by the therapist back to her room after therapy. Occupational Therapist (OT) #2 confirmed she was aware the alarm was not functioning, did not know how to fix it, and failed to report it to the nurse. Resident #1 sustained a left wrist fracture and a laceration to her left brow requiring 6 sutures. Interviews confirmed the chair pressure pad alarm was unplugged and did not alarm. The falls investigation and interventions implemented did not address the alarm being disconnected and new interventions of nonskid socks, which the resident was already wearing at the time of the fall, and clear pathways were not based on an investigation of the cause of the fall. Resident #3 was admitted to the facility for rehabilitation therapy with the goal of returning to her previous assisted living setting. The resident was identified as severe risk for falls upon admission to the facility. The resident had a change in antipsychotic medication therapy on 5/22/17. The evening of 5/22/17, the nurse contacted the family and reported the resident had gotten out of bed twice during the shift setting off alarms. The resident was assisted back to bed by the nurse without additional interventions, and left unattended. The resident got up a third time, fell , and sustained a [MEDICAL CONDITION]. The resident was admitted to the hospital, underwent a left hip hemiarthroplasty, returned to the facility on [DATE], and remained in the facility. Resident #2 experienced 3 falls on 5/19/17, 5/24/17, and 6/2/17. There was no thorough investigation to determine causes of falls with interventions implemented to specifically address those falls. Facility documentation after falls indicated implementation of educating the resident to use the call light, which was to have been in place since admission and not a reliable intervention for a resident with impaired cognition. The intervention of walking or wheelchair assessment implemented after one fall was actually a routine assessment performed by therapy. Resident #5 fell on [DATE] and the facility's intervention to address the fall and prevent further falls was a pharmacist medication review. The medications were reviewed by the pharmacist with no changes made and there were no other assessments for causes for the fall after it was determined the medications had not contributed to the fall, and no interventions put in place to prevent further falls. Resident #7 had a moderate cognitive impairment and had 4 falls. The intervention to not be left unattended while toileting was an intervention used after 3 of the falls on 3/9/17, 3/10/17, and 3/15/17. Another intervention of re-education to use the call light and request assistance was not an appropriate intervention for the fall on 3/10/17 due to the resident's impaired cognition. Resident #9 fell on [DATE] with the intervention of scheduled toileting, but the facility did not do scheduled toileting. After a fall on 3/25/17 no new interventions were implemented. After a fall on 4/18/17 the intervention of a fall mat was implemented, however, there was no evidence the fall mat had been placed at the bed side at the time of the fall on 4/24/17. Interview with the Administrator, Director of Nursing, and the Assistant Regional Director of Clinical Services on 6/8/17 at 3:20 PM, in the conference room, revealed .initiated a Quality Improvement Performance Improvement (QAPI) when we recognized we had a pattern .trend with falls . Interview with the facility QAPI Coordinator on 6/19/17 at 9:00 AM, in the conference room, confirmed the QAPI project for falls began on 11/3/16 and the QAPI program was not effective in evaluation, implementation, and monitoring residents with falls. The Immediate Jeopardy was effective 5/20/17 through 6/20/17. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the jeopardy, was received on 6/20/17. The corrective actions were validated on site through review of documents, observation, and staff interview by the surveyor on 6/20/17. 1. The Administrator, Physician, Director of Nursing, Assistant Director of Nursing, Risk Manager, Maintenance Director, Social Worker, Activities Director, Dietitian, Director of Rehabilitation, and a Certified Nurse Assistant reviewed and updated Resident #3's care plan with the intervention of a concave mattress. Resident #1 had discharged home on[DATE]. 2. Review of a facility document and interview with the DON on 6/20/17 confirmed the DON, ADON, Risk Manager, and Regional Nurses conducted a review of all residents and verified all safety devices were in place and functional as care planned. 3. Reviewed facility in-service records dated 6/19/17 and 6/20/17, and observations and interviews were conducted on 6/20/17 from 4:40 PM to 7:15 PM with 7 RNs, 2 LPNs, 4 CNAs, 2 Therapists, covering both shifts, and the DON, ADON, and the Risk Manager, to validate the nursing and therapy staff had been educated on the use of the alarms. Staff was in-serviced on ensuring interventions were in place, what to do if an alarm is not functioning and staff responsibility to implement additional interventions as needed based on resident needs. Staff received training on procedures for identifying orthostatic [MEDICAL CONDITION] and reporting concerns to the medical staff. Staff was in-serviced on a new electronic tool used to verify alarms and safety equipment are in use and working properly. The electronic tool can be updated 24/7 and is a communication tool between all disciplines. 4. Observations on 6/20/17 beginning at 5:15 PM confirmed the safety measures for 3 additional residents at risk for falls were listed on the Kardex located in the resident's inside door closet and the electronic communication tool was available with safety devices in use and measures had been implemented as assessed and care planned. 5. Review of the facility audit tool, medical record reviews, and observations revealed the facility had implemented evaluation and monitoring of safety interventions/devices, and updated care plans and the electronic communication tool by 6/20/17. Noncompliance continues at a scope and severity D for monitoring of the effectiveness of collective actions to ensure sustained compliance. Refer to F-282 and F-323",2020-09-01
1059,RAINTREE MANOR,445216,415 PACE STREET,MC MINNVILLE,TN,37110,2018-06-18,609,D,1,0,3K8X11,"**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 to follow their abuse policy for reporting allegations of abuse for 1 resident (#1) of 5 residents reviewed for abuse. The findings included: Review of the facility policy Abuse Prevention Policy & Procedure dated 10/1/11 revealed .All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint, allegation, observation or suspicion of resident abuse, mistreatment, or neglect, so that the resident's needs can be attended to immediately and investigation can be undertaken promptly .The investigation protocol must be implemented and a report given to the appropriate agencies as specified by law and regulations . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. Review of the facility investigation revealed .Date of Occurrence 6/2/18 Time of Occurrence 6:00 PM .On 6/3/18 at 7:15 PM, Director of Nursing (DON) made aware of allegation of physical abuse . Interview with Certified Nurse Aide (CNA) #1 on 6/13/18 at 10:15 AM, in the conference room, revealed (CNA #2) asked me to help her with (Resident #1) she needed changing. I was holding her hands because if you don't she will scratch you or herself, (CNA #2) was trying to get her shirt off, and (Resident #1) was restless, she moves around when you are trying to change her, and she spits all the time. She was making the noise like she does when she is going to spit, and that's when (CNA #2) popped her in the mouth. I didn't report the incident before I left the facility. I knew I should have told someone then, but I didn't. I told the charge nurse the next day what had happened. Further interview confirmed CNA #1 was unable to recall when he had reported the allegation of abuse to the charge nurse. I can't remember for sure when I told her. Interview with Registered Nurse (RN) #1 on 6/14/18 at 11:10 AM, via telephone, confirmed CNA #1 had reported the allegation of abuse to her between 4:00 PM and 5:00 PM, on 6/3/18. He reported it happened at the end of the shift on 6/2/18 .I explained he was supposed to report it immediately, and remove the patient from the situation. Continued interview confirmed she had notified the administrative staff on call, but had not called him until approximately 6:30 PM, on 6/3/18, when she was leaving the facility . Interview with the DON on 6/13/18 at 3:40 PM, in the conference room, confirmed the incident had occurred on 6/2/18 at approximately 6:00 PM, and (CNA #1) had not reported it until the following night between 4:00 and 5:00 PM to the Nurse Supervisor (RN #1). RN #1 did not report the allegation of abuse to administration until approximately 7:00 PM on 6/3/18. Further interview confirmed the facility failed to follow their abuse policy for reporting abuse, and failed to report an allegation of abuse to the State within the federally required time frame.",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
3719,SIGNATURE HEALTHCARE OF FENTRESS COUNTY,445362,208 DUNCAN ST N,JAMESTOWN,TN,38556,2017-03-28,224,J,1,0,Q88111,"**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 to prevent neglect of 1 resident (Resident #6) of 6 residents reviewed for abuse and neglect, of 13 sampled residents. The facility's failure to initiate Cardiopulmonary Resuscitation (CPR) to Resident #6, who was found in cardiac and respiratory arrest on [DATE] at 7:00 AM, constituting neglect, placed Resident #6 in Immediate Jeopardy (a situation where the providers noncompliance with one or more requirements of participation, has caused, or is likely to cause, serious injury, harm, impairment or death). F-224 was cited at a scope and severity of J and is Substandard Quality of Care. The Administrator, Director of Nursing (DON), and Corporate Nurse were informed of the Immediate Jeopardy on [DATE] at 3:25 PM, in the conference room. The IJ was effective [DATE] - [DATE]. The facility's corrective action plan which removed the IJ was received and corrective actions were validated onsite by the surveyor on [DATE] - [DATE]. The IJ was cited as past noncompliance for F-224 and the facility iss not required to submit a plan of correction. The findings included: Review of the facility policy, Abuse, Neglect and Misappropriation or Property (undated), revealed .policy to prevent the occurrence of abuse, neglect .willful means non-accidental, or not reasonably related to the appropriate provision of ordered care and services depending on the context .Neglect means failure to provide goods and services necessary to avoid physical harm .every stakeholder, contractor .and volunteer must intervene immediately, to the extent feasible and consistent with personal safety and the persons training to prevent or interrupt an incident of abuse . Review of the facility policy, Cardiopulmonary Resuscitation, (CPR), undated, revealed .Upon identifying a resident with a change of condition which presents as an unresponsive condition .check the medical record for advance directive status .if resident record indicates CPR is to be instituted, then initiate Basic Life Support (maintenance of airway, breathing, circulation) if a pulse and/or respirations are undetectable .if a resident is found unresponsive and without respirations, a licensed staff member who is certified in CPR .shall promptly initiate CPR for residents .who have requested CPR in their advance directives . Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Admission Consent Forms and the Tennessee Physicians Orders for Scope of Treatment (POST, or advanced directives form) executed on [DATE], revealed Resident #6, a [AGE] year old resident, was to receive CPR, Intubation (insertion of a breathing tube), advanced airway interventions, mechanical ventilation as indicated, transfer to a hospital or intensive care unit if indicated, and full treatment in an intensive care unit if indicated, in the event of a respiratory or [MEDICAL CONDITION]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #6 had a Brief Interview of Mental Status (BIMS) score of 15 (indicating she was cognitively intact), was independent in decision making, dependent upon supplemental oxygen to breathe, and the resident required moderate assistance of one person for activities of daily living (ADLs). Medical record review of the Physician Orders dated [DATE] at 4:21 PM, revealed .Advanced Directive .FULL CODE (full code is a hospital designation that means to intercede if a patient's heart stops beating or if the patient stops breathing) . Medical record review of a Nursing Progress Notes Report revealed on [DATE] at 6:00 AM, Resident #6 was found seated on her bed by Licensed Practical Nurse (LPN) #1, and the resident reported to the LPN she had problems breathing. LPN #1 administered ordered breathing treatments ([MEDICATION NAME], a medication to improve breathing) and oral [MEDICATION NAME] (narcotic, for pain) to the resident and informed Registered Nurse (RN) #1 of the resident's status. Medical record review of a Nursing Progress Notes Report revealed on [DATE] at 6:37 AM, Resident #6 activated the call light, RN #1 and LPN #1 responded, and found Resident #6 on the side of the bed. Continued medical record review revealed the resident remained short of breath and requested to be transferred to the hospital to be intubated (insertion of a breathing tube), and the Resident's request was not honored. Medical record review of the Nursing Progress Notes Report dated [DATE] at 7:00 AM revealed Resident #6 was found by RN #1, slumped over in bed, gray in color, and without a pulse or respirations (cardiac and respiratory arrest). Continued review of the Nursing Progress Notes Report revealed RN #1 did not attempt to perform CPR on Resident #6 in accordance with the Residents' Advance Directives and Physician Orders, and instead pronounced the resident deceased at 7:06 AM. Review of the facility investigation dated [DATE] revealed at the time of Resident #6's [MEDICAL CONDITION], LPN #1, LPN #3, LPN #15, and Respiratory Therapist (RT) #4 advised RN #1 of Resident #6's Advance Directives status as a full code. Continued review of the facility investigation revealed LPN #1, LPN #3, LPN #15 and RT #4 questioned the RN #1's decision to not perform CPR on the resident. Continued review revealed RN #1 stood between the staff and the resident's body with her arms outstretched, as if to deny them access to the resident, and informed them no CPR would be performed. None of the staff present (LPN #1, LPN #3, LPN #15, RT #4) intervened to perform CPR. Continued review revealed RN #1 refused to perform CPR on the resident when advised by Resident #6's Physician of the resident's full code status. Review of RN #1's investigative interview summary (the findings of the investigative interview conducted by the facility's attorney) dated [DATE], revealed .Entered resident's room to give drink .assisted resident with same .replaced resident O2 (oxygen) mask back on face .(LPN #1 giving meds) .Resident SATS (blood oxygen saturation) were 95% good .Later 2 CNAs (Certified Nurse Aide) approached, saying resident would like to go to hospital .I assessed resident .resident stated she wanted to be intubated .I found not needed and that resident was very tired .covered resident with blanket .put at 90 degrees in middle of the bed .relayed I would notify her family and doctor .skin color dusky color .cool to touch .room was very cool .with .(LPN #1) .started looking up family contact info (information) .then walked back to resident room to get more family names from resident .found resident slumped over with her head down to the end of bed .this was approximately 30 minutes after I had left resident .yelled for stethoscope .two other nurses nearby .one went to call resident's daughter .assessed resident .no pulse or respirations .skin dusky, eyes 1/2 open, lips and nails blue tinge .Nurse (LPN #1) said resident is full code .I responded resident has clearly passed, nothing to do .Spoke with Doctor, told him resident expired and I would not initiate code, would pronounce her at 7:06 AM . Interview with CNA #1 on [DATE] at 6:55 PM, in the conference room, revealed she witnessed the incident on [DATE] around 7:00 AM. Continued interview revealed CNA #1 stated I was getting report from the night CNA when (RN #1) came out of the room and said .(Resident #6) had passed . Continued interview revealed she witnessed a telephone call between RN #1 and Physician #3 and heard the nurse inform the Physician the resident had expired. RN #1 said she .wouldn't do compressions on a dead person . Telephone interview with Physician #3 (the attending Physician for Resident #6) on [DATE], at 10:57 AM, revealed when he was contacted by RN #1 on [DATE] between 7:00 and 7:15 am, he questioned the nurse if CPR had been initiated or was in progress and was informed by RN #1 CPR had not been attempted at all. Continued interview revealed Physician #3 advised RN #1 the resident was full code status and CPR was to have been initiated, and RN #1 stated you want me do CPR on a dead person? Continued interview revealed RN #1 informed him she had declared the resident deceased at 7:06 AM. Continued interview revealed he believed CPR .should have been attempted . on Resident #6 prior to declaration of death by RN #1. Interview with LPN #1 on [DATE] at 11:36 AM, in the conference room, revealed on [DATE] around 7:00 AM she observed Resident #6 in [MEDICAL CONDITION] and RN #1 was present. Continued interview revealed the resident's appearance was .slumped over on the side of the bed, upright with no breathing and no pulse . and LPN #1 assisted RN #1 to position the resident in the bed for assessment. Continued interview revealed LPN #1 advised RN #1 .she (Resident #6) is a full code . Continued interview revealed RN #1 replied to her and stated we're not doing nothing to this poor woman, she's gone, she's been through enough . Continued interview revealed .(RN #1) knew (Resident #6) was a full code because we had discussed it earlier in the shift when talking about the morning shift report . Continued interview revealed as she and RN #1 assessed Resident #6, LPN #15 and RT #4 entered the room. Continued interview revealed LPN #1 heard LPN #15 and RT #4 ask RN #1 if CPR was to begin and both staff members advised RN #1 of the resident's advanced directives. Further interview revealed .the day shift nurses came in the room and asked, 'Are we gonna (going to) code her' .and (RN #1) said, 'No we aren't gonna do anything' .no one else questioned it .(RN #1) was guarding the body, standing between us and everyone else and the body .arms outstretched and said to everybody, 'No, we aren't going to do a thing' .I'm screaming to call the doctor and (LPN #15) went and called the doctor and I followed her to the nurse station to call the doctor .(LPN #15) called the doctor on the phone and I started to take the phone to talk to the doctor to speak to him .Then (RN #1) comes running up the hall, snatched the phone from (LPN #15)'s hand and started talking to the doctor . Continued interview revealed LPN #1 observed RN #1 yell into the telephone, .I heard (RN #1) yell something like try to take my license .then she slammed down the phone and stormed off the unit .after that I heard someone ask can' t we still do CPR .then someone else say, 'No, the RN pronounced her' . Interview with LPN #3 on [DATE] at 12:47 PM, in the conference room, revealed she witnessed the incident. Continued interview revealed she overheard RN #1's telephone call with Physician #3 shortly after 7:00 AM. Continued interview revealed .I heard (RN #1) say 'I am not doing CPR on a dead person, you can take my license' and at that point there was big confusion .I pulled the crash cart to the nurses station, asked (LPN #15), we were confused, it wasn't protocol, especially after the phone call .didn't know exactly what was going on .stayed out of night shift's way because they were dealing with it .I didn't learn what had happened until after shift change .I did ask (RN #1) what were we going to do, and heard someone else ask her are we going to do CPR .and I heard (RN #1) say 'I am not doing CPR on a dead person' or something like that . Continued interview confirmed LPN #3 did not perform CPR on the resident. Interview with CNA #3 on [DATE] at 1:48 PM, in the conference room, revealed she witnessed the incident on [DATE], which she stated had occurred around 7:00 AM, at shift change. Continued interview revealed CNA #3 observed RN #1, RT #4 and LPN #1 enter the resident's room around 6:55 AM and the trio emerged ,[DATE] minutes later, and both LPN #1 and RT #4 were crying at the time. Interview with the Director of Nursing (DON) on [DATE] at 2:45 PM in the conference room, confirmed RN #1 had willfully withheld CPR from Resident #6. Continued interview confirmed RN #1 had failed to follow facility policy and confirmed RN # 1's actions constituted neglect of Resident #6. Interview with the Administrator on [DATE] at 4:17 PM, in the conference room, confirmed RN #1's actions on [DATE] were willful and confirmed multiple staff members failed to perform CPR on Resident #6, which constituted neglect. Interview with Respiratory Therapist (RT) #4 on [DATE] at 1:40 PM, in the conference room, revealed on [DATE] around 7:00 AM, she entered Resident #6's room and observed the resident slumped sideways in the bed with her head tilted backwards, mouth open, not breathing, and ashen in color. Continued interview revealed she informed RN #1 the resident was a full code and CPR was to begin at once. Further interview revealed RN 1# stated, .absolutely not, we are not doing a code, she has been down too long . Continued interview confirmed neither RT #4 or the other staff members attempted to perform CPR on the resident. Telephone interview with LPN #15 on [DATE] at 2:24 PM, revealed she witnessed the incident. Continued interview revealed when Resident #6 was discovered without a pulse or respirations at 7:00 AM, she responded to the room to assist in resuscitation efforts and informed RN #1 the resident was a full code. Continued interview revealed .I told (RN #1) the resident was a full code, we needed to code and (RN #1) said, 'No we are not going to code her' .I advised (RN #1) facility policy was to code the resident and (RN #1) refused even after I advised of facility policy . Continued interview revealed other personnel advised RN #1 of the resident's code status and RN #1 continued to prevent staff from performing CPR on Resident #6. Continued interview revealed LPN #15 heard RN #1 refuse to perform CPR on Resident #6, and she heard RN #1 say, I refuse to do CPR on a dead person. Continued interview revealed .I was getting the crash cart with when she (RN #1) held up her hand, mouthed 'No' to me on getting crash cart .after that we stopped, we were taught to never disobey an RN but taught to do codes, felt stuck . The facility's corrective action plan included the following: On [DATE] the facility did the following: [NAME] Held an ad hoc Quality Assurance (QA) meeting during the daily stand up meeting and reviewed the incident. Incident was reported to the State Agency. Follow up QA meeting was scheduled for [DATE]. Responsible party was the Administrator. B. The regional nurse consultant reviewed with the DON and the Administrator the education to be provided to all staff on [DATE] to include Abuse, Resident Rights, Advance Directives, Where to Locate the Advance Directives in the Medical Record, Cardiopulmonary Resuscitation (CPR), Following Physician Orders, Change in Condition and Following Care Plans. Responsible party was the Director of Nursing (DON). C. Once the Administrator and DON were educated, they were assigned to educate the Nursing Administration team Assistant Director of Nursing (DON), Unit Managers, Minimum Data Set (MDS) Nurses, and Staff Development Coordinator), who in turn were assigned to educate all the staff on Abuse, Neglect, Resident Rights, Advance Directives, Where to Locate Advance Directives in the Medical Record, CPR, Following Physician Orders, Change in Condition, and Following Care Plans. Responsible party was the DON). D. Began written competency testing of all staff educated on Abuse, Neglect, Resident Rights, Advance Directives, Where to Locate Advance Directives, CPR, Following Physician Orders, Change in Condition and following Care Plans. Responsible party was the Director of Nursing (DON). E. All staff educated, were required to submit written post-tests with scores of 100% before being permitted to work. All staff who failed to score 100% on the post-tests were immediately re-educated and re-tested until all staff scored 100% on the post tests. Responsible party was the Director of Nursing (DON). F. Initiated the first Mock Code Drill conducted by the DON, ADON, Unit Manager (UM) and the Staff Development Coordinator (SDC) to ensure staff understanding and compliance with the facility code blue policy (policy related to emergency resuscitation) and procedures. No irregularities noted. Mock codes were then planned to be completed for every shift (7 A-7P, 7P-7A) for 72 hours through [DATE], then twice weekly on rotating shifts for 4 weeks starting on [DATE] through [DATE] (scheduled to occur on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and on [DATE] on both shifts) to ensure staff understanding and compliance with the facility code blue policy. The first two Mock Codes were conducted by members of the Nursing Administration Team under observation of the DON, then Mock codes were conducted by nursing staff members under observation of members of the Nursing Administration team. Findings were to be reported to the QA committee weekly for 4 weeks to determine compliance and any further need of continued education or revision of the plan. Responsible party was the Director of Nursing (DON). [NAME] Began ongoing monitoring of staff compliance with abuse, advanced directives, resident rights, CPR, location of advanced directives and Do Not Resuscitate (DNR) forms in the medical record, following physician orders, change in condition reporting and following Care Plans. Responsible party was the Administrator. On [DATE] the facility did the following: [NAME] Resident #6's chart and care plan were reviewed by the Regional Nurse Consultant and Director of Clinical Operations. Registered Nurse (RN) #1 was to have been terminated concluding the investigation but resigned prior to termination. Licensed Practical Nurses (LPN) LPN #1 LPN #3, LPN #15 and Respiratory Therapist (RT) #4 received disciplinary action related to not following facility policy. Responsible party was the DON. B. Began audits of the medical records for all residents in the facility, by the Regional Nurse Consultant and Director of Clinical Operations, to ensure advance directives were in the medical record, were addressed on the care plan, and had current Physician orders related to each resident's code status. Responsible party was the DON. C. All residents were assessed for any possible resident rights violations. Those residents with Brief Interview of Mental Status (BIMS scores, a measure of cognitive function), greater or equal to 8 (cognitively intact) were interviewed by the DON, ADON, UM, Social Services Director (SSD), Social Services Assistant (SSA) for quality of life or resident rights violations. No issues were identified. Responsible party was the DON. D. All residents with BIMS scores less or equal to 7 (cognitively impaired) had skin assessments completed on [DATE] for any concerns by ADONs and UMs for any possible abuse or neglect issues. All residents with a BIMS greater or equal to 8 were interviewed for possible abuse or neglect violations. No issues were identified. Responsible party was the DON. E. Held a Resident Council Meeting (a group of residents who reside in the facility and meet regularly, discuss resident concerns, and discuss resident concerns with Administration) and the SSD and Activities Director reviewed the Resident Rights Statement and Policies for Prohibition of Abuse, Neglect and Misappropriation of Property and provided a copy to each resident. Responsible party was the DON. F. All deaths in the facility for the past 30 days were reviewed by the Regional Nurse to ensure advanced directives were honored with no irregularities noted. The DON reviewed all resident deaths in the facility for the prior 12 months with no irregularities noted. Results were discussed in the QA meeting. Responsible party was the Administrator. [NAME] Held first formal QA meeting to address the incident. DON, ADON, UM, Nursing Supervisors or Medical Records staff were to review all new admissions/readmits and residents with DNR related changes, 24 hour shift reports, and incidents accidents daily for 2 weeks, then Monday through Friday ongoing, starting during morning clinical meeting, to ensure sustained compliance with physician notification, physician orders, interim care plan, advance directives, and resident rights. Corporate administrative oversight of the QA meeting was completed by the Regional Vice President or member of the regional staff weekly for 4 weeks beginning [DATE], then monthly for one quarter. The facility allegation of compliance (A[NAME]) was reviewed by the committee. Responsible party was the Administrator. H. Continued staff education and post testing on Abuse and Neglect, Advanced Directives, Where to find Advanced Directives in the chart, CPR, Resident Rights, following Physician orders, Notification of Change in Condition, and Following Care plans. Responsible party was the DON. I. Grievance logs were reviewed by the Director of Clinical Operation with no irregularities noted. [NAME] Continued Mock Code drills as outlined. Responsbile party was the DON. K. Corrective actions were reviewed by the Administrator, DON, Medical Director and Regional Consultants. Responsible party was the Administrator. On [DATE] the facility did the following: [NAME] The DON, ADON, UM, Administrator and Department Heads continued advance directive/abuse post-tests with 10 random Nursing staff members daily on rotating shifts for 2 weeks through [DATE]. Then 5 random nursing staff members on rotating shifts daily for 2 weeks through [DATE], then 5 random Nursing staff members weekly for 3 weeks through [DATE], with all staff required to score 100% on the post tests. Staff members who failed to achieve 100% scores on the tests were immediately re-educated and required to re-test until 100% scores were achieved. Responsible party was the DON. B. Continued education of all staff members on the facility Abuse and Neglect Policy, Resident Rights, CPR, Advance Directives and Where to find them in the medical record, Notification of Change in Condition, Physician Orders, and Care plans. Responsible party was the DON. C. Continued Mock Code drills on every shift through [DATE] as outlined. Responsible party was the DON. On [DATE] the facility did the following: [NAME] Completed review of all residents medical records by the Director of Clinical Operations and the Regional Nurse to ensure advance directives were in the medical records, addressed on the care plans, and had a current Physician Order regarding code status. No irregularities noted. Responsible party was the Director of Clinical Operations. B. Completed a 100% audit of licensed clinical staff CPR certifications by the Regional Vice President and Regional Nurse Consultant. C. Completed 100% audit of all licensed staff to verify valid Tennessee professional licensure completed by the Regional Vice President. No irregularities were noted. D. Completed 100% audit to ensure staff were not listed on the abuse registry by the Regional Vice President with no irregularities noted. E. Mailed certified letters to all employees who had not completed mandatory training and education and advised completion of training was required prior to any return to work at the facility. The letters included all employees on vacation or paid leave, part time or prn (as needed status). Responsible party was the DON. F. The Administrator began reviews of completed audits for new admissions, readmissions and residents with DNR to ensure sustained compliance with all advanced directives. [NAME] DON, ADON, UM or Weekend Manager on duty began interviews with 5 residents with BIMS scores equal or greater than 8 and 5 family members of residents with BIMS scores less than 8 daily for 2 weeks ([DATE] to [DATE]) for any possible resident rights violations; then 3 residents and 3 family members daily for 2 weeks ([DATE] to [DATE]), then 2 residents and 2 family members daily for 4 weeks ([DATE] to [DATE]), then 1 resident and 1 family member daily for 4 weeks ([DATE] to [DATE]). Results of the interviews and assessments forwarded to the QA committee. Responsible party was the DON. H. All deaths in the facility were reviewed by the DON, ADON, UM or Administrator to ensure code status was implemented correctly as per the resident's wishes and documented on the advance directives daily for 2 weeks through [DATE]; then weekly for 4 weeks from [DATE] to [DATE], then continuing as part of the daily stand up meetings attended by the Administrator, DON, ADONs, UM, MDS Coordinator, Treatment Nurses, Chaplain, SDC, Quality of Life Department Head, SSD, Dietary Manager and Formulary Nurse (the nurse in charge of the central supply office) to ensure sustained compliance. Responsible party was the DON. I. Began Administrative oversight of the facility by a member of Senior Regional Team twice weekly for 2 weeks, beginning [DATE] to [DATE]; then weekly for 4 weeks beginning [DATE] through [DATE], then monthly for one quarter. Responsible party was the Director of Clinical Operations. [NAME] Continued Mock Code drills as outlined above. Responsible party was the DON. K. The DON and SDC began tracking all licensed staff members for CPR certification monthly for 3 months; then every 6 months to ensure all licensed nurses maintained CPR certifications. Findings documented and forwarded to the QA committee monthly to determine any need for education or revision of the process. Responsible party was the DON. L. Established plans for daily contact between the facility and nurses from the regional team or corporate office for 2 weeks, then 2 times weekly for 4 weeks. Nurses from the regional team or home office reviewed compliance with the Plan of Correction and Policy and Procedures, compliance of any code blue to occur, and review of compliance with all new/readmissions. Responsible party was the DON. On [DATE] the facility did the following: [NAME] Completed the twice daily mock code drills as outlined above with no irregularities noted. Initiated the plan for transition to twice weekly Mock Code drills to occur on rotating shifts for another 4 weeks. Responsible party was the DON. B. Continued staff education and competency testing on Abuse and Neglect, Resident Rights, Advance Directives and Where to find them in the Chart, CPR, Notification of Change in Condition, Physician Orders, and Care Plans. Responsible party was the DON. C. Held a follow up QA meeting to review findings from initial audits, scheduled weekly QA meetings for 4 weeks, then monthly, for recommendations and further follow up regarding the Corrective Action Plan. At that time, based upon evaluation, the QA committee would determine at what frequency any ongoing audits would be continued. Responsible party was the Administrator. On [DATE] the facility did the following: [NAME] Completed education and competency testing of all staff, with the exception of those on Family Medical Leave (FMLA) or PRN status who had not worked, with 100% scores attained on all post-tests for facility Abuse and Neglect Policy, Resident Rights, CPR and Advance Directives, Where to Locate Advance Directives in the Medical Records, Physician Orders, Notification of Change in Condition, and Care Plans. Employees on FMLA or PRN status were not permitted to work until all education and competency testing completed. Responsible party was the DON. B. Continued all random audits, staff and resident interviews, and competency testing as outlined above. Responsible party was the DON. C. Continued daily stand up meeting reviews as outlined above, which included reports to Administration on the progress of the facility corrective action plans and changes in resident condition. Responsible party was the DON.",2020-03-01
1096,RENAISSANCE TERRACE,445223,257 PATTON LANE,HARRIMAN,TN,37748,2020-01-22,609,D,1,0,CLGJ11,"**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 failed to report an injury of undetermined origin with a fracture for 1 resident (#2) of 3 residents surveyed for incidents or accidents. The findings included: Review of a facility policy titled Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan, undated, showed .all injuries or bruises that are suspicious in any way or injuries of unknown origin must be investigated.injury is classified as injury of unknown origin when.the source of the injury was not observed by any person.or.could not be explained by the resident.The Administrator.or.Director of Nursing is responsible for initial reporting.investigation of alleged violations.reporting of results to proper authorities.the law requires facility staff to report investigate and document injuries. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility investigation dated 1/18/2020 showed on 1/18/2020 at approximately 6:20 AM Certified Nurse Aide (CNA #1) reported the onset of redness above the left eye of Resident #2 to the Registered Nurse (RN #1). RN #1 examined Resident #2, but took no further actions and did not report the injury to the oncoming nurse (RN #2) during the morning shift change at 7:00 AM. Review of a Nurse's Note and Change in Condition form dated 1/18/2020 at 12:00 PM showed the redness to Resident #2's left eye orbit had worsened, along with the development of swelling on her forehead and the onset of bruising to Resident #2's left hand. CNA #2 reported the change to RN #2. Review of a Nurse's Note dated 1/18/2020 at 10:34 PM showed Resident #2 had increased pain in her left leg and pelvis and x-rays of the leg were ordered at 3:00 AM. Review of a Radiology Imaging dated 1/19/2020 at 8:57 AM on 1/19/2020 showed the resident had a non-displaced [MEDICAL CONDITION] femoral neck (left [MEDICAL CONDITION]). Resident #2 was transported to a local hospital at 9:14 AM by Emergency Medical Services (nearly 27 hours after her initial injury was discovered). During a telephone interview with RN #2 on 1/22/2020 at 3:00 PM the RN stated he first became aware of the resident's injuries on 1/18/2020 around 12:00 PM. During a telephone interview with CNA #1 on 1/22/2020 at 4:22 PM the CNA reported she suspected Resident #2 had fallen and she had reported her suspicions to CNA #2 at shift change, but had not reported them RN #2. During a telephone interview with RN #1 on 1/22/2020 at 5:32 PM the RN stated CNA #2 informed her of Resident #2's injury. RN #1 stated she examined the resident, determined no signs of trauma were present, and did not consider the injury suspicious or reportable. RN #1 stated she did not recall if she reported Resident #2's injuries to RN #2. During an interview with the Administrator on 1/22/2020 at 6:28 PM, in the Administrator's office, the Administrator confirmed the facility failed to report injuries of undetermined origin involving a fracture timely. Continued interview confirmed the facility did not report the injury of unknown injury until 1/20/2020 (2 days after the injury).",2020-09-01
477,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2018-06-12,600,D,1,0,TEPY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of the facility investigation, and interviews the facility failed to prevent abuse for 2 (#1 and #2) of 5 residents reviewed for abuse. The findings included: Review of the undated facility policy Abuse, Neglect and Misappropriation or Property, revealed .It is (facility's) policy to prevent the occurrence of abuse .willful means non-accidental .the individual must have acted deliberately, not that the individual must have intended to cause harm .If a Stakeholder observes a resident exhibiting any form of abuse toward another resident, the Stakeholder will intervene immediately to interrupt the incident and remove and/or separate the residents involved . Medical record review revealed Resident #1 was admitted to the facility on [DATE], readmitted on [DATE], and discharged on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Medical record review revealed Resident #2 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Review of an Annual MDS dated [DATE], revealed a BIMS score of 7, indicating severe cognitive impairment. Interview with Licensed Practical Nurse (LPN) #1 on 6/11/18 at 11:18 AM, via telephone, revealed I was in the East Wing Nurses Station across from the two residents; I was only about ten feet away from them. (Resident #2) came up to (Resident #1), and (Resident #1) asked (Resident #2) how he was doing. (Resident #2) replied he was coming to see what he was doing. I think he (Resident #1) said fine how are you? (Resident #2) replied he had come to look at the ladies, asses because he knew that was what (Resident #1) was doing. That upset (Resident #1), and (Resident #1) called (Resident #2) a Son of a [***] , at that point I stood up and said something like, now (Resident #1) don't talk like that, and he said I don't give a damn, I watched them for a minute, and then I started out from the nurses' station. I'm not sure who swung first, but they both began to swing at, and hit each other. Further interview confirmed based on what she had witnessed the two residents had intentionally hit each other. Interview with the Assistant Director of Nursing (ADON) on 6/11/18 at 3:32 PM, in the conference room, confirmed she had conducted the facility investigation, and based on interviews, and witness statements Resident #1 and Resident #2 had willingly and deliberately exchanged punches to each other, and the facility failed to prevent abuse of two residents.",2020-09-01
5065,CONCORDIA NURSING AND REHABILITATION-SMITH COUNTY,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2016-05-04,323,G,1,0,95GV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of the facility investigation, corrective action plan and interview, the facility failed to ensure a transfer with a mechanical lift was provided with 2 persons and the appropriate size lift sling for one Resident (#2) of 6 residents reviewed for falls, of 10 residents reviewed. The facility's noncompliance resulted in a fall and fracture of the 10th thoracic vertebrae (Harm). The findings included: Review of facility policy, Mechanical Lift (Sling Lift), dated 8/31/14 revealed .A patient lift team consists of at least two employees working together to perform transfers, repositioning, or lifting tasks on high risk patients .using a lift team, position the patient and apply the sling .one staff member guides the patient and one staff member maneuvers the lift . Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Comprehensive Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired, dependent for transfers and all activities of daily living. Review of the care plan revealed .transfers with mechanical lift . Review of the Certified Nursing Assistant (CNA) Kardex revealed . lift sling medium . Review of the facility investigation dated 4/5/16 at 11:10 AM revealed CNA #1 attempted to transfer Resident #2 from the bed with a mechanical lift and a size small lift sling without assistance, resulting in a fall and subsequent oblique fracture of the resident's 10th thoracic vertebrae confirmed by X-rays and Computer Assisted Tomography (CAT scan). Continued review of the investigation, facility policy, and the CNA Kardex revealed Resident #2 required transfer with mechanical lift and assistance of 2 persons using a medium sized lift sling. Interview with Registered Nurse (RN) #1 on 5/2/16 at 3:55 PM, in the conference room revealed RN #1 was the House Supervisor at the time of Resident #2's fall and responded to calls for assistance from CNA #1 from inside the resident's room. Continued interview revealed RN #1 stated she observed the resident in the floor, supine, with her back across the legs of the mechanical lift and her head near the crossbar of the lift and was informed by the CNA the resident had fallen from the sling. Continued interview revealed RN #1 stated she questioned CNA #1 as to why she had attempted to transfer the resident alone and if the CNA was aware facility policy required two persons assistance with all mechanical lift transfers and the CNA responded she was aware of the policy and had not followed it. Continued interview revealed RN #1 stated she also observed the lift was equipped with a small size sling and was aware the resident required a medium sized sling and questioned CNA #1 as to why she used the wrong sized sling and the CNA responded, there wasn't one. Interview with CNA #2 on 5/2/16 at 4:00 PM, in the conference room revealed CNA #2 had also responded to the incident and witnessed the exchange between CNA #1 and RN #1 and confirmed CNA #1 had stated to the nurse she knew the facility policy required 2 persons assistance with all mechanical lift transfers and confirmed CNA #1 stated she was aware the resident required a medium size sling and chose to use a small size sling instead. Interview with the Director of Nursing (DON) on 5/3/16 at 3:14 PM, in the conference room confirmed CNA #1 had attempted to transfer Resident #2 with a mechanical lift alone and without assistance from another qualified staff member and the wrong size sling resulting in a fall from the mechanical lift to the floor and a fracture of the resident's 10th Thoracic Vertebrae (Harm) for Resident #2. The facility's corrective action plan included the following: On 4/5/16 the facility did the following: 1. Ad Hoc Quality Assurance (QA) meeting included Medical Director and review of the facility mechanical lift policy and the resident's care plan, medical record and Kardex completed on 4/5/16 at 11:45 AM. CNA #1 suspended pending investigation of incident. The QA team formulated a QA plan with target dates for completion. 2. In-service training for all floor nurses and CNAs on duty at the time of fall related to mechanical lift policy with emphasis on two persons required at all times and use of proper sling sizes was initiated on 4/5/16 at 11:45 AM. On 4/6/16 the facility did the following: 3. Mandatory in-service training of all employees on all shifts initiated on the facility mechanical lift use policy and sling size use. Audits of all sling inventories and mechanical lifts was initiated on 4/6/16. On 4/7/16 the facility did the following: 4. Completed audits of all mechanical lifts and sling systems in use facility wide. No irregularities noted. Audits of all residents with mechanical lifts in use for accurate sling sizes per body weights per lift manufacturer recommendations was completed. No irregularities were noted. All CNA Kardexes with lift sling size highlighted and documented in same location on Kardex were completed. 5. Second mandatory in-service training to all facility staff related to location of the sling size documentation in the same location and highlighting of sling size prominently on any updated Kardexes was completed. On 4/8 to 4/11/16 the facility did the following: 6. Root Cause Analysis of the incident was completed. CNA #1 was terminated on 4/8/16. Observations of mechanical lift and sling use for all dependent residents by the DON and Assistant Director of Nursing (ADON) on all shifts facility wide including spot audits of all Kardexes for accuracy and additional reviews and interviews of all staff related to mechanical lift policy was completed on 4/8 to 4/11/16. Mandatory in-service for all clinical staff with the findings of root cause analysis were reviewed and completed on 4/11/16. On 4/12/16 the facility did the following: 7. Findings of Root Cause Analysis and Corrective Action Plan Interventions were reviewed with Administrator. The findings were forwarded to Quality Assurance Committee (QA) for full review in the (MONTH) (YEAR) QA meeting. Weekly audits of mechanical lift use and Kardexes were initiated. The first weekly audit was completed by DON with no irregularities noted and full compliance was achieved. The State Agency was notified of incident on 4/12/16. On 4/13 to 4/26/16 the facility did the following: 8. Additional weekly audits of all mechanical lifts and sling use facility wide were completed on 4/19/16 and 4/26/16 and no additional deficient practices were noted. Audits included observations of mechanical lift use and random audits of CNA Kardex documentation on dependent residents by the ADON and DON on all shifts. Weekly audits are ongoing. The surveyors verified the facility's corrective actions onsite during the complaint survey as follows: 1. Observations of mechanical lift use on dependent residents including Resident #2 were completed on both shifts 5/2/16 to 5/4/16. 2. Audits of all CNA Kardexes on all units in the facility revealed all mechanical lift use and sling size documentation was uniform and consistent with manufacturer recommendations, sling sizes were highlighted and documentation was prominently displayed on the first page of the CNA Kardex in the same location. 3. Observations of all mechanical lifts in the facility between 5/2-5/4/16 revealed all lifts were well maintained and in good repair. Additional observations of the sling inventory were completed and sufficient numbers of slings were present in all sizes required and all slings were in good repair. All lift slings of various sizes were readily available for use on all units of the facility on all shifts. 4. Interviews with 7 certified Nursing Assistants (CNAs #2, #3, #4, #5, #6, #7, #8), 3 Registered Nurses (RNs # 1, #2, #3), and 5 Licensed Practical Nurses (LPN #1, #2, #3, #4, #5) revealed all were fully aware of the facility mechanical lift policy, location of all lift slings in the facility, aware of how to appropriately fit residents to sling size based on body weight, aware of the location of sling size documentation on the CNA Kardex, and where to find the most recent weights in the written and electronic medical records for residents who clinicians suspected may need adjustments in sling sizes based on body changes. All staff interviewed were aware of the facility corrective action plan and QA team Root Cause Analysis findings and verified the facility had provided mandatory in-service training related to the incident that involved Resident #2's fall and injury. 5. Interviews with 2 residents and 3 family members of cognitively impaired persons revealed no concerns with staffing levels, abuse or neglect, transfers, mechanical lift use, or resident safety in the facility. 6. Review of the incident and grievance logs for one year revealed no similar incidents involving mechanical lift use and falls were present. 7. Interviews with the Administrator, DON, ADON, and members of the Quality Assurance Team including the MDS coordinator and Social Services Director confirmed the incident was reviewed in an Ad Hoc QA meeting and findings shared with the QA team as noted in the corrective action plan and routine audits of mechanical lift use were ongoing at the time of the complaint investigation. 8. Medical record reviews and reviews of facility fall investigations were completed for 5 additional residents (Residents #4, #5, #6, #7, #8) who had sustained falls in the facility and no deficient practices were identified. The harm existed from 4/5/16 to 4/26/16. The Harm was removed on 4/27/16. The facility's corrective action plan that removed the Harm at F-280- G and F-323 G was received and corrective actions validated onsite by the surveyor on 5/3-4/16. The harm (G) was cited as past noncompliance for F-280 and F-323 and the facility is not required to submit a plan of correction for those tags.",2019-05-01
5064,CONCORDIA NURSING AND REHABILITATION-SMITH COUNTY,445172,112 HEALTH CARE DR,CARTHAGE,TN,37030,2016-05-04,280,G,1,0,95GV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of the facility investigation, review of the facility corrective action plan, and interview, the facility failed to follow the care plan to ensure a transfer with a mechanical lift was provided with the assistance of 2 persons and the appropriate size lift sling for one Resident (#2) of 6 residents with reviewed for falls of 10 residents reviewed. The facility's noncompliance resulted in a fall with a [MEDICAL CONDITION] vertebrae (Harm). The findings included: Review of facility policy, Mechanical Lift (Sling Lift), dated 8/31/14 revealed .A patient lift team consists of at least two employees .identify patient .require a mechanical lift to transfer .include in evaluation correct lift .sling brand .model .size .validate the sling is the correct size .validate that patient falls in the slings minimum and maximum weight range for the sling . Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Comprehensive Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired and dependent for transfers and all activities of daily living. Review of the care plan revealed .transfers with mechanical lift . Review of the Certified Nursing Assistant (CNA) Kardex revealed . lift sling medium . Review of the facility investigation dated 4/5/16 at 11:10 AM revealed CNA #1 attempted to transfer Resident #2 from the bed with a mechanical lift and a size small lift sling without assistance, resulting in a fall and subsequent oblique [MEDICAL CONDITION]'s 10th [MEDICATION NAME] vertebrae confirmed by X-rays and Computer Assisted Tomography (CAT scan). Continued review of the investigation, facility policy, and the CNA Kardex revealed Resident #2 required transfer with mechanical lift with the assistance of 2 persons using a medium sized lift sling. Interview with Registered Nurse (RN) #1 on 5/2/16 at 3:55 PM, in the conference room revealed RN #1 was the House Supervisor at the time of Resident #2's fall and responded to calls for assistance from CNA #1 from inside the resident's room. Continued interview revealed RN #1 stated she observed the resident in the floor, supine, with her back across the legs of the mechanical lift and her head near the crossbar of the lift and was informed by the CNA the resident had fallen from the sling. Continued interview revealed RN #1 stated she questioned CNA #1 as to why she had attempted to transfer the resident alone and if the CNA was aware facility policy required two persons assistance with all mechanical lift transfers and the CNA responded she was aware of the policy and had not followed it. Continued interview revealed RN #1 stated she also observed the lift was equipped with a small size sling and was aware the resident required a medium sized sling and questioned CNA #1 as to why she used the wrong sized sling and the CNA responded, there wasn't one. Interview with CNA #2 on 5/2/16 at 4:00 PM, in the conference room revealed CNA #2 had also responded to the incident and witnessed the exchange between CNA #1 and RN #1 and confirmed CNA #1 had stated to the nurse she knew the facility policy required 2 persons assistance with all mechanical lift transfers and confirmed CNA #1 stated she was aware the resident required a medium sized sling and chose to use a small sized sling instead. Continued interview revealed CNA #2 reported there were multiple medium size slings available on the unit at the time the fall occurred and CNA #1 had not requested her assistance with the transfer. Interview with the Director of Nursing (DON) on 5/3/16 at 3:14 PM, in the conference room confirmed the CNA had failed to follow facility policy for mechanical lifts for a 2 person transfer and failed to follow the the care plan and CNA Kardex for the use of the proper sized lift sling to transfer the resident, resulting in a fall with a [MEDICAL CONDITION] vertebrae (Harm) for Resident #2. The facility's corrective action plan included the following: On 4/5/16 the facility did the following: 1. Ad Hoc Quality Assurance (QA) meeting included Medical Director and review of the facility mechanical lift policy and the resident's care plan, medical record and Kardex completed on 4/5/16 at 11:45 AM. CNA #1 suspended pending investigation of incident. The QA team formulated a QA plan with target dates for completion. 2. In-service training for all floor nurses and CNAs on duty at the time of fall related to mechanical lift policy with emphasis on two persons required at all times and use of proper sling sizes was initiated on 4/5/16 at 11:45 AM. On 4/6/16 the facility did the following: 3. Mandatory in-service training of all employees on all shifts initiated on the facility mechanical lift use policy and sling size use. Audits of all sling inventories and mechanical lifts was initiated on 4/6/16. On 4/7/16 the facility did the following: 4. Completed audits of all mechanical lifts and sling systems in use facility wide. No irregularities noted. Audits of all residents with mechanical lifts in use for accurate sling sizes per body weights per lift manufacturer recommendations was completed. No irregularities were noted. All CNA Kardexes with lift sling size highlighted and documented in same location on Kardex were completed. 5. Second mandatory in-service training to all facility staff related to location of the sling size documentation in the same location and highlighting of sling size prominently on any updated Kardexes was completed. On 4/8 to 4/11/16 the facility did the following: 6. Root Cause Analysis of the incident was completed. CNA #1 was terminated on 4/8/16. Observations of mechanical lift and sling use for all dependent residents by the DON and Assistant Director of Nursing (ADON) on all shifts facility wide including spot audits of all Kardexes for accuracy and additional reviews and interviews of all staff related to mechanical lift policy was completed on 4/8 to 4/11/16. Mandatory in-service for all clinical staff with the findings of root cause analysis were reviewed and completed on 4/11/16. On 4/12/16 the facility did the following: 7. Findings of Root Cause Analysis and Corrective Action Plan Interventions were reviewed with Administrator. The findings were forwarded to Quality Assurance Committee (QA) for full review in the (MONTH) (YEAR) QA meeting. Weekly audits of mechanical lift use and Kardexes were initiated. The first weekly audit was completed by DON with no irregularities noted and full compliance was achieved. The State Agency was notified of the incident on 4/12/16. On 4/13 to 4/26/16 the facility did the following: 8. Additional weekly audits of all mechanical lifts and sling use facility wide were completed on 4/19/16 and 4/26/16 and no additional deficient practices were noted. Audits included observations of mechanical lift use and random audits of CNA Kardex documentation on dependent residents by the ADON and DON on all shifts. Weekly audits are ongoing. The surveyors verified the facility's corrective actions onsite during the complaint survey as follows: 1. Observations of mechanical lift use on dependent residents including Resident #2 were completed on both shifts 5/2/16 to 5/4/16. 2. Audits of all CNA Kardexes on all units in the facility revealed all mechanical lift use and sling size documentation was uniform and consistent with manufacturer recommendations, sling sizes were highlighted and documentation was prominently displayed on the first page of the CNA Kardex in the same location. 3. Observations of all mechanical lifts in the facility between 5/2-5/4/16 revealed all lifts were well maintained and in good repair. Additional observations of the sling inventory were completed and sufficient numbers of slings were present in all sizes required and all slings were in good repair. All lift slings of various sizes were readily available for use on all units of the facility on all shifts. 4. Interviews with 7 certified Nursing Assistants (CNAs #2, #3, #4, #5, #6, #7, #8), 3 Registered Nurses (RNs # 1, #2, #3), and 5 Licensed Practical Nurses (LPN #1, #2, #3, #4, #5) revealed all were fully aware of the facility mechanical lift policy, location of all lift slings in the facility, aware of how to appropriately fit residents to sling size based on body weight, aware of the location of sling size documentation on the CNA Kardex, and where to find the most recent weights in the written and electronic medical records for residents who clinicians suspected may need adjustments in sling sizes based on body changes. All staff interviewed were aware of the facility corrective action plan and QA team Root Cause Analysis findings and verified the facility had provided mandatory in-service training related to the incident that involved Resident #2's fall and injury. 5. Interviews with 2 residents and 3 family members of cognitively impaired persons revealed no concerns with staffing levels, abuse or neglect, transfers, mechanical lift use, or resident safety in the facility. 6. Review of the incident and grievance logs for one year revealed no similar incidents involving mechanical lift use and falls were present. 7. Interviews with the Administrator, DON, ADON, and members of the Quality Assurance Team including the MDS coordinator and Social Services Director confirmed the incident was reviewed in an Ad Hoc QA meeting and findings shared with the QA team as noted in the corrective action plan and routine audits of mechanical lift use were ongoing at the time of the complaint investigation. 8. Medical record reviews and reviews of facility fall investigations were completed for 5 additional residents (Residents #4, #5, #6, #7, #8) who had sustained falls in the facility and no deficient practices were identified. The harm existed from 4/5/16 to 4/26/16. The Harm was removed on 4/27/16. The facility's corrective action plan that removed the Harm at F-280 G and F-323 G was received and corrective actions validated onsite by the surveyors on 5/3-4/16. The harm was cited as past noncompliance for F-280 and F-323 and the facility is not required to submit a plan of correction for those tags.",2019-05-01
4344,SUMMIT VIEW OF ROCKY TOP,445259,204 INDUSTRIAL PARK RD,ROCKY TOP,TN,37769,2016-10-03,314,G,1,0,HV9H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of wound reports, and interviews, the facility failed to provide timely treatment and services to promote healing and prevent worsening of a pressure ulcer for 1 resident (#2), of 5 residents reviewed for pressure ulcers, resulting in harm to Resident #2. The findings included: Review of the facility policy Pressure Ulcer Treatment dated 3/2005, revealed .Stage II Protocol .Clean, shallow, minimal drainage: 1. Protect; 2. Manage drainage; 3. Promote moist wound healing; 4. Treatment: a. Cleanse with normal saline or other skin cleanser in accordance with physician orders and facility protocol; b. Apply barrier cream, hydrogel or hydrogel sheet (cut to fit); c. Cover with non-adhesive light gauze or transparent dressing; d. alternate dressing (use of thin [MEDICATION NAME]); and e. Change per physician order and manufacturer's directions . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12 (moderate cognitive impairment). Continued review revealed the resident required extensive assistance for all activities of daily living and was always incontinent of bowel and bladder. Medical record review of the admission Braden Scale (assessment to determine the risk of the development of a pressure ulcer) dated 1/22/16 revealed the resident was at mild risk for the development of pressure ulcers. Medical record review of the interim care plan dated 1/23/16 revealed the facility had not care planned actual or potential risk for alteration in skin integrity. Continued review of the care plan revealed, on 2/1/16, the facility implemented an intervention of moisture barrier to the resident's skin after bath and incontinence care. Further review revealed the resident required extensive assistance with bed mobility and to reposition every 2 hours. Medical record review of the quarterly Braden scale dated 4/23/16 revealed the resident remained at mild risk for the development of pressure ulcers. Medical record review of the weekly skin assessment dated [DATE], revealed .New Stage II ulcer on Coccyx .2 cm (centimeters) W (width) 1 cm L (length) . Medical record review of the Treatment Record revealed .5/19/16 (12 days after the wound was discovered) .Apply [MEDICATION NAME] (antibiotic) ointment to coccyx then apply Alginate Wound Dressing cover with Island Dressing Daily . Medical record review of the care plan revealed it was revised on 5/19/16 with the identification of a new stage II wound and interventions implemented included a pressure reducing mattress, sheepskin in wheelchair due to constant scooting motion, and wound treatment as ordered. Review of the facility wound reports revealed Resident #2's coccyx wound was not added to the report until 5/29/16, when the coccyx wound had increased in size to 2 cm by 2 cm. Interview with the Treatment Nurse on 10/3/16 at 12:00 PM, in the conference room, confirmed Resident #2's weekly skin assessment completed on 5/7/16 identified a new stage II pressure ulcer on Resident #2's coccyx. Continued interview confirmed the pressure ulcer had increased in size from 2 cm by 1 cm on 5/7/16 to 2 cm by 2 cm on 5/29/16, the facility had failed to implement treatment, or initiate interventions, until 12 days after the wound was discovered, and the facility failed to add the wound to the facility wound report for tracking until 5/29/16 (22 days after discovery). Interview with the Director of Nursing (DON) on 10/3/16 at 12:30 PM, in the conference room, confirmed the facility failed to initiate timely treatment for [REDACTED].#2.",2019-10-01
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
4339,LIFE CARE CENTER OF CLEVELAND,445244,3530 KEITH ST NW,CLEVELAND,TN,37311,2016-10-20,225,D,1,0,H8BH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record, review, review of facility documents, and interviews, the facility failed to investigate and report an allegation of abuse for 1 resident (#3) of 8 residents reviewed for abuse. The findings included: Review of the facility policy, Reporting Alleged Abuse revised 2/2009, revealed .When an incident of resident abuse is suspected, the incident must be reported to the supervisor .The supervisor notifies the director of nursing and the executive director of the alleged incident .The administrator, director of nursing, or designated representative will complete an investigation of the incident .Federal requirements mandate that facilities must ensure all allegations of abuse are reported immediately to their state survey agency . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 scored a 3 out of 15 for cognition (severe cognitive impairment), required extensive assistance with transfers, dressing, eating, and personal hygiene with assistance of 1-2 persons. Review of a facility Concern and Comment Form dated 6/15/15 ar 4:04 PM, completed by the facility Quality Coordinator on behalf of the resident, revealed .CNA (Certified Nursing Assistant) to rough on resident . Review of the facility Investigation and Response form dated 6/15/15 at 4:11 PM, completed by the facility Quality Coordinator and Licensed Practical Nurse (LPN) #5 revealed .determined it was CNA named . Continued review of the Investigation and Response form revealed it was signed by the facility Administrator on 7/15/15. Interview with Resident #3 on 9/27/16 at 1:15 PM, in his room, revealed .have to have help sometimes .I feel safe here .don't remember anyone being mean to me . Interview with LPN #5 on 9/28/16 at 9:00 AM, in the South Wing Nurses Station, revealed .CNA had been rough with him .hurt him when they moved him .I hope that I reported to charge nurse but honestly I don't remember . Interview with the Activities Director on 9/28/16 at 9:15 AM, in the Staff Development Office, revealed .if someone bumps into him during an activity he becomes upset .I felt like the CNA had just rushed him and he does not like that . Interview with the Director of Nursing (DON) on 9/28/16 at 9:30 AM, in the Staff Development Office, revealed she had not been notified of the allegation of abuse. Continued interview with the DON confirmed the facility failed to complete an investigation into the allegation, failed to report the allegation of abuse, and failed to follow facility policy.",2019-10-01
3281,"THE WATERS OF SMYRNA, LLC",445502,202 ENON SPRINGS ROAD EAST,SMYRNA,TN,37167,2018-01-16,761,D,1,0,POU411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, observation and interview, the facility failed to ensure that drugs were safely and securely stored by 1 of 4 Licensed Practical Nurses (LPNs) observed. The findings included: Review of facility policy, Medication Storage In The Facility revealed, Medications and biologicals are stored safely, securely, and properly following the manufactures or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Observations on 1/9/18 at 11:37 AM at the 100 hall nursing station revealed LPN #1 received from the pharmacy a package containing 7 tablets of the antibiotic [MEDICATION NAME] 500 milligrams. The LPN was observed to remove the tablets from the outer package and place the outer package and the clear inner package containing the 7 tablets on the chair seat located in the 100 hall nursing station. The LPN was observed to leave the station and walked out of sight down the hallway leaving the medication unsecured and unattended. Interview with LPN #1 on 1/9/18 at 11:43 AM in the nurses' station, LPN #1 was asked if he could leave the antibiotic tablets lying on the chair seat and LPN #1 stated, No I am not.",2020-09-01
1479,AHC CUMBERLAND,445262,4343 ASHLAND CITY HIGHWAY,NASHVILLE,TN,37218,2018-11-07,921,D,1,0,Y07M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, observation, and interview, the facility failed to clean rooms appropriately after resident discharge and failed to maintain a sanitary environment for 9 rooms. The findings include: Review of facility policy, Cleaning, effective 7/14, revealed .The Nursing Department has the responsibility of maintaining the cleanliness and organization of their work areas and equipment .Housekeeping and laundry staff cleaning responsibilities include mattresses, bed frames, over bed tables, and bedside tables are cleaned routinely by the housekeeping staff .Linen barrels are sprayed or wiped with a disinfectant each time the barrel is empties by the laundry personnel . Observation of the facility during a tour on 11/5/18 from 2:15 PM - 3:30 PM revealed: 1. room [ROOM NUMBER]B - empty bed - wardrobe had pink cap, burgundy jogging pants, smoking apron, and a package of woman's briefs. 2. room [ROOM NUMBER]B - empty bed - first drawer of bedside table with sticky purple and green stains and a bar of Sulphur soap; second drawer with a cotton swab and food particles. 3. room [ROOM NUMBER]B - no name on door but personal belongings by the bed. 4. room [ROOM NUMBER]A - empty bed - housecoat in top drawer of bedside table; plastic and basin in second drawer; stain from spilled liquids in third drawer - wedge on the overbed table. 5. room [ROOM NUMBER]B - empty bed - disposable glove on floor between wardrobes - knife, fork, and pennies in top drawer of bedside table; spoon, straw, cigarette butt, and dried bug in second drawer 6. room [ROOM NUMBER]A - empty bed - water bottle; diapers, clear bag with packages of food in it, sweater, and incontinent pads on top of the bedside table (a return visit at 3:50 PM revealed the water bottle, sweater, and bag of food had been removed) - peanut butter and 7 packets of petroleum jelly In the top drawer 7. room [ROOM NUMBER]A - empty bed - bed on Fowler's position - pillow and pad on bedside table - container of Sani-Cloth in top drawer of bedside table and drawer was also dirty - IV pump at bedside 8. room [ROOM NUMBER]B - empty bed - name on door of resident who was discharged [DATE] - overbed table with urinal, empty water pitcher with another resident's name on it, shave cream, deodorant, 2 skin protector packets, 3 sugar packets, graham crackers and comb - pants and [NAME]et in chair between wardrobes - 2 soiled water pitchers on bedside table - drawers with stains in them - boots on floor by wardrobe in plastic bag and boots on floor near head of bed - bathroom with basin with lotion, razors, normal saline, and cleansers as well as round basin with pants and 2 very soiled towels in it 9. room [ROOM NUMBER]B - empty bed - smoking apron and gait belt on top of wardrobe room [ROOM NUMBER]A - empty bed - smoking apron on top of wardrobe - on top of bedside table was a basin with a puzzle book, urinal, towels, denture cups, and lotions - first drawer of the bedside table had briefs and pads as well as 1 unused syringe of normal saline and 1 unused syringe of [MEDICATION NAME] flush (confirmed by Registered Nurse #1 they were not supposed to be at the bedside and especially not in a room without a resident) - second drawer of the bedside table had a basin filled with wipes, lotions, and cleansers. Facility tour on 11/6/18 at 11:10 AM revealed all the above rooms had the same objects in them except room [ROOM NUMBER] which was completely cleaned out. Facility tour on 11/7/18 at 9:00 AM revealed: 1. room [ROOM NUMBER]B - box of gloves on Bed A with several gloves pulled out of box onto bed. 2. room [ROOM NUMBER]B - same items in room as on 11/5/18 and 11/6/18 3. room [ROOM NUMBER]A - same items in bedside table as on 11/5/18 and 11/6/18 - clean linen placed on top of bed. 4. room [ROOM NUMBER]A - same items in room as on 11/5/18/and 11/6/18 - name of previous resident still in wardrobe. 5. room [ROOM NUMBER]B - same items in room as on 11/5/18 and 11/6/18 - TV on. 6. room [ROOM NUMBER]A - same items in room as on 11/5/18 and 11/6/18 7. room [ROOM NUMBER]B - same items in room as on 11/5/18 and 11/6/18 8. room [ROOM NUMBER]B - contained of chocolate [MEDICATION NAME] Ensure, still cold, opened with straw in it, sitting on overbed table in front of the chair. The Administrator was requested to view the same rooms to determine her findings: 1. room [ROOM NUMBER]B - items in wardrobe 2. room [ROOM NUMBER]B - meal tray in room; string on light needs repair; items over bed need to be removed 3. room [ROOM NUMBER]A - items in night stand - items on bed need to be removed - needs pillow on bed 4. room [ROOM NUMBER]B - bed needs to be plugged in - needs bedspread - needs footboard 5. room [ROOM NUMBER]A - plug in bed - bedspread needed; footboard needed 6. room [ROOM NUMBER]A and 711B - name tag of previous resident; items on bedside tables; beds need to be made Interview with the Housekeeping Supervisor on 11/6/18 at 9:55 AM in the conference room revealed when a resident is discharged Housekeeping cleans the room. Continued interview revealed they pack up any resident items and put them in storage for the family members. Further interview revealed they deep clean the room including the lights and television. Continued interview revealed they put all fresh linens on the bed. Further interview the Supervisor confirmed this process would have been followed on 10/10/18 when Resident #2 was to have been admitted . Interview with the Housekeeping Supervisor on 11/6/18 at 9:55 AM in the conference room revealed when a resident is discharged Housekeeping cleans the room. Continued interview revealed they pack up any resident items and put them in storage for the family members. Further interview revealed they deep clean the room including the lights and television. Continued interview revealed they put all fresh linens on the bed. Interview with the Administrator on 11/7/18 at 2:30 PM in the conference room confirmed many items had not been removed from rooms which were supposed to be resident-ready. Continued interview revealed when a resident is to be admitted Admissions lets everyone know the resident is coming so everyone checks the room to be sure everything is functioning and items are removed.",2020-09-01
955,WEST MEADE PLACE,445203,1000 ST LUKE DRIVE,NASHVILLE,TN,37205,2017-09-20,280,D,1,0,SMVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, observation, medical record review, and interview, the facility failed to revise the Care Plan to reflect the resident's current status for 3 of 11 sampled residents (#4, #5, #7). The facility failed to update Care Plans for Resident #4 and Resident #7 when previous approaches were no longer appropriate and/or new interventions were needed to prevent accidents. The facility failed to update the Care Plan for Resident #4 to reflect a new intervention for a skin tear. The findings included: Review of facility policy, Care Plans - Comprehensive, undated revealed The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans: When there has been a significant change in the resident's condition .At least quarterly. Medical record review revealed Resident #4's clinical record revealed the resident was admitted on [DATE] and readmitted to the facility on [DATE], after a [MEDICAL CONDITION] (BKA) of the left leg due to a gangrenous toe. A comprehensive assessment dated [DATE], was completed, based on the changes in the resident's condition due to the amputation. Review of her Comprehensive Care Plan revealed the last care conference was held on 7/19/17 and the Care Plan showed a goal date of 10/17/17. Review of Resident #4's Care Plan revealed approaches were not revised to reflect the resident's current status. Medical record review revealed the Care Plan noted the resident was at risk for infection r/t (related to) Left BK[NAME] Approaches to meet the goal of remaining free of infection revealed the resident was to have Shoes on only during therapy r/t L (left) heel blister. The care plan also noted the resident is a fall risk r/t S/P (Status/Post) BK[NAME] Approaches to meet the goal of no avoidable falls included Therapy states that she is able to ambulate herself to and from the bathroom. Review of Resident #4's Physician order [REDACTED]. Further review of Resident #4's Comprehensive Care Plan revealed although the Care Plan identified the resident was at risk for falls, neither of these Physician Ordered interventions had been added to the Care Plan. Observation on 9/18/17 at 11:40 AM revealed Resident #4 was sitting in a wheelchair. The resident was observed to have an amputation of the left leg below the knee and was using a stabilizer to hold the stump of her leg in place. Observation on 9/18/17 at 8:35 AM revealed Resident #4 was asleep in bed with 4 side rails raised. The bed was not in a low position. No fall mats were in use on either side of the bed. Additional observation on 9/18/17 at 1:49 PM revealed the resident was asleep in bed. Although the bed was now in a low position, no fall mats were in use and all 4 side rails were raised. Interview on 9/19/17 at 9:12 AM with the Minimum Data Set (MDS) Coordinator #1 revealed the facility currently had a Care Plan Nurse. He stated, although the facility's system was changing in (MONTH) (YEAR), the Care Plan Nurse was currently responsible for developing Care Plans from required assessments, as well as making any needed revisions, including new approaches identified during falls meeting. Interview on 9/19/17 at 9:30 AM with the Care Plan Nurse revealed that it depended on the type of Care Plan revision as to who was responsible for updating the Care Plan. He stated if the resident had a fall, the floor nurse should update both the comprehensive Care Plan and the summarized Care Plan used by direct staff with new interventions to prevent further accidents. The Care Plan Nurse stated he then completed the Care Plan reviews that were required after each quarterly or Comprehensive MDS. He stated, When I review, I try to make sure what's in Matrix (the facility's electronic health system used for comprehensive Care Plans) jibes with what's in the closet (where the summary Care Plans used by direct care staff are stored.) The Care Plan Nurse confirmed the resident's Care Plan should have been updated, saying, The obvious answer is yes. He stated the approaches of shoes and walking to the bathroom were no longer appropriate for Resident #4, and the Care Plan should have been revised, as the resident had completely different needs after the amputation of her leg. Further interview with the Care Plan Nurse revealed he did not know the reason for the delay in revising the Care Plan with new interventions. He stated he was not alerted when every new order was received, and the nurse on the unit who was aware of the order should have revised the Care Plan if needed. Medical record review revealed Resident #5 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a facility Event Report dated 6/18/17 revealed Resident #5 was found with a skin tear to her right inner thigh as a result from scratching herself. Continued review revealed new orders related to the incident was a referral to the Wound Care Nurse. Continued review documented the Care Plan was updated on 6/18/17 at 7:42 PM. Medical record review of the Comprehensive Care Plan dated 2/23/17 revealed a problem of impaired skin integrity. Continued review revealed the approaches were dated 2/23/17 and no new approaches related to the skin tear were present. Interview with the Director of Nursing (DON) on 9/20/17 at 3:36 PM in the Conference Room confirmed the facility failed to revise Resident #5's Care Plan to reflect approaches related to a skin tear on 6/18/17. Medical record review revealed Resident #7's [DIAGNOSES REDACTED]. Review of Resident #7's Comprehensive Care Plan, review date of 9/7/17, revealed the resident was an elopement risk r/t dementia. Review of the approaches for this problem revealed they included, Apply wander alert safety bracelet to resident, if ambulatory, and w/c (wheelchair) if chair bound. Observation on 9/18/17 at 5:06 PM, and 9/19/17 at 8:10 AM and 3:15 PM, revealed the resident was seated in her wheelchair. No wander alert bracelet was applied to the wheelchair and none was visible on the resident. Interview on 9/19/17 at 8:10 AM with Certified Nurse Aide (CNA) #1 confirmed the resident did not have a wander alert bracelet on either her body or her wheelchair. Interview on 9/19/17 at 3:15 PM with Licensed Practical Nurse (LPN) #1 confirmed the resident did not currently use a wander alert bracelet. Interview on 9/19/17 at 3:22 with Unit Manager (UM) #1 revealed Resident #7 doesn't need or use a wander alert bracelet anymore. He stated the facility had used one when the resident was ambulatory, but it was no longer needed because she was no longer at risk for elopement and used a wheelchair for locomotion. Interview with UM #2, who was also present during the interview on 9/19/17 at 3:22 PM, confirmed Resident #7 had not used a wander alert bracelet since at least (YEAR). Interview with UM #1 revealed the Care Plan should have been revised when the wander alert bracelet was discontinued. He stated any nurse in the building could update Care Plans, and the need for revision could have also been identified when required quarterly Care Plan reviews were completed.",2020-09-01
2335,PICKETT CARE AND REHABILITATION CENTER,445390,129 HILLCREST DRIVE,BYRDSTOWN,TN,38549,2018-10-09,600,D,1,0,IMSO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, observation, medical record review, review of facility documentation, and interview the facility failed to prevent abuse for 1 residents (#1) of 4 residents reviewed for abuse. The findings included: Review of the facility policy Abuse, Neglect and Misappropriation of Property not dated, revealed .It is (Facility's) policy to prevent the occurrence of abuse .This policy applies to all residents without respect to the resident's cognitive condition, awareness, or ability to understand the event at issue . Observation of Resident #1 on 10/9/18 at 9:00 AM, in her room, revealed the resident lying in bed. She appeared to be sleeping and did not respond to verbal stimuli. No signs of distress were observed. Observation of Resident #1 on 10/9/18 at 12:30 PM, in the dining room, revealed the resident seated in a specialty wheelchair, she was awake and alert. Continued observation revealed the resident was calm, and she did not appear afraid, or nervous. Interview revealed the resident did make eye contact with the SA but made no attempt to verbalize a response to questions. Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a staff assessment was completed for mental status indicating the resident had short term and long term memory problems, and severely impaired skills for making decisions. Medical record review revealed, Resident #2 was admitted to the facility on [DATE], discharged on [DATE], readmitted on [DATE] discharged on [DATE], readmitted on [DATE] and discharged on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Continued review revealed no behaviors were identified during the assessment period. Review of a facility document Event Evaluation dated 9/14/18, revealed .Inappropriate Behavior .CNA (Certified Nursing Assistant) witnessed .(Resident #2) touching .(Resident #1) in the pelvic area through her clothing . Interview with Licensed Practical Nurse (LPN) #1 on 10/9/18 at 7:20 AM, in the conference room, revealed I was giving my meds (medications), and the CNA came to me and said I just saw .(Resident #2) touch .(Resident #1) in her pelvic area. Interview with CNA #1 on 10/9/18 at 8:00 AM, in the conference room, revealed the two residents were setting in front of the TV (television) in the common area close to the front lobby, and I was coming up the hall toward them. I thought he was just patting her leg, but when I got closer I could tell he was rubbing the top of her pelvic area, but his hand was on top of her clothes. I said .(Resident #2) what are you doing, he jerked his hand away from her, and said nothing. Interview with the Administrator on 10/9/18 at 1:30 PM, in the conference room, confirmed Resident #2 was witnessed being sexually inappropriate with Resident #1. Continued interview confirmed the facility failed to follow their abuse policy, and failed to prevent abuse of Resident #1.",2020-09-01
2377,SIGNATURE HEALTHCARE OF MONTEAGLE REHAB & WELLNESS,445393,26 SECOND STREET,MONTEAGLE,TN,37356,2018-10-04,600,D,1,0,19FB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, observation, medical record review, review of facility investigation, and interview the facility failed to prevent abuse for 2 residents (#2, #3) of 5 residents reviewed for abuse. The findings included: Review of the facility policy Abuse, Neglect and Misappropriation of Property not dated, revealed .It is (facility's) policy to prevent the occurrence of abuse .This policy applies to all residents without respect to the resident's cognitive condition, awareness, or ability to understand the event at issue . Observation of Resident #3 on 10/3/18 at 9:30 AM, on the 200 hall, revealed the resident seated in a wheelchair, awake and alert. Continued observation revealed multiple staff members, and residents passing by the resident, no aggressive behaviors were toward others was observed. Observation of Resident #3 on 10/3/18 at 3:10 PM, on the 200 hall, revealed the resident seated in a wheelchair, self-propelling for short distances, on the hallway. Continued observation revealed the resident interacting pleasantly with staff members. Medical record review revealed Resident #2 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Continued review revealed Resident #2 exhibited verbal behaviors, and wandering daily. Medical record review Revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. Review of an Annual MDS dated [DATE], revealed a staff assessment was completed for mental status indicating the resident had short and long term memory problems. Continued review revealed Resident #3 exhibited behavioral symptoms not directed towards others, and rejection of care 4 to 6 days during the assessment period. Review of the facility investigation dated 8/24/18, revealed two staff members heard something in the hall, when they arrived they saw Resident #2, and Resident #3 having a physical altercation. Resident #2 was observed striking Resident #3 on her shoulder, and Resident #3 was observed with Resident #2's arm in her mouth. Interview with Housekeeper #1 on 10/3/18 at 12:44 PM, in the conference room, revealed we had just turned the corner off the East Hall heading toward the Main hall .(Resident #3) was biting .(Resident #2) on her forearm wrist area .(Resident #2) was punching her (Resident #3) on her shoulder. Interview with Housekeeper #2 on 10/3/18 at 1:00 PM, in the conference room, revealed we were coming from the East Hall we saw the two residents having an altercation .(Resident #2) was hitting .(Resident #3) on her shoulder, and .(Resident #3) had .(Resident #2)'s arm in her mouth. Interview with the Administrator on 10/3/18 at 5:00 PM, in the conference room, confirmed Resident #2, and Resident #3 had a witnessed physical altercation, and the facility failed to prevent abuse of Resident #2, and #3.",2020-09-01
1603,CUMBERLAND VILLAGE CARE,445276,136 DAVIS LANE,LAFOLLETTE,TN,37766,2019-07-24,584,D,1,0,UTL511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, observations, and interviews, the facility failed to provide a clean and homelike environment in 2 of 2 dining rooms observed and in 2 resident rooms (#104 and #228) of 7 resident rooms observed for a clean homelike environment. The findings included: Review of facility policy Resident Rights Under Federal Law, last revised 3/1/18, revealed .patients have the fundamental right to considerate care that safeguards their personal dignity .will comply with resident rights under Federal law .Purpose .To treat each patient with respect and dignity and care for each patient in a manner and in an environment that promotes maintenance or enhancement of his/her self-esteem and self-worth . Observation of the main dining room on 7/24/19 at 7:15 AM revealed dust, a sticky substance, napkins, and dried food and debris underneath 4 of 12 dining room tables observed. Continued observation revealed dried green and yellow food particles on lying on top of 1 of 12 dining room tables observed. Observation and interview with the Housekeeping Supervisor (HKS) on 7/24/19 at 7:50 AM, in the main dining room, revealed dried debris underneath 4 dining room tables and food particles on 1 dining room table. Interview with the HKS revealed the food particles were green peas and corn. Further interview confirmed the dining room was not clean. Observation of the secure unit dining room on 7/24/19 at 8:10 AM revealed liquid spills underneath 2 of 9 dining room tables and breakfast food particles on the floor underneath 4 of 9 dining room tables observed. Interview with the Dietary Manager (DM) on 7/24/19 at 10:45 AM, in the kitchen, revealed the facility served the residents mixed vegetables containing green peas and corn for dinner on 7/23/19. Observation and interview with Licensed Practical Nurse (LPN) #1 on 7/24/19 at 7:55 AM, of resident room [ROOM NUMBER], revealed a washcloth, a plastic cup, and a book under a resident's bed. Continued observation revealed an adhesive bandage with a small piece of gauze, plastic pieces of paper, tissue paper, and food type debris on the floor beside the resident's bed. Interview with LPN #1 confirmed the resident's room did not provide the resident with a clean and homelike environment. Interview with Resident #5 on 7/24/19 at 8:05 AM, in her room, revealed .Sometimes they skip cleaning, they will come in and get the trash but they don't come back and clean . Observation on 7/24/19 at 8:50 AM, of resident room [ROOM NUMBER], revealed a wash cloth, an empty bottle of perineal wash, a knife, a fork, a denture cup, a plastic medicine cup, an empty can of potted meat, a chocolate chip cookie, various small pieces of paper, and personal clothes on the floor. Interview with the Administrator on 7/24/19 at 12:50 PM, in the conference room, revealed .in the process of daily cleaning the floors of the rooms and hallways would be cleaned .it would be my expectation as far as utensils, dishware, food debris .any type of debris and spills would be addressed as identified .all resident areas are cleaned at least daily including rooms, dining rooms, and all common areas . Continued interview confirmed the facility failed to provide a clean homelike environment in both dining rooms and in 2 resident rooms.",2020-09-01
2826,MADISONVILLE HEALTH AND REHAB CENTER,445457,465 ISBILL RD,MADISONVILLE,TN,37354,2018-11-27,600,D,1,0,V57G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, observations, medical record review, review of facility documentation, and interviews the facility failed to prevent abuse for 1 resident (#1) of 4 residents reviewed for abuse. The findings included: Review of the Facility's abuse policy Abuse Prevention/Reporting Policy and Procedure dated (YEAR), revealed .Every resident has the right to be free from abuse .Residents must not be subjected to abuse by anyone, including, but not limited to employees, other residents .Everyone has the right to be free from mistreatment .This includes the facility's identification of residents, whose personal histories render them at risk for abusing other residents . Observation of Resident #1 on 11/27/18 at 9:20 AM, in his room, revealed the resident lying in the bed, he appeared to be sleeping and did not respond to verbal stimuli. Continued observation revealed no obvious signs of distress. Observation of Resident #2 on 11/27/18 at 9:30 AM, in his room, revealed the resident seated in a wheelchair with staff present in the room. Continued observation revealed the resident stretching his arm outward appearing to be reaching for something, and moving his right arm in an outward manner appearing to be throwing something. Both movements were in a slow manner and did not appear aggressive or forceful. Further observation revealed the resident was calm, and he was pleasantly interacting with the Certified Nursing Assistant (CNA). Observation of Resident #2 on 11/27/18 at 10:45 AM, in the lobby common area, revealed the resident seated in a wheelchair, the resident appeared calm; other residents were present, and no aggressive behaviors observed. Observation of Resident #1 on 11/27/18 at 1:30 PM, in his room, revealed the resident lying in bed, he was awake and alert. Continued observation revealed the resident was pleasant, and no fearful or anxious behaviors were observed. Observation of Resident #1 on 11/27/18 at 2:15 PM, in the lobby common area, revealed the resident seated in a wheelchair, and interacting with other residents. Further observation revealed no signs or symptoms of anxiety of fearfulness. Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was not completed. Review of a Staff Assessment for Mental Status revealed short and long term memory problems, and severely impaired decision making skills. Further review revealed no symptoms of depression or behaviors were exhibited during the assessment period. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. Review of a Significant Change in Status MDS dated [DATE], revealed a BIMS score of 3, indicating severely impaired cognition. Continued review revealed the resident exhibited physical behavioral symptoms directed towards others 1 to 3 days during the assessment period. Review of a witness statement dated 11/18/18, revealed I saw .(Resident #2) grab .(Resident #1)'s wrist at the main entrance area near the chairs, and he wouldn't let go. I saw it and went over and told .(Resident #2) to let go. He hesitated for a few seconds and eventually let go. I then separated .(Resident #2) and .(Resident #1). This was on 11/18/18 at 2:12 PM . Further review revealed the statement was signed by the previous Activities Assistant. Interview with the Assistant Director of Nursing (ADON), on 11/27/18 at 11:25 AM, in the conference room, revealed I was walking down the hall toward the nurses' station and I saw a CNA pushing .(Resident #2) in a wheelchair towards his room. The Activities Assistant was at the nurses' station and told me the residents were in the lobby area and she had witnessed .(Resident #2) grab .(Resident #1)'s arm. She said she told .(Resident #2) to let go, he had hesitated but then had let go. Interview with the Administrator on 11/27/18 at 2:50 PM, in the conference room, confirmed Resident #2 had a previous resident to resident altercation on 11/1/18, and had been sent out to Geri-psych, he had returned to the facility on [DATE], and the present altercation had occurred on 11/18/18. Continued interview confirmed the facility failed to follow their abuse policy and failed to prevent abuse of Resident #1.",2020-09-01
1545,"LEBANON CENTER FOR REHABILITATION AND HEALING, LLC",445268,731 CASTLE HEIGHTS COURT,LEBANON,TN,37087,2018-04-10,658,G,1,0,P4UJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, record review and interview, the facility's nursing staff failed to accurately document one of one (Resident #4) resident's condition after the resident experienced a fall with a [MEDICAL CONDITION] and C1 vertebrae of the neck during a transfer from the bed to the shower chair utilizing the Hoyer lift. After the fall, the resident experienced bruising and [MEDICAL CONDITION] of the right ankle, [MEDICAL CONDITION] to the right neck, and bruising of the left face. Resulting in Harm. Findings include: Review of a facility investigation for a fall that occurred for Resident #4 dated 11/6/17 at 10:00 AM revealed, Certified Nursing Assistant (CNA #1) had been transferring (Resident #4) from bed to shower chair via Hoyer lift (a mechanical device used to transfer) when one strap came loose from the lift and patient (Resident#4) fell to floor, when the strap was not secured correctly, CNA #1did not have another staff helping her. report dated 11/6/17 indicated, Results, there is a fracture involving distal fibula (one of the 2 bones in the lower leg) with no displacement . Review of the Orthopedic Physician's Progress Note dated (MONTH) 7, (YEAR) revealed, Please place a pillow or air support on the R (right) ankle, Ice 15 minutes trice a day, Rewrap Ace daily- no stretch . Review of the Nurse Practitioner's (NP) note dated 11/6/17 revealed . Resident #4 had a fall this morning out of the Hoyer lift .she has some tenderness in (her) neck and shoulders when repositioned and her right ankle has some ecchymosis (bruising), [MEDICAL CONDITION] and tenderness to palpate. Review of the NP's note dated 11/7/17 revealed, .joint swelling ankle and joint tenderness ankle. Review of the NP's note dated 11/10/17 revealed, .enlarged gland right submandibular (the neck area under the lower jaw); .tender. Review of the NP's note dated 11/13/17 revealed, .The patient also presents with ecchymosis. It is located on the face Left temporal region (the left side of the face near the eye) .The symptom is gradual in onset not observed on Friday (November 20, (YEAR)). Review of the SBAR (acronym for Situation, Background, Assessment, Recommendation) Form and Progress Note dated 11/6/17 09:47 AM and signed by Licensed Practical Nurse (LPN) #1 revealed, .Situation 1. The change in condition, symptoms or signs I am calling about is witnessed fall from Hoyer lift . There was no documentation regarding the right ankle fracture. Review of Progress Notes dated 11/6/17 at 11:15 AM revealed the nurse documented, Patient observed to have [MEDICAL CONDITION] and bruising to right ankle. Also, c/o (complaint of) back pain. Assessed by NP and STAT (immediate) x-rays ordered. Review of Progress Notes revealed Resident #4's injury was dated 11/8/17 at 8:38 AM revealed, When asked if any pain, Resident denies with shaking her head and drifts back to sleep. Fall on 11/6/17. No new bruising noted. Continued review of Progress Notes dated 11/9/17 at 12:55 PM indicated the nurse documented, .Ace wrap and ice completed . There was no documentation regarding the right ankle or the bruising. Review of the Skin-Head to Toe Skin Checks dated 11/9/17 at 10:04 AM revealed the nurse checked site left ankle and left wrist .no open area noted The Progress Notes dated 11/10/17 at 14:48 (2:48 PM) indicated the nurse documented the pain medication Resident #4 received. Documentation was lacking regarding the right ankle and the bruising as well as the [MEDICAL CONDITION] of the neck as noted by the NP's note dated 11/10/17. Review of the Progress Notes dated 11/13/17 at 17:35 (5:35 PM) revealed the resident was transported to the Baptist Hospital ER per ambulance. Further review of Progress Notes dated 11/14/17 revealed, (Resident #4) returned from the Baptist Hospital ER at 2320 (11:20 PM) per ambulance. Further review revealed there was no documentation of the [MEDICAL CONDITION] to the right side of Resident #4's face or the ecchymosis to the resident's left side of her face. Review of the Skin-Head to Toe Skin Checks document dated 11/16/17 10:04 AM indicated under 1. skin integrity the nurse checked 1c. Exiting Bruises and documented, .3. Site Left Ankle and left wrist .no open areas noted. Review of the Treatment Administration Record (TAR) for (MONTH) (YEAR) revealed an entry that read, Ace wrap one time a day for right ankle fx (fracture) rewrap ace daily- no stretch right ankle dated ordered 11/8/17. Continued review revealed the Ace wrap was rewrapped for the first time on 11/9/17 at 9:00 AM. Further review of the TAR revealed, Ice pack two times a day for Right ankle fracture .The order was dated 11/8/17 and the first treatment was completed 11/8/17 at 1700 (5:00 PM). Review of the (MONTH) (YEAR) TAR revealed no documentation of the description of the bruising of the right ankle or when the ace wrap was removed. During an interview with LPN #6 on 4/9/18 at 4:10 PM in the facility's conference room confirmed she failed to chart the [MEDICAL CONDITION] of Resident #4's face and neck as well as the bruising of Resident's #4's right foot. Continued interview of LPN #6 confirmed she failed to describe the color and size of the bruise. During an interview on 4/10/18 at 9:00 AM by telephone, LPN #7 stated she failed to document in Resident #4 progress notes the color and size of the bruise to Resident #4's right foot as well as the [MEDICAL CONDITION] to her face and neck. LPN #7 also stated that since Resident #4 had an ace wrap to her right ankle, and failed to document whether the resident's right foot was cold to the touch, the color of the toes, whether the ace wrap was to tight causing swelling above and below the ace wrap, whether she could palpate the pulse in the foot, and any new bruising with a description of each bruise as to color, size, and location. LPN #7 stated Resident #4 wore a hard neck collar that was not to be removed. LPN #7 stated that nursing staff washed the resident's neck under the collar. LPN #7 stated she failed to chart whether there was any swelling, redness, or bruising of the neck area for the part of the neck that she could visualize. Review of the facility's policy titled, Changes in Resident Condition dated (MONTH) (YEAR) indicated, Guidelines .4. The SBAR (an acronym for Situation, Background, Assessment, Recommendation to facilitate prompt and appropriate communication) Communication Form and the Progress Note are used to: a. Assess and document changes in condition in an efficient and effective manner b . Provide assessment information to the physician, and c. Provide clear comprehensive documentation . Review of the facility's policy titled, Documentation Guidelines dated 8/25/17 revealed .SBARS must be done for all Incidents/Falls, change in conditions, and if anyone is transferred out of the building . Review of the facility policy titled, Documentation dated (MONTH) (YEAR) indicated, Policy, Healthcare personnel will complete documentation as outlined below and will record in the medical record using accepted principles of documentation .Integrity, Aspects of resident care such as observation and assessments .and services or treatments performed must be documented in the medication record according to policy . During an Interview with the Director of Nursing DON) on 4/10/18 at 11:40 AM in the conference room, the Director of Nursing (DON) confirmed that the facility did not have a policy to follow regarding specific information to document regarding bruises, [MEDICAL CONDITION], and the use of the ace wrap. Continued interview revealed the DON instructs the nurses to refer to the Lippincott manual for professional nursing guidance regarding documentation.",2020-09-01
5115,WYNDRIDGE HEALTH AND REHAB CTR,445304,456 WAYNE AVENUE,CROSSVILLE,TN,38555,2016-05-25,226,D,1,0,G07I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, record review, review of a facility investigation, and interview, the facility failed to follow it's own policy to suspend an employee after an allegation of abuse for 1 resident (#1) of 3 sampled residents. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., Depression, Dysphagia and [MEDICAL CONDITION]. Review of the admission MDS dated [DATE] indicated the resident sometimes makes self understood and sometimes understands others. Resident is assessed to have severely impaired cognitive skills for decision making along with inattention, disorganized thinking and an altered level of consciousness. The resident on a regular basis exhibited hitting and kicking when approached by staff to deliver care. The resident requires extensive assistance of two staff members for bed mobility, transfer, locomotion on and off the unit, dressing, toilet use and personal hygiene. The resident is incontinent of bowel and bladder and utilizes a wheelchair for locomotion. Review of the resident's Care Plan dated 9/28/15 indicated impaired cognition, impaired communication, self-care deficit and impaired mood/behavior/psychosocial well-being/psychtropic medication use as exhibited by resisting care in the form of biting, kicking, spitting and cursing during care. Review of the facility investigation dated 11/1/15 at 8 AM revealed CNA (#1) reported to the Charge Nurse the resident's mouth was bleeding. Continued reveiw revealed the CNA along with another CNA (#2) had been providing incontinence care to the resident when the resident began to kick, throw punches and bite CNA #1. Further review revealed CNA #1 had to raise his arm to block a punch from the resident whose arm flew back against his face. Reveiw of the facility investigation revealed CNA #2 collaborated what was told by CNA #1. CNA #1 was placed on another hall to finish the shift pending the investigation. Continued review of the facility investigation revealed it was determined the incident was an accident not abuse. Interview with the Charge Nurse on 5/24/26 at 8 AM revealed the Charge Nurse stated CNA #1 had worked at the facility for several years, had never been reported and worked well with residents and staff. Interview with CNA #1 on 5/24/16 at 11:55 AM revealed The resident was not letting us change his brief and attempted to punch me in the face. I raised my arm in defense and his arm flew backwards. Interview with the Director of Nursing on 5/14/16 at 1:05 PM confirmed the incident was an accident and stated CNA #1 should have been interviewed and sent home, not sent to finish the shift on another unit as the facility policy stated.",2019-05-01
4921,"THE WATERS OF CLINTON, LLC",445135,220 LONGMIRE RD,CLINTON,TN,37716,2016-06-18,323,J,1,0,153F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of Material Safety Data Sheets (MSDS), medical record review, review of facility investigation, observation, and interview, and review of facility forms, the facility failed to provide adequate supervision to prevent unsafe wandering and elopement from the facility for one Resident (#3) with a [DIAGNOSES REDACTED].#1); failed to ensure neurological assessments were completed with unwitnessed falls for two Residents (#1, #2); and failed to revise the Certified Nursing Assistant Care Cards for one Resident (#2) at-risk for falls of five residents reviewed for supervision of six residents reviewed. The facility's failure to provide supervision resulted in Resident #3 wandering into an area with access to unsecured chemicals and dangerous equipment and eloping from the facility, resulting in lacerations, abrasions, and bruises, and placed Resident #3 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator (NHA) was informed of the Immediate Jeopardy on 6/16/2016 at 6:00 PM in the Conference Room. F-323 resulted in Substandard Quality of Care. The findings included: Review of facility policy, Elopement Guidelines, (no date) revealed, Definition: Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. Review of facility policy, Elopement Book and Documentation, creation date 5/5/2016, last review date 5/10/2016, effective date 5/10/2016, revealed, .It is (Facility's name) to maintain up to date and accurate 'Elopement Books' at each nurse's station and in the business office. Each book shall contain pictures and face sheets of Resident's at risk for elopement . Review of Material Safety Data Sheets (MSDS) for bleach, fabric softener, and laundry detergent revealed, .Bleach .II Health Hazard Data-DANGER: CORROSIVE. (MONTH) cause irritation or damage to eyes and skin .Harmful if swallowed .Medical conditions that may be aggravated by exposure .heart conditions .IV Special Protection and Precautions .wear safety glasses .avoid breathing vapors .avoid eye and skin contact and inhalation of vapor or mist . Continued review revealed, .Fabric Softener .Section II-Hazards .gastrointestinal irritation .eye irritant .skin irritant .Section VIII-Exposure Controls-Personal Protection .Eye and face protection: If a splash of solution is likely, chemical goggles may be needed. Skin Protection: Minimize skin contact with protective gloves . Further review revealed, .Laundry Detergent .Caution: Harmful if swallowed. Eye irritant: Avoid eye contact, which may cause mild to moderate transient irritation . Medical record review revealed Resident #3 was admitted to the facility 7/12/2010 with [DIAGNOSES REDACTED]. Medical record review of Resident #3's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident had short and long term memory problems and cognition was moderately impaired (decisions poor; cues/supervision required). Continued review revealed Resident #3 required extensive assistance of 2 or more staff for most Activities of Daily Living (ADLs). Further review revealed the Resident used a wheelchair with limited assistance for mobility. Medical record review of the electronic Nurse's Notes dated 4/23/2015 at 9:12 PM, revealed, .Res (Resident #3) was outside in parking lot and found lying face down on the ground with overturned wheelchair . Continued review of the Nurse's Notes at 9:25 PM revealed Resident #3 egressed (exited) the facility through the 300 South Hall Door. Review of a facility investigation dated 4/23/2015 revealed a Plan of Correction was initiated and included: 1. In-servicing on the Elopement Policy on 4/23/2015. 2. Red laminated Stop signage on all Fire and Egress doors implemented on 4/23/2015. 3. Small door alarms (purchased at local electronic shop) installed on all Fire Doors to alert when a door is opened (in addition to previously installed 15 second delay magnet (mag) locks with key code pads) placed on 4/23/2015. 4. Every 15 minute checks initiated on 4/25/2015. 5. Moved Resident #3 to the 200 South Hall where the hall's Fire Door egressed to a grassy area versus pavement. 6. Initiated installation of door screamer alarms (audible alarm will sound immediately upon opening the door and can be heard facility-wide) on all Fire Doors on 7/10/2015 and completed on 8/6/2015. 7. Every 15 minute checks discontinued on 8/6/2015. 8. Obtained State Life Safety approval for installation of metal fencing with gates for all Fire and Egress Doors on 8/5/2015. 9. Installation of fencing initiated on 10/1/2015 and completed on 10/15/2015. Medical record review of the Nurse's Notes revealed: 4/27/2015 at 2:24 AM, .confused . 4/28/2015 at 2:24 AM, .wanderguard (bracelet placed on the Resident and transmits a signal to an alarm attached to a door if egress (exit) is attempted) . 5/30/2015 at 9:00 PM, .Resident has propelled about the unit today looking for a way out . 6/5/2015 at 4:41 PM, .continues to exit seek . 6/12/2015 at 9:58 PM, .Resident .kicked the door hard enough to set off the alarm .resident responded 'I am getting out of here.' 6/21/2015 at 3:52 PM, .decreased safety awareness . and at 11:32 PM .Up in wheelchair. Pushed on fire doors at beginning of shift . 8/14/2015 at 6:41 PM, .Exit seeking behavior noted .went to .door and kicked it open but was stopped before exiting . 10/17/2015 at 11:54 AM, .Up and about in w/c propelling self ad lib (as much and as often as desired) . 11/12/2015 at 11:34 AM, .Redirected away from emergency doors many times this shift .Propelling self in hallways in w/c (wheelchair) at present . 4/28/2016 at 9:08 AM, .confusion. Oriented to self only . 5/3/2016 at 2:59 PM, .Has poor judgement and decision making skills . 5/7/2016 at 3:45 PM, .confusion .Propels self about facility via wheelchair . 5/9/2016 at 2:13 AM, .confused. Up in wheelchair wheeling self around facility . 5/10/2016 at 9:42 PM, .found resident lying on side in wheelchair across the parking lot .Abrasion and bruising noted on Rt (right) knee. Skin tear and bruising to left elbow. Scratches and abrasions noted around left eye, cheekbone, and temple . 5/12/2016 at 4:01 PM, .Propels self about facility via wheelchair . 5/14/2016 at 3:01 PM, .confusion noted to time, place, and events . 5/19/2016 at 3:40 PM, some confusion .Propels self about facility via wheelchair . Medical record review of Resident #3's Risk for Elopement Assessments dated 4/25/2015, 5/7/2015, 7/17/2015, 10/23/2015, 1/14/2016, and 4/25/2016 revealed the Resident was at risk for elopement from the facility. Review of a facility investigation dated 5/10/2016 revealed Resident #3 was found lying on her side in a wheelchair in the parking lot. Continued review revealed Resident #3 was interviewed and stated, I want to go home. Further review revealed the facility's investigation identified confusion and Dementia as contributing factors. Continued review revealed the outcome of the facility's investigative findings identified a visitor held door open for resident to go outside. Continued review revealed a 4 Point P[NAME] (Plan of Correction) was initiated on 5/10/2016: 1. Immediately in-service all available staff. Resident was immediately assessed for injury. Wonder Guard (wanderguard) was verified to be on resident and working. All doors were verified by maintenance to be in working order. All residents were verified to be in the building. 2. An audit was completed by the Director of Nursing (DON) to ensure all residents who are in the elopement book are up to date. Four residents were identified as having wandering behaviors. Their care plans and care cards were updated. No employees will be allowed to work until they have been in-serviced on elopement policy and procedures. 3. Signage placed on all exit doors stating please do not let residents out without checking with staff first. Executive Director (Administrator) sending out letter to all R.P.'s (Responsible Parties) asking them to use the main entrance (for entry and exit from the facility) and not let residents out (of) facility without checking with staff first. 4. Director of Maintenance to check all exterior exits daily to ensure wanderguard systems are in place and functioning properly. Director of Maintenance to bring findings to QAPI (Quality Assurance Performance Improvement) and Safety meeting for 3 months. Review of the facility Investigation Summary dated 5/13/2016 revealed Resident #3 was an elopement risk and exited the building through the back door on the facility's Service Hall. Observation and review of the Elopement Books on 6/1/2016 at 10:55 AM revealed an Elopement Book was located at the North and South Nurse's Stations and Business Office; and each book contained Resident #3's picture and identified the Resident as at risk for elopement. Observation of the surveillance video for 5/10/2016 revealed Resident #3 was on the Service Hall at 3:22 PM in a wheelchair, cradling a baby doll in her left arm; the Resident was alone and unsupervised. Continued observation revealed as Resident #3 propelled down the hallway toward the egress doors, a male visitor entered the Service Hall, walked past Resident #3 to the Service Hall egress doors, entered a code to unlock the doors, exited through the doors and held the door open for Resident #3 to exit. Further observation revealed the visitor exited the building and went into the parking lot, then out of surveillance range. Continued observation revealed Resident #3 exited the building and rolled onto the downward sloping parking lot, and the speed of rolling the wheelchair increased as the Resident continued to roll downward, without control, toward a parked truck. Further observation of the video was not visually clear as Resident #3 neared the edge of the pavement to determine if the Resident flipped over in the wheelchair after dropping off of the pavement, or if the Resident impacted with the truck and flipped over in the wheelchair. Observation of Resident #3 on 6/1/2016 at 11:00 AM, revealed the Resident was not in or near the Resident's room on the 200 South Hall. Continued observation revealed the Resident was in a wheelchair with a self-release lap belt in place and was wandering on the 300 South hallway 15 feet from the fire door (where the initial elopement occurred on 4/23/2015). Further observation confirmed staff made no attempts to redirect Resident #3. Observation of the facility's Service Hall on 6/1/2016 at 1:15 PM, revealed the double doors providing access from inside the facility to the Service Hall had no signage to instruct no entry for unauthorized persons (visitors, families, alert residents with intact cognition); and had no type of monitoring or equipment to alert staff of unauthorized entry into an unsecured area. Continued observation into the Service Hall revealed the laundry area was on the left side of the hallway and the entry door into the laundry area was not locked. Further observation revealed the unsecured laundry area consisted of two unsecured areas, with the first area being the soiled laundry area where soiled items were brought for holding and washing. Continued observation revealed the unsecured soiled laundry area contained 1 regular residential-size washing machine, 2 stainless steel commercial washing machines positioned on elevated platforms (with an uneven flooring surface), and 3 commercial soiled laundry bins (to hold soiled items to be washed) and measured 3 feet by 2 feet (side-to-side, front-to-back) by 2 feet deep (top-to-bottom). Further observation revealed the far right bin was one-third full of residents' soiled clothing and bed linens (soiled from urine and fecal incontinence; and food spillage). Continued observation revealed the regular washing machine had a shelf over it with an unsecured 12-ounce disposable clear plastic cup setting atop the shelf and was half-full with a blue liquid. Further observation revealed 11 buckets containing unsecured liquid chemicals were setting on the floor and each bucket held 5-gallons. Continued observation revealed 4 buckets contained bleach, 4 buckets contained fabric softener, and the remaining 3 buckets contained laundry detergent. Continued observation of the unsecured laundry area revealed the second area adjacent the soiled laundry area contained 3 commercial dryers for drying washed items. Observation of the Service Hall egress area and parking lot on 6/1/2016 at 1:30 PM, in the presence of the Administrator (NHA), confirmed the exterior of the Service Hall egress area was surrounded by a metal fence and gate with the fenced area measuring 88 inches (side-to-side) by 35 inches (front-to-back). Continued observation confirmed a 60-inch gate was positioned straight across from the egress doors and did not have any form of positive (non-locking) latch to close the gate; and the gate swung freely both inward and outward and did not close. Continued observation of the exterior Service Hall egress area and parking lot confirmed the NHA measured the area from where Resident #3 exited through the Service Hall egress to the point of her impact, which measured 60 feet. Interview with Dietary Employee #1 on 6/1/2016 at 1:59 PM in the Conference Room confirmed she was aware of Resident #3's risk for elopement and elopement from the facility in (MONTH) (YEAR). Continued interview revealed Dietary Employee #1 stated, (Resident #3) was on the ground off the parking lot (off the pavement). I went in to call the nurse .(Resident #3) is determined .we were all aware she tried frequently to get out (of the facility) .since she got out last year, she has gotten into the Service Hall several times before getting out this last time (on 5/10/2016) .she went into the Service Hall again that night (5/10/2016) .I went and got the nurse and told her (Resident #3) is at it again, trying to get out .I can't remember the nurse's last name for sure, but I think it was (Licensed Practical Nurse #1) . Interview with Dietary Employee #2 on 6/1/2016 at 2:19 PM, in the Conference Room, confirmed she was exiting the building on 5/10/2016 and found Resident #3. Continued interview revealed Dietary Employee #2 stated, .(Resident #3) was on the ground .wheelchair was on its side and (Resident #3) was on (the Resident's) left side off the pavement on gravel .(Resident) was beside a truck and was fastened in the wheelchair with a lap belt. It looked like (the Resident) hit the truck; it flipped (the Resident) over and stopped (the Resident) from going over the embankment behind the truck. I went to (the Resident) .(the Resident) lifted (Resident's) head up and looked at me .(Resident) didn't say anything .just looked at me .(Resident #3) has been in the Service Hall in the last two-to-three months at least two or three times trying to get out the doors .(Resident) would be on the Service Hall, we'd take (Resident) back to the nurses station and sometimes (Resident) would come back to the Service Hall on the same night multiple times . Interview with Laundry Employee #1 on 6/2/2016 at 9:30 AM, in the Conference Room, revealed Laundry Employee #1 stated, .During the past year, I have seen (Resident #3) in the Service Hall 10, maybe 15 times .I would take (the Resident) to the main hall, nurses station, or to (Resident's) room .The nurses saw me bring (the Resident) from the Service Hall many times, but they never did anything about it . Continued interview revealed Laundry Employee #1 stated, .There's three, 5-gallon buckets of (laundry detergent), four, 5-gallon buckets of bleach, and four, 5-gallon buckets of (fabric softener) in the laundry (soiled linen area) .The plastic disposable cup contains (laundry detergent) in it .from the 5-gallon bucket .I would not want a resident in the laundry area, especially a confused resident .there are chemicals back there they could get into and drink it or get it on their skin or in their eyes .it's dangerous .it could cause their skin or eyes to get burned, such as the bleach .I guess it could even kill them .the two larger (commercial) washers (washing machines) get hot .190 degrees (Fahrenheit) and the (three) dryers do, too .150-to-170 degrees (Fahrenheit) .hot enough to burn them .they could get hurt .there are electrical wires, too .this is dangerous and could kill somebody if they did the wrong thing or didn't know what they were doing .the door to the soiled area (from the Service Hall) is never locked . Interview with the Director of Laundry and Housekeeping on 6/2/2016 at 10:03 AM, in the Conference Room, revealed the Director stated, I'm aware (Resident #3) has been in the Service Hall .I would not want residents in the laundry area .There's soiled linens and clothes with urine, BM (feces), body fluids .and they could get into that and make them very sick. There's chemicals and that could kill them if they drank it. They could get their hands caught in the washer or dryer doors and cause injury. Plus the washers and dryers get hot and could cause burns . Continued interview with the Director of Laundry and Housekeeping confirmed the door from the Service Hall into the soiled linen area is never locked and chemicals were accessible. Interview with Licensed Practical Nurse (LPN) #1 on 6/2/2016 at 2:27 PM, in the Conference Room, confirmed LPN #1 worked the 2:00 PM-10:00 PM shift on 5/10/2016 and was assigned to the 200 South Hall when Resident #3 was on the Service Hall and eloped. Continued interview revealed LPN #1 stated, .I was aware (Resident #3) was an elopement risk .When (Resident) got out (eloped), (Resident) was on the Service Hall unsupervised. A visitor let (the Resident) out. (The Resident) rolled down the parking lot to the edge of the pavement which drops off maybe about 5 or so inches. When the wheelchair went off the pavement it probably threw (Resident) forward. When I got to (the Resident), (Resident) was on mostly the gravel with (Resident's) upper body, and (Resident's) knees were on the edge of the pavement. (The Resident) was beside a white truck and may or may not have hit the truck .(The Resident) had abrasions on (Resident's) face and forehead and knees. (The Resident's) arms and knees were bruised .I assessed (the Resident) to determine if (Resident) was able to get into the wheelchair, then to (Resident's) room for further assessment .Later that night, (the Resident) was back on the Service Hall without supervision .(the Resident) was brought back to the nurses station (by Dietary Employee #1) and they let me know (Resident) was back on the Service Hall. I did not know (the Resident) had gone back .I had told the CNA (Certified Nursing Assistant) we need to keep a closer eye on her .check on her every 15-to-30 minutes .This wasn't effective (keeping a closer eye on the Resident by checking every 15-30 minutes) because (the Resident) got back on the Service Hall the same night .All throughout the past year (Resident #3) has tried multiple times to get out .I felt like it was just a matter of time before (the Resident) got out again (after the (MONTH) (YEAR) elopement). Continued interview revealed LPN #1 stated, .The laundry room door is not locked .no residents should ever be back there .it's unsupervised and dangerous .they could fall or drink the chemicals and we wouldn't know it. It's dangerous and could kill a resident . Further interview with LPN #1 confirmed adequate supervision was not provided to prevent Resident #3 from wandering into unsafe areas (on the Service Hall and outside without supervision). Interview with CNA #2 on 6/14/2016 at 7:17, PM in the Conference Room, confirmed CNA #2 initially worked in the Dietary Department from (MONTH) (YEAR) until (MONTH) (YEAR), and transferred to the Nursing Department. Continued interview revealed CNA #2 stated, .I used to work in Dietary and there were plenty of times (Resident #3) was on the Service Hall without supervision .we've caught (Resident) back there alone and we would typically push (Resident) back off the Service Hall through the double doors .to the nurses station .I saw (Resident #3) back there (Service Hall) 10-to-15 times without supervision . Interview with CNA #3 on 6/14/2016 at 7:45 PM, in the Conference Room, confirmed CNA #3 worked the 2:00 PM-10:00 PM shift on 5/10/2016 and was assigned to the 200 South Hall when Resident #3 was on the Service Hall and eloped. Continued interview revealed CNA #3 stated, .(Resident #3) wanders throughout the building and is free to wander. I've seen (Resident) wandering all over the building. (Resident) was free to go down the Service Hall prior to 5/10/2016. If I had seen (Resident #3) go down the Service Hall I wouldn't have stopped (Resident) because I thought there was a wanderguard alarm on the door .If I know one of my residents is at risk for elopement, I check on them every two hours as I'm doing my rounds .looking back, the Service Hall is not safe for residents to be on .the chemicals could kill them. Interview with CNA #4 on 6/14/2016 at 10:22 PM, in the Conference Room, confirmed CNA #4 worked the 2:00 PM-10:00 PM shift on 5/10/2016 and was assigned to the 200 South Hall when Resident #3 was on the Service Hall and eloped. Continued interview revealed CNA #4 stated, .It was known (Resident) wandered onto the Service Hall and would try to kick doors open to get out. On the day (Resident) eloped last (5/10/2016), when I came in I went to get (Resident's) vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure) .(Resident #3) was saying (Resident) wanted to go home, this was not (Resident's) home .(Resident) tried to get out .wanted to leave .I knew (Resident #3) was a wanderer .was always trying to get out .I ran into (Resident's) daughter later and the daughter asked where (Resident) was .I told her I just did (Resident's) vital signs .daughter said she didn't see (Resident #3) .I continued to assist my other residents .then I later heard them calling a code yellow (to alert staff a resident has eloped) . Interview with the NHA on 6/16/2016 at 9:30 PM, in the Conference Room, revealed the NHA was aware Resident #3 was at risk for elopement and consistently wandered onto the Service Hall. Continued interview confirmed the NHA stated, .Yes, I knew (Resident #3) wandered onto the Service Hall .(Resident) has wandered onto the Service Hall ever since I've been here .I've been here three years this coming (MONTH) (2016) .with the gate the way it is (no positive non-locking latch), it's not a deterrent to prevent elopement .We had the older version of the wanderguard alarm on the Service Hall (egress) door and if someone put the code in, then even if a resident had a wanderguard on, it wouldn't alarm because the code disabled the alarm, and they could go through the door with no alarm sounding .We do safety rounds monthly, but I just didn't think about the Service Hall being an unsupervised area .now, I realize it is .I never thought about a resident being able to go into the laundry . Continued interview with the NHA confirmed the facility failed to ensure adequate supervision for Resident #3 to prevent unsafe wandering on the Service Hall and elopement. Telephone interview with Resident #3's attending Physician (Medical Director) on 6/17/2016 at 2:09 PM, confirmed Resident #3's unsupervised wandering on the Service Hall with unsecured chemicals, contaminated laundry linens and clothing, and equipment placed her at risk to cause serious injury, harm, impairment or death. Medical Record review revealed Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of facility policy, Falls Management Guideline, dated 10/21/2015 revealed, .The licensed nurse assesses the resident for injuries (including neuro checks (assessment to detect abnormalities of the brain, spine, and the nerves that connect them) if indicated) and provides necessary treatment and initiates the Change in Condition Report-Post Fall/Trauma (Post Fall Analysis/Plan) .Appropriate interventions are implemented .Care plan is updated .The Interdisciplinary Team reviews the Change of Condition Report-Post Fall/Trauma and makes additional recommendations within 72 hours of the fall . Review of a facility policy, Neurological Checks, (undated) revealed, .Neurological checks (assessments) are to be performed whenever a resident strikes their head or face and for any un-witnessed fall . Review of facility policy, Care Cards (Cardex-CNA Care Plan), dated 5/10/2016 revealed, .It is (facility) policy to communicate .Resident specific information .Each Resident's Cardex is to be updated weekly and as needed .Cardex's are to be printed and distributed to the CNA's at the begging (beginning) of each shift . Review of instructions on a facility form, Post Fall Analysis/Plan, revealed, .(page 2 of 3) Specify Recommendations/Interventions taken to prevent reoccurrence .(page 3 of 3) Recommendations and Interventions Post Fall (Check all that apply) . Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1's cognition was moderately impaired. Continued review revealed the Resident required limited assistance with bed mobility, transfers, ambulation, dressing, and personal hygiene. Medical record review of a Care Plan dated 12/11/2015 revealed Resident #1 was at risk for falls. Medical record review of a Nurse's Note dated 12/23/2015 at 1:00 AM, revealed, .SBAR (Situation, Background, Assessment, and Recommendation; a standardized communication tool)-Change of Condition .Res (Resident #1) fall from bedside to floor .found laying up against wall next to her bed .Cut to underside of left forearm (minor) . Medical record review revealed no new interventions were implemented to prevent further falls. Review of a facility investigation dated 1/6/2016 at 7:01 AM, revealed, .nurse was standing just inside the door with her back to the resident (#1) .When (Nurse) turned, resident was sitting in the floor at the foot of the bed with her knees drawn up to her chest .no injuries . Medical record review revealed no evidence a neurological assessment was completed for Resident #1's unwitnessed fall on 1/6/2016. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] revealed Resident #2's cognition was severely impaired. Continued review revealed the Resident required limited assistance with transfers and ambulation. Review of facility investigations for Resident #2 revealed the Resident had one unwitnessed fall while bending over to pick an object up from the floor on 4/1/2016 and a second unwitnessed fall from the bed on 4/28/2016. Continued review revealed no injuries from the falls. Medical record review revealed no evidence neurological assessments were completed for Resident #2's unwitnessed falls on 4/1/2016 and 4/28/2016. Medical record review of Resident #2's Care Plan dated 7/1/2015 revealed, .At risk for falls .4/1/16 Safety cues, and reminders. PT (Physical Therapy) to screen .4/28/16 Remind resident to lay in center of bed. Non-skid strips on floor . Medical record review of Resident #2's Cardex (CNA Care Plan) updated 6/2/2016 revealed . Wanderguard Bracelet .Additional Information . (Blank) . Interview with CNA #1 on 6/2/2016 at 3:15 PM, on the 200 South Hall, revealed, .(Resident #2) would have a star (symbol of a star) above (Resident's) bed if a fall risk .not sure if (Resident) is or not .nope not one there (star) .(Resident) walks with a cane and holds on the rail .can review Cardex to see what devices should be in place for the residents . Interview with LPN #2 on 6/2/2016 at 3:25 PM, at the South Wing Nurses Station, revealed, (Resident #2) slides .doesn't like to wear socks .so strips were placed at bedside .(Resident) has had a couple of falls .if (Resident) has anything special ordered it will be on his Care Plan .that's how we know .CNA's use the Cardex . Interview with the DON on 6/2/2016 at 6:40 PM, in the Conference Room, confirmed the facility failed to follow their policies to prevent falls, and to complete a Post Fall Analysis/Plan, and to develop new interventions on 12/23/2015 to prevent further falls for Resident #1. Continued interview with the DON confirmed the facility failed to follow their policies and revise the CNA Cardex to include new interventions developed on 4/1/2016 and 4/28/2016. Further interview with the DON confirmed the facility failed to follow their policies and complete neurological assessments after Resident #1's unwitnessed fall on 1/6/2016; and Resident #2's unwitnessed falls on 4/1/2016 and 4/28/2016. The Immediate Jeopardy was effective from 5/10/2016 through 6/17/2016. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated through review of documents, observations, and staff interviews conducted onsite on 6/18/2016. The surveyor verified the allegation of compliance by: 1. Observing a door monitor posted at the interior Service Hall Doors on 6/1/2016 at 6:20 PM, to prevent residents from unsupervised wandering onto the Service Hall. 2. Observing a Commercial Door Company in the process of installing an alarm system on the interior Service Hall Doors to alert the facility of unauthorized entry from inside the facility into the Service Hall on 6/2/2016 at 5:00 PM (installation completed at 7:00 PM). Observing the normal and proper functioning of the alarm system on the interior Service Hall doors and the removal of the door monitor at 7:30 PM. 3. Observing all egress doors on 6/17/2016 for signage (Red Stop signage implemented on 4/23/2015); Notice to Visitors (not to let residents out of the facility without staff notification) implemented on 5/11/2016; and proper functioning of anti-elopement systems on the following doors: A. 100, 200, 300 North Hall Fire Doors B. 100, 200, 300 South Halls Fire Doors C. 200 South Alcove Fire Doors D. 200 North Alcove Egress Doors D. Dining Room Egress Doors E. Main Entry Egress Doors F. Service Hall Egress Doors G. Interior Service Hall Doors (leading into the Service Hall from inside the facility). All Egress Doors (excluding the interior Service Hall Doors) had (1) Red laminated Stop signage (implemented 4/23/2015); (2) signage to not let any resident out of the facility without nursing notification and consent to do so implemented on 5/10/2016; (3) a 15 second delayed mag lock with key code pad implemented prior to the elopements; and (4) a wanderguard alarm system (if a resident with a wanderguard bracelet attempts to exit the door locks, alarms sound, and the door will not open until the resident with the wanderguard is removed from the door area). The wanderguard alarm system in place did not have the upgraded version (tail gate feature) on the Service Hall Egre",2019-06-01
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
1752,BEECH TREE HEALTH AND REHABILITATION,445292,"240 HOSPITAL LANE, PO BOX 300",JELLICO,TN,37762,2018-12-17,600,D,1,0,CCVC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review, and interview, the facility failed to prevent abuse for 1 resident (#1) of 3 residents reviewed for abuse. The findings included: Review of the facility policy Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, not dated, revealed .(Facility) will not tolerate Abuse, Neglect, Exploitation of its residents .Willful means the individual must have acted deliberately .Prevention .monitoring of residents with needs and behaviors which might lead to conflict .such as residents with a history of aggressive behaviors . Review of a facility investigation dated 12/7/18 revealed Resident #1 was in the hallway and as Resident #2 was going to her room she stopped and struck Resident #1 on her upper arm. Continued review revealed Resident #2 had behavior issues and often refused medication. Further review revealed .(Resident #2) is [MEDICAL CONDITION] and had an escalated outburst . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of an Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored a 2 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Further review revealed Resident #2 was discharged on [DATE]. Review of a Quarterly MDS dated [DATE] revealed the resident scored a 9 (moderate cognitive impairment) on the BIMS. Continued review revealed the resident had physical and verbal behavioral symptoms directed toward others 1 to 3 days during the assessment period and rejection of care occurred 4 to 6 days during the assessment period. Interview with Certified Nursing Assistant (CNA) #1 on 12/17/18 at 11:40 AM, in the conference room, revealed .I was coming up the hall I heard .(Resident #2) yelling, she was in the day room, the nurse was already in there with her. I walked in to see if she needed help, the nurse said to stay with her for a few minutes. She (Resident #2) started to leave the day room, and I followed her, she was in a bad mood, and kicking, and trying to hit another resident, but I told her we can't hit and I just followed her down the hall .(Resident #1) was coming down the hall toward the day room .(Resident #2) was just mad, and when we passed .(Resident #1) In the hall she (Resident #2) just reached out and intentionally hit .(Resident #1) on the arm. She just hauled off and hit her . Telephone interview with Licensed Practical Nurse (LPN) #1 on 12/17/18 at 1:40 PM revealed .(Resident #2) was coming down the hall, I was close to her because she just had a look on her face, so I was staying close but I wasn't close enough .she (Resident #2) just stopped and just popped .(Resident #1) on the upper arm. It was intentional, she meant to hit her, yea it was intentional . Interview with the Director of Nursing on 12/17/18 at 4:20 PM, in the conference room, revealed .We were aware .( Resident #2) was having increased behaviors .she had frequently refused her medications and had exhibited some aggressive behaviors toward staff, but none toward other residents . Continued interview confirmed the facility failed to protect Resident #1 from abuse and the facility failed to follow facility policy.",2020-09-01
475,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2020-02-19,600,D,1,0,XNV111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review, and interview, the facility failed to prevent abuse for 1 resident (Resident #3) of 6 residents reviewed for abuse, resulting in Resident #3 being hit by another resident. The findings include: Review of the facility's policy titled, Abuse, Neglect, and Misappropriation of Property, dated 5/8/2019, showed .It is the organization's intention to prevent the occurrence of abuse . Review of a facility investigation dated 2/5/2020 showed .(Resident #1) in (Resident #3's) room standing over him and (Resident #1) was observed hitting the resident (Resident #3) in the forehead with his fist . No injuries were noted. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Care Plan for Resident #3 dated 8/30/2019 and reviewed on 11/13/2019 revealed the resident had an intermittent [MEDICAL CONDITION] and would cuss at staff and make threats toward roommates. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] showed Resident #3 scored an 8 (moderate cognitive impairment) on the Brief Interview for Mental Status. The resident had no behaviors during the look back period. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of an admission Care Plan dated 1/24/2020 showed Resident #1 was assessed for behaviors including verbal aggression toward others, including yelling and threatening others, and physical aggression toward others. Review of an admission MDS dated [DATE] showed the Resident #1 had short and long term memory problems and had exhibited verbal behaviors towards others 1-3 days during the look back period. During an interview on 2/19/2020 at 2:02 PM, Certified Nursing Assistant (CNA) #1 stated .(Resident #3) was upset .(Resident #1) was punching (Resident #3) on his head . During an interview on 2/19/2020 at 2:55 PM, CNA #2 stated .heard (Resident #3) hollering .went to check on him .(Resident #1) was hitting (Resident #3) .told him we can't hit other people . During an interview on 2/19/2020 at 3:00 PM, the Administrator confirmed the facility failed to prevent abuse to Resident #3.",2020-09-01
2140,"LAKEBRIDGE, A WATERS COMMUNITY, LLC",445358,115 WOODLAWN DRIVE,JOHNSON CITY,TN,37604,2019-10-09,600,D,1,0,YKDA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review, and interview, the facility failed to prevent abuse for 2 residents (#2 and #3) of 5 residents reviewed for abuse. The findings include: Review of facility policy Abuse Prevention Program, last updated 1/19/17 revealed .It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property .This facility will not tolerate resident abuse or treatment by anyone, including staff members, other residents . Review of facility investigation dated 10/2/19 revealed on 10/2/19 at 3:30 PM Resident #2 was seated in a wheelchair in the dining room and rolled up to where Resident #3 was sitting at a table. Further review revealed Resident #2 told Resident #3 to .get out of his (expletive) spot . Further review revealed Resident #3 told Resident #2 that he was sitting there. Continued review revealed Resident #2 then kicked Resident #3 and Resident #3 then hit Resident #2 on the mouth with a closed fist, resulting in a skin tear to Resident #2's mouth. Further review revealed Resident #3 fractured his 5th finger has a result of hitting Resident #2. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to an acute care facility on 10/2/19. Review of a Quarterly Minimum Data Set (MDS) for Resident #2 dated 9/4/19 revealed the resident scored a 10 (moderate cognitive impairment) on the Brief Interview of Mental Status (BIMS). Continued review revealed the resident had no history of behaviors during the assessment period. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an Admission MDS for Resident #3 dated 8/16/19 for Resident #3 revealed the resident scored a 12 (moderate cognitive impairment) on the BIMS. Continued review revealed the resident had no history of behaviors. Interview with the Activity Aide on 10/9/19 at 10:00 AM, in the Director of Nursing's (DON) office, revealed .I was passing out BINGO cards in the dining room .(Resident #2) yelled for (Resident #3) to get out of his spot .(Resident #2) kicked (Resident #3) .(Resident #3) hit (Resident #2) in the face with his fist . Interview with the DON on 10/9/19 at 1:00 PM, in the DON's office, revealed .the resident (Resident #3) did hit the other resident (Resident #2) .they hit each other . Continue interview confirmed the facility failed to prevent abuse to Resident #2 and Resident #3.",2020-09-01
476,SIGNATURE HEALTHCARE OF ROCKWOOD REHAB & WELLNESS,445143,5580 ROANE STATE HWY,ROCKWOOD,TN,37854,2020-02-19,609,D,1,0,XNV111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review, and interview, the facility failed to report an allegation of abuse to the State Survey Agency within 2 hours for 1 resident (Resident #3) of 6 residents reviewed for abuse. The findings include: Review of the facility's policy Abuse, Neglect and Misappropriation of Property, dated 5/8/2019, revealed .all alleged violations involving abuse .are reported immediately, but no later than 2 hours after the allegation is made . Review of a facility investigation dated 2/5/2020 showed .(Resident #1) in (Resident #3's) room standing over him and (Resident #1) was observed hitting the resident (Resident #3) in the forehead with his fist . The incident was reported to the State Survey Agency on 2/6/2020 at 4:14 PM (the next day). Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During an interview on 2/19/2020 at 3:00 PM, the Administrator confirmed the facility failed to report the incident to the State Survey Agency within 2 hours after the incident occurred. Refer to F-600",2020-09-01
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
358,"NHC HEALTHCARE, OAK RIDGE",445128,300 LABORATORY RD,OAK RIDGE,TN,37831,2017-09-06,225,D,1,0,KIGC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review, and interview, the facility staff failed to report an allegation of abuse timely for 1 resident (#1) of 3 residents reviewed for abuse. Review of the facility policy Patient Protection and Response to Policy for Allegations/Incidents of Abuse, Neglect and Misappropriation of Property, dated 11/28/16, revealed .Reporting Policy .Any partner having either direct or indirect knowledge of any event that might constitute abuse, neglect, or misappropriation of patient property must report the event immediately . Review of a facility investigation revealed a witness statement completed by Certified Nursing Assistant (CNA) #3 dated 8/10/17. Further review revealed CNA #3 alleged she witnessed CNA #4 stuff a wash cloth in the mouth of Resident #1 on 8/6/17 (4 days prior) and .(CNA #4) told her (Resident #1) that she better shut up because she had[***]all over her and we were cleaning her up . Continued review revealed CNA #3 reported the allegation to CNA #2 and Registered Nurse (RN) #1 on 8/10/17. Further review revealed CNA #2 and CNA #3 reported the allegation to Licensed Practical Nurse (LPN) #2 on 8/10/17 before the start of the evening shift (7:00 PM) and LPN #2 immediately called the Director of Nursing. Medical record review revealed resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum (MDS) data set [DATE] revealed Resident #1 had a Brief Interview Mental Status score of 8 (moderate cognitive impairment). Continued review revealed the resident was resistant with care 1-3 days during the 7 day look back period. Further review revealed the resident required maximum assist with transfers, dressing, and personal hygiene with 2 person assist. Interview with the Director of Nursing (DON) on 9/5/17 at 11:35 AM, in the conference room, confirmed she was notified by LPN #2 on 8/10/17 at approximately 7:00PM of the allegation of abuse (4 days after the alleged incident). Interview with CNA #2 on 9/6/17 at 7:00 AM, in the conference room, revealed .was working with (CNA #3) on Sunday (8/10/17) .she (CNA 3#) told me would not believe what (CNA #4) had done to (Resident #1) .ask if she reported it .she said no . Interview with RN #1 on 9/6/17 at 7:15 AM, in the conference room, revealed . was leaving work (8/10/17) that morning .had clocked out . (CNA #2) called me over to the table and made (CNA #3) tell me what (CNA #4) had done on Wednesday (8/6/17) .DON was not there that morning so I planned to catch her the next morning . Telephone interview with LPN #2 on 9/6/17 at 11:55 AM revealed .was on break (8/10/17) when 2 night shift CNA's were getting ready to start their shift told me what had happened (on 8/6/17) .immediately called the DON . Interview with the DON on 9/6/17 at 9:00 AM, in the conference room, confirmed she would have expected to have been notified immediately of the allegation of abuse and the facility failed to do so. Interview with the Administrator on 9/6/17 at 9:05 AM, in the conference room, revealed facility staff .should have followed the policy as they were trained . Continued interview confirmed the facility failed to follow facility policy.",2020-09-01
2280,PIGEON FORGE CARE & REHAB CENTER,445382,415 COLE DRIVE,PIGEON FORGE,TN,37863,2019-07-15,684,D,1,0,YY1011,"**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 2 residents (#1 and #2) received medications as prescribed by a physician and in accordance with professional standards for medication administration for 8 sampled residents. The findings included: Review of facility policy Medication Administration dated ,[DATE], revealed .Prior to administration, review and confirm MEDICATION ORDERS FOR [REDACTED] Review of policy .Emergency Pharmacy Service and Emergency Kits . dated ,[DATE], revealed .Emergency pharmaceutical service is available on a 24-hour basis .The provider pharmacy supplies .medications/items according to the provider pharmacy agreement .Medications are not borrowed from other residents. The ordered medication is obtained either from the emergency kit or from the provider pharmacy .The emergency medication kit may contain controlled substances . Review of a facility investigation dated [DATE], not timed, revealed on [DATE] Licensed Practical Nurse (LPN) #3 administered Resident #1 his routine evening medications and around 11:00 PM Resident #1 woke up and reported he did not get his medications. Further review revealed LPN #3 then gave the resident a Multivitamin, Acidophilus (used for digestive issues), and [MEDICATION NAME] (anti-[MEDICAL CONDITION]). Continued review revealed Resident #1 had a history of [REDACTED]. Further review revealed the resident did not have a physician's orders [REDACTED]. Continued review revealed LPN #3 told co-workers that Resident #1 was calling out and the resident did not remember LPN #3 giving him his medicines so LPN #3 .just mixed up some vitamins and gave them to him (Resident #1) . 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 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Continued review revealed he received Antipsychotics, Antianxiety, and Antidepressant medications. Medical record review of Resident #1's Medication Administration Record [REDACTED]. Continued review revealed a physician's orders [REDACTED]. Medical record review of a Nurse's Progress Note dated [DATE] revealed Resident #1 had multiple episodes of yelling out, including yelling at the nursing staff. Interview with Registered Nurse (RN) Consultant #1 on [DATE] at 1:20 PM, in the Conference Room, confirmed LPN #3 had administered Acidophilus and a Multivitamin without a physician's orders [REDACTED]. Review of a facility investigation dated [DATE], not timed, revealed on [DATE] at 10:00 AM Resident #2 was out of his [MEDICATION NAME] (narcotic pain medication) and complained of terrible pain. Continued review revealed LPN #3 borrowed 10 mg of liquid [MEDICATION NAME] from an expired resident's discontinued medications and gave it to Resident #. Further review revealed LPN #3 placed the liquid [MEDICATION NAME] in Resident #2's drinking water and without telling the resident what she had done she give it to the resident to drink. Continued review revealed Resident #2 stated the .water tasted funny . and LPN #3 told the resident .it was old water . Further review revealed the resident drank all of the water containing the [MEDICATION NAME] without his knowledge. Continued review revealed LPN #3 stated she knew it was wrong and she should not have done it. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's MAR indicated [REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #2 scored a 14 (cognitively intact) on the BIMS. Further review revealed the resident had frequent complaints of pain. Interview with Resident #2 on [DATE] at 1:15 PM, in the front lobby, revealed he was not aware of what happened until the facility told him. Interview with RN Consultant #1 on [DATE] at 1:20 PM, in the Conference Room, confirmed Resident #2 was prescribed [MEDICATION NAME] in a tablet form and LPN #3 administered liquid [MEDICATION NAME] prescribed to another resident to Resident #2. Further interview revealed LPN #3 should have called the NP or the physician when she realized Resident #2 was out of [MEDICATION NAME] tablets and should not have given any medication without a physician's orders [REDACTED].>",2020-09-01
2378,SIGNATURE HEALTHCARE OF MONTEAGLE REHAB & WELLNESS,445393,26 SECOND STREET,MONTEAGLE,TN,37356,2018-11-13,600,D,1,0,8ME911,"**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 prevent abuse for 1 resident (#1) of 4 residents reviewed for abuse. The findings included: Review of facility policy Abuse, Neglect, and Misappropriation of Property, not dated, revealed .It is the organization's intention to prevent the occurrence of abuse .This policy applies to all residents without respect to the resident's cognitive condition, awareness, or ability to understand the event at issue . Review of a facility investigation dated 10/29/18 revealed Resident #1 and Resident #2 were involved in an allegation of abuse. Continued review revealed a Certified Nursing Assistant (CNA) took Resident #2 into the Gated Community dining room for a sandwich. Further review revealed Resident #1 was already seated in the dining room by the window. Continued review revealed Resident #2 stood up and approached Resident #1 and before staff could reach Resident #2 he put his hands on Resident #1's neck. Further review revealed the residents were separated within seconds, with no injury to either resident, and Resident #2 was placed on one to one supervision until he was discharged from the facility to an inpatient psychiatric facility. Medical record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a Significant Change in Status Minimum Data Set (MDS) for Resident #1 dated 10/17/18 revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment. Continued review revealed Resident #1's behaviors included periods of delusions. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged on [DATE]. Review of an Admission MDS dated [DATE] revealed Resident #2 had short and long term memory problems and was severely impaired with decision making skills. Continued review revealed the resident had behaviors of wandering, hallucinations, and delusions. Further review revealed no physical or verbal behaviors towards others occurred during the assessment period. Medical record review of Resident #2's Comprehensive Care Plan dated 8/8/18 revealed .Resident has hx (history) of Physical Aggression toward others. Hitting others with open/closed hand, wandering, pacing . Continued review of the care plan updated on 10/23/18 revealed .Redirect to quiet environment .encourage to relax .discuss with IDT (interdisciplinary team) eval (evaluate) for multi-sensory room . Review of a Nurse's Progress note for Resident #2 dated 10/22/18 at 5:55 PM revealed .Aggressive behaviors noted this evening. Attempted to sit in a recliner in the dining room that was already occupied. When staff attempted to redirect him he yelled out and tried to strike out at caregivers .Later .assisted to shower room for a shower and became combative, hitting caregivers . Review of a Nurse's Progress Note dated 10/23/18 at 9:40 AM revealed .(Resident #2) Pacing early this morning. Entering others rooms. Striking out at and grabbing staff member X (times) 1 when he attempted to redirect him. Allow to pace with close staff observation . Review of a Nurse's Progress Note dated 10/27/18 at 6:10 PM revealed .Resident (#2) has been overly anxious and agitated all day. Continues to pace back and forth in and out of other resident rooms causing problems .when trying to redirect resident .becomes very agitated and yells out. Throwed to (threw a) coffee pot at tech (Certified Nursing Assistant) this AM during breakfast. Took food cart out of day room and would not return it. When approached by tech to get the cart he tried to turn it over. Resident then picked up pill crusher off this nurses med (medication) cart and was going to hit another resident in the back of head. Resident was taking other residents food away from them and eating it. Refused to let this nurse get vital signs .yelling and saying 'hell no' .MD (Medical Doctor) notified and gave order for [MEDICATION NAME] (antianxiety medication) .5 mg (milligram) tablet. Give 1 tab (tablet) by mouth every 8 hours as needed for increased anxiety and agitation . Interview with the Quality of Life (QOF) Assistant on 11/13/18 at 11:00 AM, in the Gated Community dining room, revealed the QOF Assistant was a witness to the incident involving Resident #1 and Resident #2 on 10/29/18. Further interview revealed .I saw the CNA walking .(Resident #2) down the hall and into the dining room, he (Resident #2) sat down in a chair by the door .(Resident #1) was in his wheelchair across the room by the windows. I had turned away from the dining room and I heard .(Resident #1) yell, I turned around and .(Resident #2) was standing over him (Resident #1) .had his (Resident #2's) hands around his (Resident #1's) neck. I was told by the nurse he (Resident #2) had been having like panic attacks, with an increase in his pacing for a few days before this incident occurred, but nothing was reported to me about him being aggressive towards other residents . Interview with CNA #1 on 11/13/18 at 11:40 AM, in the conference room, revealed .I took .(Resident #2) into the dining room, I walked outside the doorway, I could see the hall and the dining room, I heard a growl sound, but I don't know which one made the sound, when I looked in the dining room .(Resident #2) was standing up over .(Resident #1) .had his (Resident #2) hands around his (Resident #1) neck . Interview with the Social Service Director (SSD) on 11/13/18 at 2:05 PM, in the conference room, revealed .I started tracking a behavior on him (Resident #2) starting on the 22nd (10/22/18) for a behavior of aggression in the shower, which was a new behavior since last December. I followed him for the next 2 days .increase in his pacing identified. On the 26th (10/26/18) the nurse reported he was combative with ADLS (activities of daily living) intermittently. On the 27th (10/27/18) he was noted to be anxious, agitated, and pacing; he tossed a food cart and a coffee pot . Interview with the Administrator on 11/13/18 at 3:05 PM, in the conference room, confirmed Resident #2 was witnessed with his hands around Resident #1's neck and the IDT was aware Resident #2 had an increase in his behaviors. Continued interview confirmed the facility failed to follow facility policy and failed to prevent abuse to Resident #1.",2020-09-01
2165,STANDING STONE CARE AND REHAB,445363,410 W CRAWFORD AVENUE,MONTEREY,TN,38574,2020-01-06,677,D,1,0,Y9RD11,"**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 provide incontinence care in a timely manner for 1 resident (#2) of 4 residents reviewed for incontinence care. The findings included: Review of a facility policy Disposable Products for Incontinence dated 5/23/18 revealed .Residents using briefs will be checked at least every two hours and as needed for incontinent episodes and removal/replacement of soiled briefs . Review of a facility investigation dated 12/12/19 revealed Certified Nursing Assistant (CNA) #4 reported at the beginning of his shift that Resident #2 reported she needed to be changed and the last time someone changed her was midnight (approximately 6 hours earlier). Continued review revealed a facility video recording showed a CNA entered the resident's room at 2:00 AM and exited at 2:02 AM. Further review revealed a Licensed Practical Nurse (LPN) entered the resident's room at 3:06 AM and exited at 3:07 AM. Continued review revealed the resident was not checked during the 4:00 AM - 5:00 AM resident rounds by staff. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged home on[DATE]. Medical record review of a 5 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 scored a 13 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of 2 for transfers, ambulation, and toileting. Interview with CNA #4 on 1/2/20 at 11:00 AM, in the conference room, revealed .when I went in (Resident #2's room) that morning .(Resident #2) told me she hadn't been changed since midnight. I had to change her entire bed. She was soaked she had also had a loose bowel movement. The bed was wet to her feet but it was clear and there wasn't any brown dried rings .she was just soaked. I don't think she was changed during the last round on night shift. It didn't look like it had been there any longer than that . Telephone interview with LPN #6 on 1/2/20 at 1:25 PM revealed .unless I answered her (Resident #2's) call light I wouldn't have routinely gone back in her room, but I would have expected that (CNA #5) would have checked on her during her last round between 4:00 AM and 5:00 AM . Telephone interview with CNA #5 on 1/2/20 at 2:15 PM revealed .the last time I was in her (Resident #2's) room I asked her if she need to be changed and she said no. I thought she would ring her call light if she needed to be changed. I check on incontinent residents every 2 hours and usually stick my head in to check on the residents that are continent or residents who will use their call light, but if you say the camera video shows the last time I was in her room was 2:00 AM then I must not have checked her during my last round . Interview with the Administrator on 1/6/20 at 1:55 PM, in the conference room, revealed .when she voiced her concern about not being changed I asked her if she had turned on her call light and she had said she had not. Theoretically yes she should have been checked on every 2 hours, but with alert and oriented residents there is the expectation they will use their call light and report they need to be changed .it would have been my expectation the CNA would have checked on her during her last round between 4:00 AM and 5:00 AM, however I viewed the camera video and .(CNA #5) did not go back into her room after 2:00 AM. She was offered incontinence care at 2:00 AM, but did not need to be changed and the nurse checked on her at 3:06 AM . Continued interview confirmed the resident was not provided incontinence care in a timely manner.",2020-09-01
3359,WHARTON NURSING HOME,445510,878-880 WEST MAIN STREET,PLEASANT HILL,TN,38578,2019-09-09,609,D,1,0,ZOX511,"**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 report an allegation of abuse within 2 hours for 1 resident (#4) of 3 residents reviewed for abuse. The findings included: Review of facility policy Abuse, Neglect and Exploitation, last revised 8/2019, revealed .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies .within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . Review of a facility investigation, not dated, revealed Resident #4 and Resident #5 were married and cohabitated the same room in the facility. Continued review revealed on 3/7/19 at approximately 4:00 PM staff witnessed Resident #5 cursed and slapped Resident #4 on the shoulder. Further review revealed staff intervened and during the attempt to separate the residents, Resident #5 kicked Resident #4 on the front of the leg. Continued review revealed Resident #5 was admitted to an inpatient psychiatric facility on 3/7/19. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) for Resident #4 dated 6/23/19 revealed a Brief Interview for Mental Status (BIMS) score of 4, indicating the resident had severe cognitive impairment. Medical record review revealed Resident #5 was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. Review of a Discharge MDS for Resident #5 dated 3/7/19 revealed a BIMS score of 3, indicating the resident had severe cognitive impairment. Interview with the Social Service Coordinator on 9/6/19 at 2:55 PM, in the conference room, confirmed .I reported the incident the next day during the morning meeting . Interview with the Director of Nursing (DON) on 9/9/19 at 3:30 PM, in the conference room confirmed the incident occurred on 3/7/19 at approximately 4:00 PM, but was not reported to the Administrative staff until 3/8/19 at approximately 8:30 AM (16.5 hours after the incident). Continued interview confirmed the facility failed to report the incident to the State Survey Agency until 3/8/19 at 1:35 PM (21.5 hours after the incident). Further interview confirmed the facility failed to report abuse within 2 hours of the alleged incident and confirmed the facility failed to follow facility policy. Refer to F-600.",2020-09-01
996,WOODLAND TERRACE CARE AND REHAB,445205,8249 STANDIFER GAP ROAD,CHATTANOOGA,TN,37421,2019-09-25,600,D,1,0,ZR0911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review, observation, and interview, the facility failed to prevent abuse for 1 resident (#2) of 7 residents reviewed for abuse. The findings included: Review of facility policy Abuse Neglect, Mistreatment and Misappropriation of Resident Property, last revised 10/2017, revealed .it is the policy of this facility to prevent abuse .Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pair or mental anguish .Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Review of a facility investigation dated 7/27/19 revealed on 7/27/19 at approximately 11:00 AM Resident #6 entered Resident #2's room. Further review a nurse entered Resident #2's room after hearing the residents cursing loudly. Continued review revealed as the nurse was removing Resident #6 from Resident #2's room; Resident #6 reached over and hit Resident #2 on the foot. Further review revealed the nurse grabbed Resident #6's arm and placed it close to his body, but Resident #6 quickly reached back and hit Resident #2's foot again. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not completed due to .resident is rarely/never understood . Review of a Staff Assessment for mental status revealed the resident's short and long memory was good. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and discharged [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #6's Annual MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4, indicating the resident had severe cognitive impairment. Observation and interview with Resident #2 and Licensed Practical Nurse (LPN) #1 on 9/23/19 at 10:20 AM, in the hallway outside the resident's room, revealed the resident was seated in a wheelchair, was well groomed, and had no anxious or fearful behaviors. Interview with Resident #2 revealed .(Resident #6) hit my foot (translated by LPN #1) . Telephone interview with LPN #2 on 9/23/19 at 1:40 PM revealed .He (Resident #6) was in (Resident #2's) room visiting her roommate .(Resident #2) was yelling so I went in the room and was rolling him (Resident #6) out. When we passed the foot of her (Resident #2's) bed he (Resident #6) reached out .hit her (Resident #2's) foot .before I could get (Resident #6's) arms he hit (Resident #2's) foot again .he meant to hit her . Interview with the Director of Nursing on 9/25/19 at 11:18 AM, in the conference room, confirmed Resident #6 deliberately hit Resident #2 on her foot twice. In summary, the facility failed to prevent abuse to Resident #2.",2020-09-01
2376,SIGNATURE HEALTHCARE OF MONTEAGLE REHAB & WELLNESS,445393,26 SECOND STREET,MONTEAGLE,TN,37356,2019-10-03,600,D,1,0,LT3911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review, observation, and interview, the facility failed to prevent abuse to 1 resident (#1) of 6 residents reviewed for abuse. The findings included: 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, exploitation, injuries of unknown origin, and misappropriation of resident property .This policy applies to all residents without respect to the resident's cognitive condition, awareness, or ability to understand the event issue .Abuse is the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm pain or mental anguish .willful means non-accidental .willful as used in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Review of a facility investigation dated 8/29/19 revealed Resident #1 wandered into Resident #2's room. Continued review revealed Certified Nursing Assistant (CNA) #1 heard someone yelling, entered Resident #2's room, and observed Resident #2 hit Resident #1 on the head with a hairbrush. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had short and long term memory loss and had no physical or verbal behaviors during the assessment period. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly MDS dated [DATE] revealed the resident scored a 6 (severe cognitive impairment) on the Brief Interview for Mental Status. Continued review revealed the resident had no physical or verbal behaviors during the assessment period. Observation of Resident #1 on 10/1/19 at 2:35 PM, on the 200 hall, revealed the resident seated in a wheelchair in the hall beside her room. Continued observation revealed no anxious or fearful behaviors. Observation and interview with Resident #2 on 10/1/19 at 2:50 PM, in her room, revealed a STOP sign placed across the door way entrance into the resident's room. Continued observation revealed Resident #2 was lying in bed awake and alert with no aggressive or agitated behaviors observed. Interview revealed .she (Resident #1) scared me she was behind the curtain and came at me I thought she was going to attack me and I whacked her in the head with a hairbrush .I wanted her (Resident #1) out of my room . Interview with Licensed Practical Nurse (LPN) #1 on 10/1/19 at 3:30 PM, in the conference room, revealed .It was right at the end of my shift .after 5:00 PM .(Certified Nursing Assistant (CNA) #1) came to me .had (Resident #1) with her (CNA #1) said 'oh my gosh, I heard .(Resident #2) screaming and I went in the room, and when I walked in I saw (Resident #2) hit .(Resident #1) on the head with a hairbrush' .(Resident #1) had a small laceration to the right side of the front part of her scalp . Interview with CNA #1 on 10/2/19 at 10:22 AM revealed .I heard .(Resident #2) hollering I ran down to the room, I saw (Resident #2) being aggressive with (Resident #1) .hitting (Resident #1) with a hair brush .(Resident #1) she said I don't know if I am in the right room or not .(Resident #2) kept saying over and over get out of my room this isn't your room .(Resident #2) was deliberately hitting her with the brush .hit her (Resident #1) twice . Interview with the Director of Nursing (DON) on 10/3/19 at 9:20 AM, in the conference room, confirmed Resident #2 hit Resident #1 on the head with a hair brush. In summary, Resident #2 hit Resident #1 with a hair brush on the head twice resulting in a small laceration to Resident #1's scalp.",2020-09-01
2360,SIGNATURE HEALTHCARE OF MONTEAGLE REHAB & WELLNESS,445393,26 SECOND STREET,MONTEAGLE,TN,37356,2019-03-05,600,D,1,0,NHF911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review, observation, and interviews the facility failed to prevent abuse for 1 resident (#1) of 5 residents reviewed for abuse. The findings included: Review of the facility policy Abuse, Neglect and Misappropriation of Property, not dated, revealed .It is the organization's intention to prevent the occurrence of abuse .This policy applies to all residents without respect to the resident's cognitive condition, awareness, or ability to understand the event at issue For purposes of this policy, willful means non-accidental . Review of a facility investigation dated 2/25/19 at 5:30 PM revealed .(Resident #1) wandered into (Resident #2's) room .attempted to take (Resident #2/s) walker .began a 'tug of war' with said walker .resulting in a skin tear to (Resident #1's) hand .elders were separated . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Medical record review of Resident #1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive impairment). Continued review revealed behaviors of wandering occurred daily during the assessment period. Observation of Resident #1 on 3/4/19 at 8:50 AM, on the 100 hall, revealed the resident seated in a wheelchair, he was awake, alert, and well groomed, and no anxiety or fearful behaviors were observed. Observation of Resident #1 on 3/5/19 at 7:25 AM, in the main dining room, revealed the resident was seated at a dining room table conversing with 6 other residents. Further observation revealed the resident was smiling and no fearful or anxious behaviors were observed. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Medical record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 10 (moderate cognitive impairment). Further review revealed no behaviors occurred during the assessment period. Observation of Resident #2 on 3/4/19 at 9:05 AM, in his room, revealed a Stop sign was placed across the door. Continued observation revealed the resident was lying in bed, awake, and alert. Interview with Certified Nursing Assistant (CNA) #1 on 3/4/19 at 10:30 AM, in the conference room, revealed .it was supper time .(Resident #1) wasn't in his room. He wanders in and out of others rooms .I started looking for him. I heard a noise in (Resident #2's) room .the door was shut and (Resident #1's) wheelchair was backed up against the door and I couldn't get it open. I yelled for the nurse .pushed on the door and we were able to open it enough for the nurse to squeeze in. When I got in I saw .(Resident #2) with his walker raised in the air .didn't actually see him hit .(Resident #1) . Interview with Licensed Practical Nurse #1 on 3/4/19 at 12:00 PM, in the conference room, revealed .(CNA #1) yelled at me to come to (Resident #2's) room .(CNA #1) had been looking for (Resident #1) to take him to his room to assist him with supper. As she was walking up the hall she heard something in (Resident #2's) room .she attempted to open the door but it was blocked by the wheelchair .(Resident #1) was sitting in. I managed to get the door open enough to squeeze by the wheelchair and I saw .(Resident #2) strike .(Resident #1) with his walker . Interview with the Interim Director of Nursing on 3/5/19 at 8:15 AM, in the conference room, confirmed the facility failed to prevent abuse to Resident #1 and the facility failed to follow facility policy.",2020-09-01
1061,RAINTREE MANOR,445216,415 PACE STREET,MC MINNVILLE,TN,37110,2019-07-30,609,D,1,0,0I8X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, review of a facility investigation, medical record review, observation, and interviews, the facility failed report an allegation of abuse timely for 1 Resident (#1) of 5 residents reviewed for abuse. The findings included: Review of facility policy Abuse Prevention Policy & Procedure revised 2/26/18 revealed .All allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the state survey agency .per state and federal guidelines .Immediately means as soon as possible, but not later than 2 hours after the allegation is made . Review of a facility investigation dated 7/18/19 revealed a Hospitality Aide (HA #1) reported on 7/18/19 to the Staff Development Coordinator (SDC) that on 7/14/19 a Certified Nursing Assistant (CNA #1) cursed and verbally threatened Resident #1. Continued review revealed Resident #1 denied any staff member was rude to him or threatened him. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident had severe cognitive impairment. Telephone interview with CNA #1 on 7/30/19 at 8:55 AM revealed .I never cursed him (Resident #1) .threatened him .or did anything or say anything out of the way to him .I just don't know why she (HA #1) would say something like that . Observation of Resident #1 on 7/30/19 at 9:30 AM, in the activities room, revealed the resident seated at a table actively participating in an activity. Further observation revealed no signs of anxiety or fearful behaviors. Interview with the SDC on 7/30/19 at 10:15 AM, in the conference room, revealed .she (HA #1) came in my office on (7/18/19) in the afternoon about 1:30 PM, she said I need to talk to in private .she said I was working with a CNA and she asked me to help her with a resident .they went into (Resident #1's) room .(CNA #1) said 'I can't stand this (f------) place' .(HA #1) said (CNA #1) roughly turned the resident over startling him and the resident grabbed (HA #1's) scrub top and the grab bar with his other hand .said (CNA #1) told the resident 'if he didn't let go of the bar (CNA #1) was going to punch him in the (f------) face.' (HA #1) stated that (CNA #1) always states she hates her job here .and (CNA #1) hates the residents .I asked (HA #1) why she hadn't reported it and she said she was scared because she had to work with (CNA #1) a lot . Interview with the Human Resource Director on 7/30/19 at 10:55 AM, in her office, revealed .we go over abuse .the different types of abuse .what to do including reporting (abuse) .(Hospitality Aide #1) received her abuse education on 6/10/19 . Telephone interview with Hospitality Aide #1 on 7/30/19 at 11:55 AM revealed .it (incident) happened on (7/14/19) .(CNA #1) asked me to help change (Resident #1) . when we turned (the resident) he must have thought he was falling because he grabbed the bar and my shirt .(CNA #1) told him to 'let go of the f---ing rail' or she 'was going to punch him in the f---ing face.' I didn't report it .supposed to report abuse immediately . Interview with the Administrator on 7/30/19 at 12:40 PM, in the conference room, revealed HA #1 stated the allegation occurred on 7/14/19. Further interview confirmed the incident was not reported until 7/18/19 (4 days after the alleged incident). Continued interview confirmed the facility failed to follow their abuse policy for reporting an allegation of abuse to the State Survey Agency within 2 hours.",2020-09-01